Health IT – What is in the Way of Progress?

In the last few weeks I have been ruminating on what is in the way, and what are the roadblocks, to improved Health IT deployment and use in Australia.

There is no doubt that this is a multi-factorial issue that involves human, technical and financial aspects. If we consider the current situation there are some clear facts.

1. It is possible to build, deploy and have used computer systems that can assist with the operations, efficiency, safety and quality of hospitals. Suitable systems both from here and overseas are available to suit most of the patient management, clinical and administrative operations of both small, medium and large hospitals. The same can also be said systems to operate diagnostic laboratory and imaging services.

2. The same is true in the provision of support for General Practice and Specialist Office Practice with the market beginning to mature and evidence of significant contestability of system selection emerging. (Medical Director’s market share is no longer more than 2/3 of the market with IBA, Genie and Best Practice making some headway). Recent changes in the Commonwealth Practice Incentive Program is also ensuring more of the available functionality is actually being used.

3. Messaging of pathology and radiology results is being widely deployed via a number of providers (Argus, Medical Objects, HealthLink, Promedicus etc). Referrals to specialists are also gradually beginning to happen electronically – albeit as yet in pretty un-standardised form by and large. At present there is a great deal of prescription printing but very little, if any, in the way of prescription transmission electronically.

4. There has been considerable investment on development of a range of Standards which have facilitated the communication of pathology results at the individual test level using HL7 V2 which has made these results more usable. At present, however, a majority of results are still transmitted using the PIT format.

All this is very positive and if there could be near to complete penetration of these technologies where ever they are needed it would be a major public good.

Consideration of what has been achieved and what is known to work today leads to a recognition of there being a range of gaps.

First messaging of useful clinical content in computable, as opposed to “blob” forms is yet to be developed and needs to be as a priority.

Second the information held in many systems (both Ambulatory and Hospital) is held in forms which are not easily transferred between competing systems (leading to a level of ‘vendor lock in’) Indeed some vendors even encrypt information and them refuse to provide access keys without payment of maintenance fees – a most cynical exercise indeed.

Third the data, information and terminological standards to enable more that be most basic system inter-operation are still under development or unproven.

Fourth there is a very complex and highly contested debate about how information should be stored, versioned and structured within the EHR. Both the openEHR Foundation and HL7 have spent a very long time working in this area – especially trying to work out how to preserve the clinical meaning of patient information as it is moved from one computer system to another – and it is by no means clear if either have a practical and workable solution to the problem. This issue is in turn causing some difficulties as far as the finalisation of CEN/ISO 13606 (EHRCom) standard for the transmission and receipt of extracts of patient clinical records.

Fifth Australia’s full deployment of SNOMED CT is still years off given the need for localised subsets and other necessary enabling add-ons.

Australia at present has also not decided on the approaches it will use for clinical documents sharing in more general messages and in the shared EHR environment (CDA RII, plain XML and the CCR are all possible candidates among others I understand).

What is common in all the areas that are outstanding as not yet being easily soluble?

I would like to suggest that moving to the next level of information sharing and interoperation is an order of magnitude more complex than what has so far been achieved and that the standardisation and ontological issues that need resolution for confident forward investment to be made are not easily resolvable and may take many years of further effort for resolution and clarity to be achieved. If it were easy it would have been done by now!

My discussions with those close to and my readings of a range of sources from the key camps involved in these efforts (and in the harmonisation efforts) admit to very considerable levels of difficulty in defining a way forward – especially if consensus is to be reached. There are many strong opinions and a lot of conviction around forward paths which may not be easily harmonised.

It seems to me that this situation argues strongly for focus and investment on those things that are proven and known to work while there is continued (but lesser) investment in attempts to solve the five and ten year problems.

There is plenty to do to get the basics in place, develop the privacy and other necessary policy infrastructures and get some simple generalised messaging in place (covering referral, discharges and prescriptions) while waiting for the much more complex issues to be sorted by those capable of really ‘deep thought’.

I would suggest NEHTA would be better of sponsoring a set of proven basics as a major part of its forward work plan rather than the current laudable, but risky, push towards a form of health informatics nirvana which may prove essentially unreachable. If neither HL7 or openEHR have fully implemented scalable demonstration systems after a decade or more of development how much longer are we to wait on trust?

David.