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Tuesday, January 16, 2007

AusHealthIT's First Guest Blogger Article!

After a recent article reflecting on the recent NEHTA release of an outline of the technical specifications for secure messaging I was approached by Mr Tom Bowden, the CEO of HealthLink – asking if he could provide a comment in the form of his view as to a sensible 'roadmap' for secure health messaging in Australia.

I thought this was a very good use of the blog and so readily agreed. The article I have been forwarded is reproduced below.

Before handing over to Tom can I also say that Dr Ian Colclough has also been hard at work and has written a comprehensive comment to the earlier post (8 January, 2007) on “Why Implementation Matters”. I commend this also for your careful review. Just click on the comments tag at the bottom of the article.

With that said – over to Tom Bowden.


A Connected Health Sector
– However Can We Get There From Here? –

Imagine a health sector in which nearly all of a General Practice's clinical and administrative communications are electronic. Doctors provide better patient care and they spend nearly an hour less per day on administration. Cutting through the paper-war makes the profession much more financially rewarding and enjoyable. With a universal communications framework available, the government can readily develop and implement national vaccination and screening systems, prepare for pandemics and possible bio-terrorism and speed up implementation of much-needed sector reforms.

Unfortunately if you are a GP in Australia, imagining the above scenario will be close as you get to achieving it in the near future. Australia's track-record in health sector automation (e-health) is among the worst in the developed world. Using another approach, Holland, New Zealand, and some of the Scandinavian countries have almost entirely connected their primary-care sectors. While they haven't solved every problem known to mankind, their family doctors' routine clinical and administrative communication is now all electronic. For example, in New Zealand a doctor is more than three times as likely to use an electronic service to perform a routine task as his or her Australian counterpart

Why is Australia's health system so substantially lacking in this important respect?

The answer is perhaps not one that you would expect; nevertheless, it is quite a simple one. In countries with well developed communications systems, automation of pathology services has been the initial platform upon which a wide range of electronic services has been built. Because of the large volume of information flowing between general practices and laboratories, automation of pathology messaging provides the best opportunity to initiate electronic communications. Beginning with pathology result delivery, a number of countries, including Holland, Denmark, New Zealand and to a lesser extent Canada have been able to build extremely useful standards-based e-health frameworks. These countries have used the opportunity to learn about and implement standards-based communications systems and to build the capacity of the practice and patient management systems that they link. In Australia however, the major pathology companies developed their own individual non standards-based systems for delivering pathology results.

Unfortunately the emergence of the Pathology Information Transfer (PIT) result delivery format as a de-facto standard has severely hampered adoption of internationally supported messaging standards within the Australian health sector. While Australia has a small number of half-hearted implementations of Health Level Seven (HL7), there has been nothing like the uptake of secure messaging seen in other countries. For instance, we now have a range of incompatible HL7 pathology report delivery implementations; approximately one for each major laboratory group.

By far the majority of results are still delivered using the PIT format. As well as being a proprietary, non standards-based message format, a PIT message is unable to be usefully incorporated within an electronic medical record (EMR). A PIT message can only be displayed in its entirety and stored as an object. By contrast, separate data elements of each HL7 message can potentially be incorporated into the EMR of the recipient, which permits the monitoring and display of trends, alerts the clinician to developing problems and significantly enriches the patient's medical record.

Without a reasonable base-level of standardisation in use in the Australian health sector, there is little opportunity to add further standards-based types of communication. The lack of activity has meant that there is a shortage of expertise in communications standards use and thus great difficulty implementing standards compliant services. Furthermore, Practice Management System applications vendors have gained little or no understanding of how to implement communications related capabilities within their application software and thus build better, more useful systems and richer EMRs that are capable of utilising the incoming clinical data.

The really sad thing is that Australia has already spent huge amounts of effort and money developing many of the standards, support services, systems and capabilities needed to do the job. The basic tools to enable there to be a connected health sector do exist; they are just not being used properly.

Unfortunately, instead of drawing upon and utilising pre-existing effort, the National e-Health Transition Agency (NEHTA) is using very little of the immense amount of work that was already underway prior to its formation. NEHTA's wish to start with a clean slate is in some ways understandable given some of the structural difficulties that met them. However, based upon the present rate of progress, it is likely to be some years before we see any implementable results.

Strategic Options

Clearly there has to be a better way of achieving useful results, so let us look at the broad strategic options. Around the world the health sector connectivity issue is being tackled using three contrasting approaches;

1. Implement a nationally funded state-run infrastructure, as is happening in the United Kingdom. This is typically expensive, slow and controversial as a nationally implemented 'one size fits all' communications system is imposed upon the sector.

2. Take a hands off approach, fund development of a few standards and hope that the sector will work together to make things happen. This has been the approach used in the Australian health sector for the past twelve years, since the commencement of electronic communications here. Judging by the results, it has clearly failed and should be discontinued. This approach provides too much opportunity for interested parties to drive the agenda to meet their own individual profit objectives, rather than strive for the good of the sector as a whole.

3. Work in partnership with specialised system integrators and service providers to implement international standards and champion the cause of connectivity. This is the approach that has worked very successfully in Scandinavia and New Zealand where small, specialised service organisations are given government backing and modest financial incentives to ensure that automation actually occurs.

Option Three is the approach most likely to succeed. Highly effective sector integration of the kind enjoyed by other countries will occur when a clear course of action is agreed upon and the task given to organisations whose success is based upon achievement of successful integration outcomes.

Action Is Urgently Needed

To get results I believe NEHTA needs to:

1. Recognise and involve sector participants.

Foster the establishment of an integration community. Encourage the participation of sector players in whose interest it is to make the transition from paper-based to electronic processes, such as Divisions of General Practice, specialised system integrators, practice management system vendors, and industry associations. All of these parties need to work together - not be kept at arms length - to get results.

2. Implement what we already have, properly.

Properly implement existing core HL7 messaging standards (AS 4700.2 and AS4700.6). These are the core messaging standards required to automate 40-60% of all general practice messaging. These internationally recognised, proven standards presently exist in Australia, but they are not properly implemented. The current quality of integration poses significant risks to patients. Industry bodies should be encouraged to demand fully certified implementation.

3. Define ONE standard for each purpose and rigorously enforce it.

Ensure rigorous policing of standardisation to prevent proliferation of different non-standard formats. The Australian Healthcare Messaging Laboratory (AHML) exists to certify all messages. All software organisations and industry players should be required to obtain AHML certification. Immediately, AHML should lead the process of making all laboratories use a common implementation of HL7 (AS 4700.2).

4. (Re)Engage and fully support a single national authentication framework.

Agree upon and implement an easy to use, dependable national authentication framework. This is critical for success. The Australian Health e-Signature Authority (HESA) was set up specifically for this purpose; NEHTA has however not embraced what HESA has done. HESA has since been merged with Medicare Australia. Further work needs to be done with HESA to ensure that the HESA certificates etc are easier to implement and support. (Much has already been done to improve the usability of HESA certificates but this work has since been mothballed.)

5. Tie payment to certified use of standards.

Tie funding policy to the communications strategy. It is important that the payment incentives to all health sector players, especially GPs, hospitals and laboratories, are tied to certified use of communications and security standards. International experience shows that tying payment of incentives to outcomes is an extremely successful way of implementing new communication systems.

6. Focus on achieving simple and measurable steps in the context of a practical, consultative National e-Health Plan.

Ensure that we succeed in walking before we try to run. Beginning with simple readily implementable formats and standards that will deliver day-to-day benefits is key to building momentum. In the health IT integration business success breeds success.

7. Set ambitious but achievable targets and ensure they are met.

Tackle the project in a down-to-earth, business-like manner. Set aggressive adoption targets. Reward participants for hitting milestones with incentive payments, tax-breaks or whatever else will motivate them. Provide disincentives to parties that are dragging the chain.


It's all about setting firm, clear targets and providing the leadership - and incentives - to ensure that targets are met.

At present a number of key influencers have a clear incentive to maintain control of proprietary communications frameworks and thus protect their referral streams and income.

To get real results, this must be turned around. Those parties who can and will help the sector make the transition from paper-based to electronic communications should be supported and where appropriate provided with incentives to do so.

Those who stand in the way of true sector integration need to be reined in and either provided with incentives to change, or prevented from continuing to obstruct progress.

Swift, decisive action in line with the above recommended steps could see Australian GPs, the wider health sector and ultimately the Australian public enjoying the benefits of proper health sector automation within 3 to 6 months.

Let's do what we can to make that happen.

Statement re Potential Conflict of Interest

Tom Bowden is CEO of HealthLink Ltd, an integration services provider operating in Australia, New Zealand and Canada.


laurent said...

It is interesting to note that many of Tom's points were actually implemented as part of Medicare Australia's strategy for HIC ONLINE & ECLIPSE deployment. While these initiatives have also been criticised (rightly or wrongly), they actually have achieved demonstrable implementation and successful take-up . Without delving in the technical merits of their implementation and the lack of international standard, the incentive and industry partnership programs worked.

Rene said...

I agree that option 3 has been crucial in the success of the infrastructures in Scandinavia and Holland. However, incentives for the participating healthcare providers play a crucial role as well, see my column on this topic.