Australian E-Health Policy – Is NEHTA’s Board Steering in the Right Direction?

On the 30th January 2007 The Australian published a long article entitled “ Doing the numbers on e-health” by Karen Dearne which was described as the “world according to Dr Ian Reinecke” CEO of the National E-Health Transition Authority (NEHTA).

It seems to me that a sensible way to approach the article is to endeavour to distil what was being said or implied and to offer commentary on that basis. As the comments were made by the NEHTA CEO it seems fair to assume he is accurately reflecting the views and understanding of the NEHTA Board and it is my plan to address the apparent policy directions and choices being made by that Board, based on the position reflected in the comments documented in the Australian.

First it was obvious throughout the interview that NEHTA has no sense of urgency about advancing the e-health agenda. We are told that the business case for the National Shared Electronic Health Record (SEHR) may be ready for Council of Australian Governments (COAG) in 2007 (or if not 2007, hopefully 2008) although it was not clear, even if ready, whether it could actually make it onto COAG's agenda. Elsewhere we are told that (presumably) after approval has been given it will take three years (at least) to develop before it can be progressively implemented (over how long is not specified). What this says is that implementation may start in 2011 at the earliest and then proceed at presumably an equally relaxed pace.

Given Australia has been working on a variety of Shared EHR proposals since a House of Representatives Report in 1997 it is just flabbergasting that it can take a decade to get to the stage of developing a business case for e-Health which is yet to be completed or released. (The UK, the US and Canada did this years ago.) Worse it seems they are then prepared to wait another un-specified number of years to actually begin to deliver benefits in terms of patient safety and the quality of care – to say nothing of health sector efficiency. We know from studies overseas the opportunity costs of not implementing Health IT are billions of dollars in benefits forgone per annum (Canada thinks about six billion per annum in their country, which is similar in size to Australia) but it seems clear the NEHTA Board is content to just ignore such costs and proceed at the current leisurely pace. NEHTA itself, in documents published almost a year ago, has shown it understands this opportunity cost – so where is the action?

The lack of urgency with which NEHTA is proceeding becomes even clearer when it is recognised that responsibility for development of the SEHR was passed to NEHTA from the Commonwealth Health Department in April 2005. What progress has been made since then has not been obvious to this observer. Very little - is likely to be the answer given the interview comment like “A lot of that detail will start to move into the public domain, and (the SEHR) will be the subject of intensive work over the next 12 months”.

Second we are told by Dr Reinecke that “My understanding is that the access card will operate quite separately from the healthcare identifier. At this point there's really no place where the projects intersect.”

Just how can this be right?. The Access Card is going to allocate an identifier for use in the access of Health Services - how then can it be that this doesn't intersect with the identifier NEHTA plans to allocate for use in the Health Sector? If this proceeds all it means is that essentially every user of the Health Sector will have two identifiers on their health records – one from Minister Ian Campbell and one from NEHTA. I wonder does the Board understand just how bizarre and potentially wasteful this is?

Worse than that, the NEHTA identifier is likely to be the less robust of the two and yet it is the one that is intended to assure reliable linkage of health records rather than the much more carefully verified Access Card identifier!

Even more difficult to follow is that NEHTA thinks it can provide a health identifier for $15 million a year over three years ($45 million) and the Access Card project is costed at over $1.1 billion over about four years. Someone surely has their costings badly wrong?

Third we are told that it is NEHTA's preference to change the law so they can mine the most reliable of the Medicare client databases for names and addresses to populate their identity database.

I wonder what Professor Alan Fels of the Access Card Privacy Task Force and Ms Karen Curtis of the Commonwealth Privacy Commission would think of this proposal to covertly, and without consent, mine a Medicare database for details provided by citizens in good faith. My suspicion is that they would be gravely concerned. The Board should certainly make sure they are consulted (if it hasn’t) before any more money is spent.

Last we learn that NEHTA is confident the Standards it needs will be ready and that great progress is being made. This is true to the extent that we see the emergence of pragmatism and a sense of urgency in the US and also work in the UK to simplify implementation of HL7 V3.0. While progress is being made at a good pace on the Healthcare Services Specification Project Overview (a collaboration between HL7 and OMG) this work is unlikely to be ready for “prime-time” anytime soon.

It should be remembered that when NEHTA was conceived its job was to *quickly* choose amongst the available (and evaluated) standards - now it is trying to write the standards, which will probably take a decade to agree upon and even longer to generate the evidence that says they actually work. The much lower risk profile for using proven currently working standards versus scrapping them for their obvious defects (they will have these, by definition, of course) and going for long term high risk standards development has never been discussed, nor acknowledged. It is a fundamental shift in NEHTA's program, and seems to almost have happened by accident. Yet it is a profound shift. For this to happen without anyone worrying about it, seems to show an apparent loss of control on the part of the Board in its oversight of NEHTA’s direction.

Without rehearsing again all the other matters I have raised over the last month or two it seems to me that the NEHTA Board has not demonstrated (after two years) it is up to the task of providing National E-Health Leadership and delivering the required oversight to NEHTA. If NEHTA’s CEO reflects the Board’s priorities and views accurately, and I am sure he does, it is my opinion that, on the public evidence to hand, the Board is strategically inept, ill-informed, technically out of its depth, out of touch with the e-health community and stakeholders and their requirements and simply inadequate to the task.

It would be of value to the whole E-Health domain in Australia if the NEHTA Board was to produce a paper documenting their understanding of the issues raised herein and their proposed strategic action plan to address them.

I would also suggest a lot of the problems we now see are related to the loss of the Australian Health Information Council (AHIC) and its role in providing technical and strategic governance of NEHTA. AHIC is apparently to be re-constituted in the next few months (after a two year hiatus) but unless it is properly constituted, resourced and empowered this may be more of a hindrance than a help. We will see.

What I was hoping to hear, and didn’t, was that work on a National E-Health Strategy was well underway and that calls from a large number of stakeholders for improved pragmatism, responsiveness, transparency and consultation from NEHTA’s stakeholders and customers were being taken seriously and actioned. I would also have liked to hear that NEHTA was going to push for rapid progress in implementation of the Health IT applications and approaches that are known to work in saving lives and improving efficiency while pursing its long term R&D agenda. No such luck it seems!

The E-Health Domain is one area where a Commonwealth takeover and Commonwealth leadership is to be welcomed!

David.