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Tuesday, November 28, 2006

Questions for Minister Abbott to Ask – How to Decide whether to Continue NEHTA.

An article by Julian Bajkowski of The Australian Financial Review on the 28th Nov 2006 suggests that the AMA is seeking to have Health Minister Tony Abbott to create legally enforceable standards that govern the sale and use of electronic health systems.

Quoting an AMA position paper obtained by The Australian Financial Review we are told that medical practitioners remain deeply concerned about various state electronic health initiatives. We are also told the AMA fears the plans, if not properly governed, will recreate rail gauge incompatibilities - various state health systems will be unable to share critical patient data at a clinical level.

This will come as no shock to any reader of this blog who will be aware that for the last eight months I have been suggesting there is a critical pressing need for the development of a consensus based National E-Health Plan, Business Case and Implementation Plan. The AMA is dead right that nationally E-Health is in one serious hole and urgent action is required to correct the situation.

As my manifesto of last Friday made clear I hope we can lift from the present rather messy base. To quote

“My view is that right now there is a lot of unfocussed, uncoordinated activity going on (some good and some bad) and that it is the time to take a step back, work out, at a national level, what is needed and how best to get there. As a nation in 2000/1 we had some good ideas with HealthConnect but we then lost the plot and momentum by early 2005. We can’t afford another wasted four years.

In the blog I hope to alert and warn where I see mistakes being made and lessons we should already have learnt being repeated. Hopefully the assumptions above will point to those things which need to be assured before investments are made.

Overall I am hoping to foster the change from a heard of cats to a sleek shoal of fish all swimming towards real, practical and achievable goals.”

The article also goes on to say – as its second main point – that the continuing funding of NEHTA beyond 2008/09 is now under review by the Health Minister. This review is timely as NEHTA has now been operational for a decent period. As I stated previously “My view is that unless there are some really useful and practical outcomes within the next six months (i.e. NEHTA having been in action for just on three years (Authorised by COAG July 2004) serious questions will start being asked. The opportunity cost of all this inactivity is really astronomical in terms of patient suffering and lives lost.”

Before continuing funding there are a number of questions I suggest Mr Abbot should ask:

1. Has NEHTA developed and articulated the consensus based National E-Health Plan, Business Case and Implementation Plan which is needed to frame all other E-Health activity and investment? If not, why not?

2. With the effective gutting of both the E-Health Implementation Branch of DoHA and the Australian Health Information Council (AHIC) should NEHTA have been more aware of the strategic gap at the core of Australian E-Health an moved promptly to address this gap?

3. Have NEHTA’s interventions and work products contributed positively to the development of the E-Health industry in Australia through the provision of clear, usable advice and technical frameworks?

4. Have clinical users of E-Health system seen a perceptible improvement in the quality and availability of satisfactory systems which interoperate and also allow for the smooth and reliable communication of clinical information?

5. Has the agenda of improving Clinical Decision Support within E-Health Systems to assist with the quality and safety of patient care seen a significant advance since NEHTA’s inception?

6. Has access to critical clinical information in life-saving and emergent situations been improved in the last 2-3 years under NEHTA’s guidance?

7. Is the present governance of NEHTA with a CEO level board and advisory committees whose membership is not made public the right way to manage a critical national effort such as the National E-Health Agenda?

8. Has NEHTA’s cross jurisdictional nature lead to a much improved alignment of the E-Health initiatives in each of the States and Territories?

9. Are the stakeholders who are involved in the delivery of E-Health products and services finding it easier or harder to make progress with NEHTA’s presence in the arena?

10. Is the value obtained for the investment in NEHTA becoming clear to the extent that funding should be continued or is a major strategic re-assessment required?

11. Should Australia have both NEHTA and Standards Australia involved in E-Health Standards setting or should this role be clearly placed in one place of the other?

12. Is it realistic for NEHTA to continue to work on a National Shared EHR when the financial, technical and human aspects of such a project remain so uncertain and problematic?

13. Why is it that NEHTA has not addressed the issues around clinical software quality and certification despite significant clinical and industry concern that guidance is important and needs careful consideration?

14. Does NEHTA have adequate clinical input given its technical importance to the health system?

It seems to me that unless most of these questions can be confidently answered in the affirmative by the Minister then a serious strategic review is virtually mandatory.

The more astute reader may notice that the emphasis in the list above is on strategic rather than technical issues. This actually offers the Minister another approach. He could formally re-constitute AHIC and provide it with a strategically trained and aware E-Health secretariat and have NEHTA then change its role to a technical delivery arm for the AHIC strategy. This would be a very, smart choice. To leave things the way they are would not be.



Teki said...

A select group of six key people could seal NEHTA's future over tea at Kirribilli. John Howard (for his constituents in Bennelong), his favourite outsourcing consultant, Tony Abbott (for informed choice), Peter Costello (for the private health industry), John Horvath (CMO, for the medical lobby) and Diana Horvath (for Dr Death's victims).

"4. Have clinical users of E-Health system seen a perceptible improvement in the quality and availability of satisfactory systems which interoperate and also allow for the smooth and reliable communication of clinical information?"

Er, does Medical Director interoperate with anything of a clinical nature? (Health trial stalled)

I blame Labor for the state of Health IT. If they'd run their Medicare Gold policy properly, a lot of good, focused discussion would have allowed construction of the essential concepts. They are still running scared, for all I can see.

Aus HIT Man said...

Er teki,

I think you need to explain how Labor is to be blamed after having been out of office for over a decade?


Teki said...

By way of explanation, David, it's quite simple if we accept that a decent national Health IT system needs the national government's investment of resources, willpower and moral support.

As to Labor being a party to this end only one observation is required. The 30% PHI rebate props up Tory ambitions for a two-tier health system.

Labor has been in power in the States for the better part of the ten years. So what have State governments been doing? Let's accept there is a horrible legacy of mish-mashed IT, but put a question on the grounds that the States are actually motivated to do anything about it. "When the Health IT people from the States and NZ get together, what do they agree are the Top Ten issues?" If they have asked themslves, and agreed on aims, where is the list?

Sure, the Howard government is responsible, but we know they are driven to find market-based solutions to all services. As much as they lie about wanting to preserve Medicare, we know what's in their miserable hearts regarding the concept of universal health care. The only alternatives will be espoused by a credible Opposition.

The way out of the Health IT mess is very much in the hands of Labor. To keep half sane, I am looking in only a couple of directions.

1. ALP leadership. Either Beazley will regain the support of his entire team (despite persisting with two hollow men, Sercombe and O'Connor, on his front bench) and grow into the public's confidence over next year, or he will crash and burn at the next silly slip-up. Labor has to find out very soon what Peter Beattie is thinking. Beattie has the Bundaberg scandal fresh in his mind, and has the inside from two very good enquiries. He knows whether he could make a run next year, by handing over to Bligh and stepping through a by-election, in preparation for 2010. Someone like Beattie, a known quantity, in Canberra alongside Beazley would solidify Labor and flush away a lot of the dross. As long as Beazley continues to put up with the appearance of being a solo act, particularly with an unviable deputy, he risks falling a victim to his own weaknesses.

2. The PM chooses the election date. This is the sine qua non of Howardism, and it beats me why Labor doesn't keep a sustained argument for fixed terms. There will be no new direction for Australia unless the reasons are clearly articulated - by Labor, not the Dems and Greens.

David Streeter said...

I don't accept the "rail gauge" analogy of the AMA, it is flawed. Almost all computers now use TCP/IP to communicate.
Barriers to data sharing are usually introduced (or not overcome) by vendors that try to lock their customers into their products.
I agree with teki that the vast bulk of decisions with respect to health IT systems are made by the State governments.
In recent years the State Governments have generally supported a more centralised IT approach which (counter-intuitively) hampers the intercommunication of systems. If you have lots of different systems, then there is incentive to have well-defined and well-implemented protocols to allow them to communicate. If you have one behemoth computer system (the approach favoured so far by the state governments) then there is no incentive for protocols to be established. Look at email programs compared to word processors. Email programs can all communicate to each other fairly well, because there are a lot of different email programs. MS Word, on the other hand, is dominant, and Microsoft actually have an incentive to make newer versions incompatible with older versions!

Aus HIT Man said...

Hi David,

The AMA is saying, and I agree, that its the layers above the TCP/IP that are not well standardised and are posing a real challenge to information sharing and inter-operability.

On the area of state influence I think you may find that the Private Hospital Sector would say they are totally independent and the Aged Care Sector and GPs say the Commonwealth is very influential.

The variation of State Health IT strategies is also a problem in my view. I don't want common systems just improved information flows between the different states.

Part of the problem is the lack of any effective co-ordination and coherent strategy to have these sectors work together.


Aus HIT Man said...

A correspondent has suggested these issues should also be addressed. To quote:

"Some you might consider adding:

1.What ongoing governance for the critical building blocks of patient and provider identification along with medication and clinical terminology services will be in place to ensure on-going free, public domain access and adequate maintenance?

2. Has consideration been given to mechanisms to assist the local health software industry with the change management required to implement these critical systems?

3. If NeHTA does not have a mandate to move the Clinical Decision support agenda forward how should this be addressed?

4. When will federal agencies such as PBS, Medicare Australia, DVA and MBS announce a time line for internal use of the identification and terminology services as agreed at COAG?"

These are also all vital and important questions.


Anonymous said...

(this is david streeter)

Well, the layers above TCP/IP can't be standardised, not if you want systems to improve over time. That's why XML/SOAP is becoming so popular in recent years.

I think the AMA, like most of people in Health IT with no actual computer programming skills, are confusing local technical problems with nation-wide policy problems.

Take a simple example of a patient's name. We tend to think that a person has only one name, but in practice this is far from the truth. A person usually starts life in a hospital computer system as "baby of Jane Doe". They then are usually given a name by their parents. If they are female they may marry and change their surname. Of course, there are even more complications (e.g. Did you know that Malcolm Fraser's first name is John?).

Add to that character set issues e.g.ASCII vs Unicode vs whatever delimiters are needed in the protocol you are using.

Then add to THAT output formatting issues (how a name is formatted to look nice on an envelope) and international issues (in Malaysia a person's family name comes second and any aliases may form part of the name e.g "David Liew Choon Hee @ Yousef bin Abdullah" is a the way a name is formatted in Malaysia, while we would format it "Yousef bin Abdullah (formerly David Choon Hee Liew)"

So then your system wants to talk to another computer system. The other system might accept your registrations, but what names are you going to send? At what point will it decide that it is a duplicate registration? Will it search on all previous names as well as current ones?

Now the common sense approach is to get the data manager of the each system, plus the relevant computer programmer of each system together in a room and nut it out. Four people and maybe a day's work, if that.

What actually happens is that the problem is mistaken for a "patient identity policy" problem, and the group that actually makes the decision is about five levels of management higher than the four people that have to implement the solution, none of whom are invited to the meetings. Six months of meetings and maybe a consultant or two later, a document is produced that details in excruciating detail how to send and match names.

Needless to say, this document is in English, and nowhere near rigorous enough to actually code against - how could it be? It's written by a group of doctors, ex-nurses and accountants (if you are very lucky, you might have an ex-scientist in there with a smattering of actual programming skills). So ultimately the four people I mentioned above toss the document aside and spend a day getting the interface working. Probably for free out of hours, because all the money has been spent on consultants for the high level decision making group.

Aus HIT Man said...


I think it is important to distinguish between standardization of messaging, messaging content and EHR's (or whatever you want to call the clinical information repositories.)

It seems to me HL7 and CEN/ISO 13606 are working along quite well on much of this in the messaging area. SNOMED and others are also adding to the computability and usability of data flows and content.

I do agree that there is more work to do in the inter-operation domain and that some of the already developed standards may have some gaps which need to be addressed.