Wednesday, March 29, 2006
The whole day was sprinkled through with flavours of Web Services and its bigger brother Service Orientated Architectures (SOA). While the slides were colourful, what was not made clear is that Web Services and SOA are both still very much works in progress and still having much of their implementation complexity worked out. I think it is rather early in the 'hype cycle' to hitch Australia's e-health future to these, as yet, unproven technological approaches. Time will tell, but another false architectural start - like HealthConnect - would be a very bad thing.
The worst aspect of the day was a speech given by a DoHA representative who should have known better given his background. His argument was based on the premise that because it is not possible to work out how to distribute the benefits from Health IT between governments, consumers and providers each should fund their own infrastructure. This is facile in the extreme. It is well known that the majority of benefits flow to the payers (Government in our case) and consumers and that most of the costs are incurred by the providers. If there is not a policy response to this stark fact nothing will happen - as has largely been the case to-date.
The only reason any competent bureaucrat would assert otherwise has to be because they have been told there will be no money and they need to put the best spin possible on a sad situation.
It will be interesting when the NEHTA Benefits Realisation Project identifies the truth. I wonder where DoHA will hide then?
Sunday, March 26, 2006
The central issue in e-health as I see it is that Australia has not developed, articulated, discussed and agreed a National e-Health Strategy, which brings together all the work being undertaken around the country, assembles it into some sort of coherent whole and provides forward direction and leadership for all involved. In response to the apparent movement from NEHTA I want here to expand my arguments and suggest just what the National Strategy I am proposing may look like.
Before doing that I must answer the “why do we need one?” question. This is easy. Without a plan in virtually every walk of life there is a tendency to see a lack of progress, waste of resources and repeated false starts. The reason this sounds familiar is that this accurately describes the National progress in the e-Health domain. As a colleague so delightfully puts it – all we have seen is largely ‘Brownian Motion’ with no solid progress in any direction. In large projects, such as National e-Health, even with a plan progress can be difficult and slow, but without one failure is inevitable. The second reason we need a plan in my view is that we humans work best and contribute most if the goals and objectives are clear – hence the need not only for a plan, but for it to be publicly articulated and communicated.
On the basis that we need the plan, what should it contain and what factors and constraints should it consider.
Before anything is done the first step is to ensure it makes sense to proceed with planning. This is done by developing a generalised Business Case for National e-Health implementation. If overseas experience is any guide this will confirm the need for action and a plan.
What is involved in doing a plan? The first thing the National Strategy needs is a current view of just what is going on everywhere, and what is working well and needs to be preserved and encouraged. Next, once we have worked out where we are we need to work out where we need to be. This will involve a lot of consultation with all interested stakeholders to develop a vision of future Health Service delivery and then ensure we can put in place the technology to make it work. Fortunately there has been a lot of work done on the desired future state of the Health System and this can be utilised to guide the planning of the supporting technology initiatives.
Out of the requirements and consultative process there should emerge a number of options reflecting the use of different technical approaches, different priorities, different levels of preparedness to invest and so on. These will ideally be worked up into three or four roadmaps and then a second consultative process with stakeholders and the public will choose the most appropriate. This roadmap will then be worked up, in detail, and all the implications for consumers, professionals and others, risks, costs and so on thought through.
At this point there will exist both a clear reason for action and agreement at a high level as to what direction should be taken.
What might an overall strategy look like. The objectives and mission are easy. What we want from technology is better co-ordination of care (only answer questions once, don’t fall between the system’s cracks etc), greater safety with relevant knowledge provided to carers at the point of care, greater efficiency of service delivery at all levels and ideally our own little personal health record that has all our health information securely stored so that when needed it can be made available to those who need it – our doctor, nurse or who ever.
What technologies and systems do we need? Essentially there are five.
First all our hospitals need clinically rich and administratively effective internal systems that enhance patient safety and operational efficiency. These you can buy off the shelf from a range of Australian and overseas vendors – (IBA, Cerner, etc). These need to be advanced systems that provide excellent care documentation and physician order entry with advanced decision support.
Second our GPs and Specialists need similarly effective systems which manage all aspects of our care electronically and can receive and transmit information (referrals, prescriptions, test requests etc) securely and safely. These can be obtained reasonably cheaply but ideal ones are still a little way off.
Thirdly we need service providers (Specialists, Laboratories, Radiological Practices, Pharmacists etc) to provide their product (i.e. reports etc) electronically. Systems to do all of this are available off the shelf.
Fourthly we need in place a secure set of message standards to allow the information to flow where it needs to go safely and privately. These exist in simple form and are improving quite quickly.
Lastly we need some Standards to ensure all information that flows can be properly and reliably linked to the individual it relates to and contains information in a form that can be properly actioned by the receiving system. These largely exist today
With some will, and a rational funding plan that pays those who create the information that is of benefit to those who get to use it, implementation need take no longer than three to four years. The Implementation Plan will need to adopt a simple, walk before you run, bottom up style but is eminently doable for reasonable cost given the potential benefits.
There will be some issues with integration with previous initiatives but there is nothing that is not doable in all this, other than the need to have a plan and the will and resources to execute it.
What could this achieve? The answer has not yet been fully worked out but if the experience overseas is any guide savings of 5-10% of the health budget and a considerable reduction in clinical errors of all sorts is well within our grasp. We should stop talking about it and get on with it!
(Please note - for the expert readers - this commentary is very high level and lacks detail - but I am convinced it is basically sound - comments welcome!)
Thursday, March 23, 2006
There is only one fly in the ointment. No matter who is assessing benefits opportunities they need to be clear as to what strategic implementation plan it is they are assessing the benefits of!
One can only hope that very soon NEHTA takes us all into their confidence and lets us know just what this plan is and what it involves.
Only with that done, and a costing of the strategy planned developed, will the first step of my master plan for e-health be underway, i.e. the development of a national business case that can mobilise government and public support.
We will all be watching NEHTA closely over the next few weeks to see what comes.
Tuesday, March 21, 2006
Today we learned that the NSW HealthConnect Trial for NSW - the Health-E-Link project is coming apart for the most basic of reasons - the lack of proper involvement and consultation of healthcare providers and consumers.
It seems that NSW Health has been so keen to get the project operational they have altered NSW Health Information Privacy regulations - to the annoyance of many who are interested in the issue - and have also failed to sign up the local doctors before attempting to 'go live'.
This is very sad as the project has cost a lot of money and was probably the best resourced of all these so called 'trials'.
Again it seems the bureaucracy has not understood the basic tenets of the management of complex change.
The losers, as always, are the Australian public, who deserve a great deal better.
Saturday, March 18, 2006
Some were very positive hoping to see much improvement in the timeliness and responsiveness of the e-health standardisation process and looking forward to more input from the relevant interests and stakeholders.
One correspondent made the very useful suggestion that it would be very valuable if technology was used to facilitate standards development and to make the processes more transparent and clear. A suggestion I heartily endorse - pity it was not a specific action point in the framework.
Mostly, however, there seemed to be disappointment about the lack of specific clarity in the action plan and the funding plans. One correspondent repeatedly muttered - "just a marketing doco with no real content".
Amusingly there has been fun when another correspondent pointed out in the GP e-mail list that the spelling standard for the document was confused and rather US like (or may be mid-pacific) with the use of centre and center occurring. I wonder what language standard was intended
The total proof of all this will be, however, where e-health standards are in 12 months.
We will all watch with interest.
Thursday, March 16, 2006
The intent of the document is to explain how NEHTA is going to operate in the Standards space and what its relationship will be to Standards Australia.
I suspect this document will cause some consternation among a range of stakeholders as the general tone of the document is that when we work out what the Standards are to be and then compliance will be obtained via control of government procurement and funding in the e-Health space. Given the dominance of the various government entities in e-Health via the States and funding provided to GPs this approach could impose all sorts of unexpected compliance costs on what is at best still a nascent industry. For any standardization effort to succeed it must benefit all stakeholders in balanced ways and not favour one stakeholder group over another
It must be hoped the proposed E-Health Standards Forum is actually as its name implies - a Forum for the exchange of ideas - and not a convocation where pre-determined outcomes are announced.
It is good to see the document recognises the progressive withdrawal of Government funding to e-health standards activities and it is to be hoped this recognition will be followed by positive funding action. Ongoing "monitoring and assessment" of available resources does not suggest a strong commitment to major change!
It must be said the order and depth in which current Standards Development Organisations are reviewed is telling. The virtual dismissal of DICOM, the IHE inter-operation approaches and the ASTM Clinical Care Initiative are of note. Its also likely openEHR proponents will be disappointed with the lack of even a single mention directly - given their activity in the EHR space at the very least.
The action plan is also of some interest in that all of these issues ought, in my view, have been sorted out ages ago. The relationship between NEHTA and SA has been disconcertingly vague for at least a year. It seems likely to be resolved, at the earliest, later this year. The other plans are relatively low impact if they are the whole 2006 agenda and a great deal more than this could be desired.
One is also left wondering just what are the full scope of the e-health standards to be addressed. This document should have contained a detailed listing as an Appendix at least - given such work is readily adaptable from the work done by Infoway in Canada and the US CHI Initiative.
Lastly - the value and utility of the document is greatly diminished by not being placed in the context of a published National e-Health Strategy and Plan. Without this overaching document it is hard to know what value is being delivered by the present document other than a collection of relatively warm motherhood statements and a very underwhelming and underpowered action plan.
Tuesday, March 14, 2006
Two major ideas have struck me.
Firstly it seems that the continuing rise in spending on Healthcare in general is becoming un-sustainable. In the US it is now thought it will reach 20% of the Gross Domestic Product (GDP) by 2015 (As identified in the US Health Policy magazine Health Affairs 2 weeks ago) and despite the best efforts of Mr Abbott and Mr Costello we look like reaching 15% of GDP in a similar time frame - despite the cost control mechanisms of the PBS etc.
Secondly it seems to me the Knowledge Management task now required of physicians is also becoming un-sustainable and it increasingly needs the support of information technology.
IT is good at helping with improving efficiency, managing and communicating information and identifying variations from the norm.
We need all this to allow us to see an improving health system and not one that fails under its own weight.
What do you think are the major drivers for better use of IT in the Health Sector?
Monday, March 13, 2006
The key conclusion of relevance to Australia is that it shows that there are a number of ways of "skinning the cat". With this clear there is a very serious implication.
This is that the National e-Health Strategy should be contestable and should be developed in a way that all reasonable options are carefully considered. There is nothing in the Roadmap that is totally "out of court" for adoption in Australia and I believe we should expect NEHTA to provide a clear statement of their roadmap and then let the contest of ideas operate to sort out the best way forward.
The previous HealthConnect strategy would appear to have been abandoned (after 5+ years of effort) but that is no justification for not putting all the reasonable choices on the table and having a carefully considered review.
I doubt this will happen but it would be good for all concerned if it did.
Friday, March 10, 2006
It seems to me that, while there is a lot of concern about the place of proprietary systems in Health Care, without some market making we simply would be confined to having systems developed by governments and thus have much less choice for a particular situation or institution.
It seems to me the best role the open source movement can play is keeping the commercial providers honest and keeping their costs reasonable while leveraging the investments made by government to provide the widest choice possible.
I seriously doubt that open-source will lead to the demise of proprietary systems any time soon.
Thursday, March 09, 2006
To quote the article:
"A STAGGERING 500,000 Medicare cards have been lost or stolen in the past 12 months, with some being used to create fake identities and make fraudulent benefit claims.
In a bid to tackle identity fraud, Human Services Minister Joe Hockey called for a photo of the holder to be included on Medicare cards, which currently only contain a person's name and Medicare number.
Criminals are using the lost or stolen cards to set up fake identities, open bank accounts and claim Medicare benefits and prescription medicine subsidies that they are not entitled to."What is clear here is that the system simply lacks the robustness required, and to be made fit for purpose (i.e. to prevent fraud and to permit accurate identification of individuals) a large investment will be required.
Recently a UK expert suggested that the total cost of identifying each citizen reliably with appropriate biometrics is of the order of $250 per individual. Even if it is just 1/2 this we are talking billions of dollars and with the loss rates of the Medicare card - huge ongoing replacement and renewal costs.
One hopes the business case for taking on this expenditure is sound - and that all the parts of government involved in identification schemes (Health, Human Services, Attorney General and Immigration) are co-ordinating their activity to minimise waste and to preserve privacy.
Wednesday, March 08, 2006
This is version 2.0 of their RoadMap efforts - and builds on a year of experience derived from the initial release.
It can be found here.
It is currently open for discussion until the 31st of March 2006.
I think this is a very valuable document that deserves a very thorough read and has a lot that should be considered in the Australian context. I hope NEHTA have noticed the release and will give the ideas due and careful consideration.
Tuesday, March 07, 2006
Karen Dearne in the Australian today discusses the request from Queensland to clarify what is going on at last weeks Australian Health Minister's Advisory Council meeting.
She concludes, based on the level of activity in evidence and the likely costs, that the program has been largely shelved and that we have not yet been told.
It seems to me the official announcement will have to wait until a replacement strategy is in place and I am pretty sure work to develop and clarify is a high priority with NEHTA.
Speculation on what you imagine is planned in the new direction is welcome!
Monday, March 06, 2006
Agnes King has had a conversation with the CEO of NEHTA the AFR is reporting. The article can be found here if you have subscription access.
In summary it suggests that after two years work NEHTA has developed the framework for the "unified national Health IT system" and that this framework will be released to the vendor community in the next few weeks.
These comments make it clear there will be little if any significant spend at the National level and that all vendors who hope for new sales will need to work with the states and territories where they are relevant and with GPs and private hospitals which are under less national of state control.
Issues of how any required changes in hospital and GP systems are to be paid for an so on are still unresolved in this article as are all the issues of information ownership, privacy and so on. It will be interesting to see just how practical and evolved the framework is when it is released.
One thing appears certain - the older concept of the national system of HealthConnect repositories which share summary records across the nation is well and truely dead.
We await the next installement with interest.
Sunday, March 05, 2006
Just asking does anyone understand just what the National E-Health IT Strategy is?
In case anyone is wondering - I have been working and researching in this space since 1983.. and am tired at the level of apparent progress. I want to hear from all who think it is going well - or going badly.
Comments - suggestions as to sources etc of the truth also welcome.
In future posts we can explore what the truth might be - or maybe someone will tell us!
The aim to to provide clarity and transparency for all involved as to what is going on, who is doing what with whom and what is driving what is happening.