Guest Article II - Supporting Diversity in Views.

Today's guest article is from a frequent commenter who asked for a little more space to present his views. Others are welcome to also ask for space!

Short Biography of Our Guest.

Dr.Ian Colclough has over 30 years experience in medical informatics in a career spanning medical practice, hospital administration and strategic and tactical sales and marketing in the corporate sector in Australia, South Africa and the United Kingdom. He has been involved in the research, development and design of hospital administration and departmental clinical systems, medical practice systems, the computerised medical record, patient profile systems and occupational health and safety systems.

Secure Health Messaging - Where to tomorrow?
An independent commentary on “A Connected Health Sector”.

That 'sensible' Roadmap

Tom Bowden touches on some very important points when presenting what he describes as “a sensible ‘roadmap’ for secure health messaging in Australia”.[1]

His arguments have merit and bear careful consideration. Is it a sensible roadmap? If yes – why has no-one come up with it earlier? If no – we need to know why it is not sensible. This is the sort of question NEHTA has been established to answer.

In posing his question - “However Can We Get to A Connected Health Sector from where we are today? ” - Tom echoes a presentation given by Ian Reinecke at the Health-e-Nation Conference in 2005: “e-Health – Getting There from Here”. Ian said that the new company (NEHTA) “will provide the critical standards and infrastructure required to support connectivity and interoperability of electronic health information systems across Australia”. How far have we travelled along that road?

The Pathology Sector

Many will argue strongly with Tom's view that “Australia's track-record in health sector automation (e-health) is among the worst in the developed world” [1]! Few, however will differ with his claim that the way to speed up implementation of much-needed health sector reforms is to put in place a universal communications framework. This is predicated on the proviso that the framework is independent of any one messaging vendor and accessible by all.

He asks “why Australia's health system (is) so substantially lacking in connecting its primary care sectors by comparison with Holland, New Zealand, and some of the Scandinavian countries” [1].In seeking the answer he points to the Pathology sector as offering the most expedient way forward.

Pathology laboratories are high-volume transaction-based entities totally dependent on sophisticated computer software systems to manage their large complex enterprises. In the 1970’s they were at the forefront of health care computing and over the last three decades they have continued to invest heavily in deploying ICT to deliver efficiencies and drive down costs.

Significant rationalisation of this sector occurred throughout the 1990’s. This led to the emergence of a small number of very large pathology providers such as Sonic, Healthscope and Symbion. Also, around 1992-1993 a small group of Australian laboratories collaborated to develop a way to deliver pathology reports by e-mail using standard print-file formats. This led to development of the Pathology Information Transfer (PIT) messaging format as an expedient way to solve the immediate problem at hand.

Pathology Information Transfer

PIT has served the pathology sector well to-date. It has however not been adopted elsewhere outside of Australia. Other countries have adopted either HL7 or some other alternative, such as EDIFACT which is used widely in Scandinavian countries. This has left Australia hostage to its own solution; one which developed locally through necessity and which, through its widespread adoption, ultimately became a de-facto standard throughout Australia.

Within this context Tom makes the point that the PIT message is “unable to be usefully incorporated within an electronic medical record” [1] (EMR) as it can only be displayed in its entirety and stored as an object. This means that, unlike an HL7 message, the PIT message cannot be broken down into separate data elements which can each be incorporated into the EMR. Hence PIT messages do not easily allow for follow-up recalls, the monitoring and display of trends using graphs and bar chats, and large scale epidemiological and other population-based research studies.

Clearly the widespread use of PIT as a de-facto Australian standard has ‘severely hampered adoption of internationally supported messaging standards within the Australian health sector”
[1].

The vendor community would agree that the best opportunity to initiate the adoption of widespread electronic communications throughout the Primary and Secondary care sectors is to drive into place as quickly as possible the deployment of automated secure messaging (based on internationally accepted standards) between pathology centres (and radiology) and their medical practice clients.

The argument for the immediate adoption and standardisation of HL7-based messaging is well founded and should receive widespread support.

HL7 Messaging Standards

In passing, it is important to note that the National E-Health Transition Authority (NEHTA) has stated that pathology providers “have indicated support for the open, web service standards (which) NEHTA has proposed and that they (the pathology providers) understand the benefits they would bring in a contestable market.” [2] That having been said however NEHTA has also noted that pathology providers “perceive a business imperative to address the issues arising from the current market situation” … and more importantly … “they are considering creating a message environment that will still form barriers to cross-sector connectivity and interoperability[2].”!

Regardless of whether they have a vested interest in maintaining the status quo or not the pathology service providers need to accept that PIT's days are over. They should move on without further delay. How might this be achieved? Should it be left to market forces alone to address, or to the State and Federal Governments, or to NEHTA? Or should the vendor community together with their clients, the pathology providers, drive the changeover? Ideally, Government should provide appropriate support to the vendor community to enable them to 'assist' their clients to make the change.

There is a further point about PIT which needs to be borne in mind. Part of its attraction could be that the reporting pathologist is legally liable for the content and accuracy of the pathology report. By sending information in the PIT format the pathologist has taken all legally necessary and reasonable steps to ensure the results in the report cannot be altered. (Just like an Acrobat .PDF file.) At the medical practice end the report is simply attached to the patient record as a document.

When dispatching HL7 format results, the reporting pathologist needs to be satisfied that the atomic data that will populate the patient clinical record, at the medical practice, is similarly protected. This requires some additional software complexity at the medical practice end to ensure that these results cannot be altered. The associated complexities of cross-mapping the incoming results definitions to those of the clinical desktop system also need to be addressed.

Nevertheless, HL7 V2.3.1 is the method of choice for transmitting pathology messages. There are sufficient numbers of organisations and people well versed in HL7 in Australia today to drive HL7 standards based solutions into place. The changeover to HL7 will be a formidable exercise given that the majority of pathology results being delivered today use the proprietary, non-standards-based, PIT message format. To bring this change about will require astute enlightened leadership underpinned by some very sophisticated strategies and a finely-honed understanding of all parties that will be impacted by the change and the obstacles and issues that will be encountered. The key to the solution lies in the strategies required to effect the change and the political will to bring it about. Careful analysis of the problem reveals that it can be resolved reasonably quickly.

Tom is not alone in expressing the thoughts of many in the vendor community when he says, “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” …. and … “that the basic tools to enable there to be a connected health sector do exist; they are just not being used properly. [1]”

He observes that “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” …. and that …. “based upon the present rate of progress it is likely to be some years before we see any implementable results. [1]”

Standards can be so contentious

The standards argument is divisive and very complex. Yet, all would agree that work on developing standards and resolving the many conflicts and issues involved is very important. The unresolved issues however should not be permitted to impede the development of interoperability between software vendors. Nor should they be permitted to impede the step-by-step resolution of problems encountered in building an integrated, shared, longitudinal Electronic Health Record (EHR) for widespread use across all health sectors. [3]

On this subject David More presents a well reasoned view in his recent blog on Archetypes and Standards 4. He points to the "considerable successes achieved in the Health Sector with messaging technologies including EDIFACT and HL7 V2.x.". He also notes that "to-date - in the messaging arena - HL7 V3.0 and EN13606 are still in the process of development and tools and implementations are by no means common.[4]"

In terms of the ‘clinical data’ to be transmitted, it is clear from his discussion that much of the work based around standardising ways of storing and retrieving the atomic elements of information required to populate the EHR over a patient's lifetime is still in its infancy and evolving slowly.

It should be apparent that NEHTA has a major R&D role to play in the years ahead. That being the case the marketplace cannot and should not be made to wait until NEHTA has completed its deliberations on the many complex and elusive issues which it is trying to solve. Rather, the Government's and Health Departments should embrace David's call for a dual approach. One which supports "appropriate and promising R&D" ……. "blended with dramatically more energetic investment and deployment of systems which are already known to work and for which evidence as to their value is quite unarguable" [4].

Engaging 'the' stakeholders

NEHTA was established to drive forward critical e-health initiatives. Its governance is under a Board of Directors made up of CEOs from the Health Departments of the Federal, State and Territory jurisdictions across Australia.

The jurisdictions provide NEHTA's funding. As a consequence they are stakeholders and also NEHTA's only shareholders. However, they are not the only stakeholders to be impacted by NEHTA's work; far from it. The IT vendor community, medical, pharmacy and allied health care practices, hospitals, nursing homes, aged care and community health centres, and others, have a major vested interest as stakeholders in NEHTA's outcomes.

NEHTA's governing stakeholders are predominantly driven by imperatives arising from the highly politically sensitive public hospital (tertiary) sector. Yet, in many ways NEHTA has more to offer the Primary and Secondary care sectors than the Tertiary hospital sector. Hence, the absence of Primary and Secondary care sector stakeholder representation and influence at the highest level of NEHTA's governance is disconcerting; more so, should the immediate e-health needs of the Primary and Secondary care sectors become bogged down by the complex web of e-health and ICT related issues and politics so prevalent in the Tertiary care sector.

Fundamentally, the Primary and Secondary care sectors (organisationally, functionally and politically) are quite distinct from the Tertiary (hospital) sector; even more so when it comes to categorising health-ICT vendors into the particular health sector niche which each predominantly services.

A strong case can be made for allocating significant resources to focussing on addressing some of the more immediate e-health needs of the Primary and Secondary sectors separately from the needs of the Tertiary sector. The urgency of this is further reinforced by Ian Reinecke's comment that "we need to be carefully aligned with the powerful players internationally"[5]. Reflecting on this leads one to enquire as to which powerful international players NEHTA may have in mind. Could they be Cerner, Philips, GE Healthcare, and Siemens?

Whoever it may be it seems to indicate that NEHTA has blatantly failed to appreciate that the Primary and Secondary care sectors are not the domain of the powerful international players. Rather, they are serviced, professionally and competently, by a cohort of small, highly skilled, agile, homebred software vendors. Some have made very impressive inroads internationally. Some are at the cutting edge of standards-based implementation projects that test the operability of HL7 V3 and OpenEHR technology as an investment in advancing towards the EHR. They work in a market sector in which the powerful international players have shown little or no interest!

In February 2006, NEHTA discussed the consequences of a “proliferation of incompatible systems and technologies” and it noted that “harnessing the capabilities of software vendors and service providers in the health sector to provide this connectivity will be a key to success” [2]. In light of this the time has come to clearly distinguish between what activities should be classified as R&D and what should be classified as ‘implementable today’.

It is time to reconsider what benefits could flow from drawing upon and utilizing a lot more of that 'pre-existing effort and the skills and expertise' so readily available in the vendor community.

HL7Messaging – What is NEHTA’s view?

In order to achieve widespread standardisation of messages there needs to be a process in place to achieve consistency when implementing standards.

Few would disagree that Australia should “define one standard for each purpose and rigorously enforce it ……… to prevent proliferation of non-standard formats.” [1] The general consensus among industry experts seems to be that Australia should implement HL7 V2.3.1 (AS 4700.2) as the minimum health industry standard.

A strong case can be made for populating medical practice records with discrete results without further delay as opposed to continuing with the PIT format. As this can be achieved using HL7 V2.3.1 and transmitted under control of the HL7 messaging protocol it is clear that HL7 V2.3.1 provides a nationally consistent base from which to move forward building upon what is readily available today.

NEHTA’s view on messaging standards is unclear at this time although it would be enormously beneficial to everyone if it could be clarified quickly.

Australian Health Messaging Laboratory

Tom comments that the Australian Healthcare Messaging Laboratory (AHML) has an important role to play in helping to secure the consistent deployment of HL7 messaging standards by software vendors.

AHML, as part of the Collaborative Centre for eHealth (CCeH) based at the University of Ballarat, is unique in Australia. Having been accredited by the National Association of Testing Authorities (NATA) it has positioned itself to act as an on-line test-bed laboratory for the technical evaluation and certification of electronic messages in healthcare applications being deployed by vendors in more than 30 countries. It is therefore well placed to test for conformance and monitor compliance against Australian and International Standards.

State jurisdictions and the Federal Government have a vested interest in securing AHML's future as the central reference point for HL7 messaging standards[6]. It should not be too problematic to find the funding required for this to happen without undue delay.

This will likely necessitate AHML having to be constituted formally as a Reference Laboratory. Under this arrangement AHML's funding should be derived from a mix of Government support and self-generated revenue. Its staff and management should be focused entirely on the testing, certification and compliance of messages against standards. The Reference Laboratory will need to be seen to operate transparently and impartially, totally devoid of any potential for the development of conflicts which could arise should its management and staff elect to undertake consulting assignments where they may be compromised by competing against vendors whose messaging software is subject to AHML testing.

HL7 V2.3.1 is widely implemented, tried and proven. It offers substantial benefits over PIT and even more importantly, it provides a way for the entire e-health community in Australia to move forward. It is therefore time for a seriously concerted effort to be made to move the pathology sector away from PIT towards the adoption of HL7 V2.3.1 or above. This seems to be a very good way to go for the next few years and it can be done today; delivering enormous benefits with minimal pain by using standards which have a good track record of runs on the board worldwide. An important element in driving the uptake of standards is to implement strategies which will create a dynamic contestable market environment.

Is there a better way?

There has to be a better way to move the e-health agenda forward. Tom lists three strategic options for the way ahead, opting for some form of collaborative partnership in which “small, specialised service organisations are given government backing and modest financial incentives[1]” to achieve sector integration.

In broad principle the concept of a ‘collaborative environment’ has the most likelihood of succeeding. It should be appreciated however that the optimal selection and order of enrollment of ‘participants’ is not a straightforward exercise. It is absolutely imperative that the setting up of a ‘collaborative structure’ (consortium) is done thoroughly and properly at the outset in order to contain risk and ensure the consortium’s longevity and success.

Collaborative consortia are quite complex to construct, more so in the health sector than in most other industries. Building a successful Health-E-ConsortiumTM requires a unique business model and organisational structure. The partners must work in harmony together, where often they are in competition with each other. They must be committed, highly motivated, well led and well rewarded, and they must be prepared to work in an environment which promotes a culture that is based on trust, a concern for each other's profitability, and a mutual commitment to customer satisfaction.

References.

[1.] Bowden T, A Connected Health Sector – However Can We Get There From Here? (16 January 2007) Guest Blogger Article www.aushealthit.blogspot.com

[2.] NEHTA, Towards a Secure Messaging Environment – An E-Health Transition Strategy Version 1.0 – 2/02/2006 For Comment, page 6.

[3.] Colclough I, Comment attached to Implementation Really Matters (8 January 2007) Blogger Article www.aushealthit.blogspot.com

[4.] More D, Archetypes, Standards and All That Jazz - Part 2 (28 January 2007) Blogger Article www.aushealthit.blogspot.com

[5.] Dearne K, Doing the numbers on e-health - the world according to Dr Ian Reinecke, The Australian (30 January 2007) IT Business, page 3.

[6.] Australian Health Messaging Laboratory, Available Test Profiles, accessed 30 January 2007, http://www.ahml.com.au

© Copyright 1 February 2007
Dr Ian Colclough - Integrated Marketing and e-Health Strategies
ihsipl@smartchat.net.au, 0412 059 392

Note: These views are those of our guest commentary provider and should be read as such. This forum is to provide a space for comment and debate and I hope this contribution helps. Thanks Ian.

David.