Paths to Benefits – A Clearway or Not?

We have a new document from NEHTA. It is entitled “PATHS TO BENEFITS. NEHTA’s approach to modelling the benefits of investment in national e-health infrastructure - Version 1.0 — 20 August 2006 - For Comment”

According to the document’s introduction “The purpose of this document is to describe the approach NEHTA is using to model the benefits realisable from investment in national e-health infrastructure. In order to model the benefits realisable from national e-health infrastructure investment, it is necessary to examine both the most likely approaches to developing Australia's e-health infrastructure and the quality of evidence supporting these approaches. The document also outlines the technical approach to modelling costs and benefits being used by NEHTA for the Benefits Realisation Study.”

I have endeavoured to approach this document with a positive mind-set and in the hope that something useful will come from the modelling and associated efforts outlined. Sadly the more I have read, the more I am concerned.

The first issue that occurs to me concerns the second sentence of the introduction quoted above and relates to the admission that NEHTA does not know what the national e-health infrastructure approach is and so it is going to model some likely approaches. NEHTA has been in existence for just over two years having been authorised by Health Ministers on July 29, 2004 to commence immediate operations. For NEHTA to still not know the approach that will be adopted to the establishment of a National E-Health Infrastructure two years after its founding would be hilarious if it were not so dreadfully serious. What on earth are they being paid to do?

It is clear that what is needed, before benefits analysis is undertaken, let alone before benefits realisation is undertaken, is a clear statement of the technology and e-health functionality assumptions and directions being assessed. Appendix 1 suggests there are eighteen NEHTA initiatives & deliverables that “Contributes to >0.5 Billion annual benefit”. Such assertions are simply not credible unless there is a clear articulation of just what is referred to in each and (hopefully) what the cost of each might be. It is just not possible to model the cost-benefit of system Y or infrastructure X without knowing, in some functional and technical detail, what it is!

Secondly there is to me a fundamental issue with the context of this document. Benefits Realisation is a process that is undertaken as part of the planning of and implementation of new business processes and supporting or enabling computer systems. Before it begins there are a few prior steps which NEHTA has omitted which render the present document problematic. These prior steps include identification of problems to be addressed, development of a strategy to address the problems and the subsequent development of a business case (with costs and benefits) to justify the planned investments and activity. Only once this is agreed should implementation planning and business realisation (of the identified benefits) be undertaken. The work covered here, in the absence of the pre-work, is clearly a cart put much before the horse.

It should be noted that in the US (ONCHIT Plans), the UK (Information for Health) and Canada (Health Infoway) the national plan and approach has been developed first and costed and analysed for benefits before implementation is begun. In Australia a plan (HealthConnect) was in development for five years, but having not been funded has largely gone nowhere, while we now see NEHTA making infrastructure investments without either a National Plan or a National Business Case and in the absence of a clear view of what is being built towards!.

A third concern relates to the nature of Business Cases for Infrastructure Investment. In developing the various identification initiatives and SNOMED CT, it seems to me NEHTA is adopting a “build it and they will come” mentality, which may or may not turn out to be true. Additionally it is widely recognised that there is seldom a business case for infrastructure development that, of itself, is positive. Building a railway can only be justified when one knows how many trains of what type will use it and what they can be charged. The same with NEHTA infrastructure. NEHTA does not know who (GPs, Specialists, Hospitals, Pathologists etc) will use its planned infrastructure, what their needs will be and how much they are prepared to pay. The central issue is that while NEHTA has some understanding of the needs of the Jurisdictions which own it, it would seem to have little information and understanding of the needs of the private sectors comprising GP, Specialist and Private Hospitals. Any approach to examining the benefits of e-Healthand to developing a business case for investment, must review the Health Sector as a whole and not serve just the sectoral concerns of NEHTA’s owners.

Fourthly it is clear that the lack of interest in, and understanding of, the office practice needs and requirements has led to substantial imbalance in the benefits being sought and a denial that anything needs to be done in these areas. An example is the discussion of decision support (Section 3.2.1)

"3.2.1 Role of decision support

The diagram highlights the important role of decision support in the realisation of quantifiable clinical benefits. Information from the shared electronic health record, clinical evidence and evidence arising from the monitoring of health services utilisation (such as the monitoring of the under use or overuse of specific medications, trends in laboratory results and regional variation in access to specific elective procedures) are used to present to both health consumers and healthcare providers sophisticated decision support tools designed to assist health consumers and healthcare providers make better decisions when choosing to access specific healthcare services.(13)

In the case of health consumers, decision support is primarily designed to assist self management of clinical conditions and to assist a health consumer in making choices concerning the most appropriate healthcare services to meet their needs, given their clinical, cultural and geographical context.(14) Decision support for healthcare providers is primarily targeted at improving the appropriateness of prescribing and referral for specific consultations, procedures or investigations in order to reduce misuse, overuse and under use of individual healthcare services. (15-18)”

It is well known that the key driver of Health Sector costs are medical activities. These activities are notoriously difficult to change and the only good evidence for causing change in behaviour centres around decision support and alerts provided at the point of clinical decision making. Non-interactive reporting back to doctors, weeks or months later, of what they were doing inappropriately runs a very poor second in effectiveness – yet this is really the only type explored in the report. Why one asks? NEHTA simply does not want to address the issues of quality and functionality of the client systems which may use its infrastructure. This is a real “head in the sand” approach which means any assessment of benefits will be pure guesswork without explicit assumptions as to the capabilities of the client systems being modelled.

Let us be quite clear on this – it is interactive, point of care, advanced clinical decision support and alert systems that offer the largest opportunity for benefit realisation from e-health. The fact this point is not emphasised in this report provides evidence that the document is lacking an appropriate direction and focus.

Next the report notes, without giving adequate emphasis, the issue of the distribution of benefits and the place of incentives in obtaining the adoption and use of Health IT. This issue has been explored in a previous note (Who pays the Piper? May 28,2006) but the essential truth is that small business people (as GPs and Specialists are) will not adopt any technology that reduces their net income. Time and time again it has been demonstrated altruism is not enough and it won’t be here as well. Any modelling will need to carefully analyse the source and recipients of the benefits. NEHTA would be well advised to workshop the suggested provider benefits with a range of practitioners as I know few who would see many of the claimed benefits affecting them and many who could foresee much increased cost and time expenses.

A mystifying omission from the potential benefits of secure messaging is the use of such a service for the transmission of Specialist’s Letters. If ever there is a considered reliable document produced regarding a patient it is such letters (much more so than discharge summaries) and priority should be given to their communication. Their omission is another reflection of the lack of a whole-of-health system perspective in the document.

Another concern is that many of the benefits are predicated on a Shared EHR that is not yet being built, is not funded and in the present climate, realistically, never will be. It is mentioned in the document that NEHTA has recently published a “Concept of Operations” document for the SEHR. This document has been under development for over a year and has yet to see the public “light of day”. It would be useful if this were made available as soon as possible to assist in providing comments to NEHTA on the present document.

It is this commentators belief that the key benefits that can be derived from e-Health will occur from the provision of quality information and advice at the point of clinical care. To not focus on the high quality delivery of these services is a major strategic omission from both this report and NEHTA’s overall agenda.

Lastly the following from Section 7.1 is telling. “It is intended to circulate, for comment, a Study findings document outlining the major Study findings prior to completion of the final Study report. In reporting the findings, it is intended to group benefits (and costs) for NEHTA’s current COAG funded initiatives, (foundation services, identifiers and clinical information structure/terminologies) separately from the shared electronic health record benefits.” It may be that NEHTA is hoping to provide the basis of a business case for the SEHR in a form which will be accepted by Government for funding. If so it will be crucial to address the issues raised here. Benefits studies for HealthConnect have been done previously and have been ignored, one can hope maybe this one won’t be ignored but I for one will not be holding my breath.

In summary this project is the wrong project at the wrong time with the wrong scope. What is needed is a National e-Health Strategy and Business Plan (covering the whole Health Sector) based on the modelling of a considered, agreed and realistic implementation approach. The benefits realisation comes after we have decided to invest and implement and want to ensure success.

David.

Small Nits Appendix:

1. Why is the document so badly formatted?

2. Why is the role of the private sector in Health Services Delivery so underplayed?

3. Is the ASTM Clinical Care Record (rather than HL7 CDA) now on the NEHTA agenda?

Enquiring minds would like to know!

Note - the original report is found at:

http://www.nehta.gov.au/component/option,com_docman/task,cat_view/gid,141/Itemid,139/

D.