Quote Of The Year

Timeless Quotes - Sadly The Late Paul Shetler - "Its not Your Health Record it's a Government Record Of Your Health Information"


H. L. Mencken - "For every complex problem there is an answer that is clear, simple, and wrong."

Monday, March 05, 2007

Why Should Commonwealth e-Health Executives be having Sleepless Nights?

NEHTA gave a presentation at the 9th Annual AFR Health Congress last week. This presentation confirms my worst fears. From the presentation it is now clear that fantasy and wishful thinking have replaced any rationality that may have once been evident.

I am now able to confidently declare the NEHTA experiment to be a dangerous, destructive (of many committed professionals in the area) and expensive failure, and I am confident it will soon become a 'career limiting' blot on the resumes of many of those involved.

It cannot be too long before the Minister is forced to intervene and try and rescue some of the worthwhile cargo from the sinking ship. How can I be sure? Let me provide the evidence.

Let's start with the title of the presentation “Accelerating e-Health in Australia”. This is hardly true – we are told in the presentation that the time frame for benefits realisation is 10 years and that current implementation plans for the most basic of services will take at least 3-4 years from now.

NEHTA claims to be managing four major projects. Let us consider each in turn

1. Benefits – Seeking to identify the greatest benefits for least cost, in the shortest time, with least risk

Great words but from where will the benefits come?

We are told the benefits will come from (presumed enhancements in):

“Safety –reduced incidence & severity of injury
Effectiveness –avoiding under-use, misuse & over-use
Patient-centeredness -supports continuity of care & patient self-management
Timelines –reducing queues, overcrowding, harmful delays
Efficiency –avoiding waste in equipment, supplies, resources
Equity –in location, socioeconomic status, ethnicity & gender”

What we are not told is ‘the how’. What systems, doing what, used by whom, paid for by whom, with what functionality and so on will yield this bounty?

The benefits are said to be coming from improvements in pharmacy, hospital and general practice processes, messaging efficiency and clinical decision support. How much more generic could one be. Of course if you put quality systems in to support these activities there will probably be benefits.

Work like this was done over five years ago in the US, UK and Canada and it was done better and provided much more detail regarding the systems required, the dependencies and the scale of investment required.

Furthermore the brightly coloured graphs provided are completely meaningless as they lack any scales, values or axes. I would suggest that benefits claimed without any quantification (or even estimates) are hardly real believable benefits. Where, one asks, is the information to support these slides – secret I suppose yet again – or does it actually exist?

Without this information what we have is a claim for benefits derived from systems we don't presently have and at present do not seem to have any plans (or funds) to purchase. It is fantastic – in the true sense of that word.

The two reasons to undertake benefits studies are to justify investment in Health IT and to assist in the management of benefits realisation during system implementation. What NEHTA provides is wholly inadequate to either task. Without much more detail one is left with the distinct impression no detail exists when it is clear a compelling case for investment can be made and should be made but this must be backed up by substance and free of the motherhood as provided here.

2. Identifiers -Uniquely identifying individuals and healthcare providers across Australia

This project has been overtaken by events. With the decision to implement the Human Services Access Card in April 2006, there should have been an immediate review by NEHTA of the plans earlier (February 2006) for identification management systems, to understand how the Access Card proposal could be best melded with the need for individual identification in the e-health environment before too much time and money were wasted.

This has not happened and any relationship between the two projects is disavowed by NEHTA. This is just silly! The facts are:

(a) The Access Card is intended to identify Health Sector Clients for Medicare Benefits and NEHTA is planning to use Medicare ID data for its Identifier.

(b) Both Projects are allocating citizens an ID number and establishing a data-base of basic demographic information.

(c) The NEHTA identifier will be allocated to citizens without their knowledge or consent and if errors occur the citizen will not have access to correct and view the information held.

(d) The NEHTA identifier is likely to be both less 'robust' and more potentially privacy invasive due to its covert existence.

I suspect NEHTA has been given some money and really wants to spend it – and that the ultimate casualty will be a very angry public when it is realised how they are all essentially being secretly numbered while at the same time having to obtain an access card. Again this seems to me to be 'career limiting' for the responsible bureaucrats if not remedied.

3. Terminologies -Exchanging clinical information electronically, using a common language with consistent terms, descriptions and formats.

This is important work but it is not being delivered at the pace NEHTA promised. It is clear the Australian Medicines Terminology extension of SNOMED CT (the national clinical terminology) is significantly delayed (it was promised for January 2007) and the work released on pathology terminology is, by NEHTA's own admission, not ready for implementation.

Without attributing any blame it is also clear that negotiations to set up the international Standards Development Organisation to manage SNOMED CT is also taking longer than expected. (It was meant to be done late in 2006).

4. Shared EHR (SEHR) -Designing a national system of shared electronic health records for authorised practitioners and consumers.

Work in this area would seem to have slowed to a dawdle with only a two page statement of intent issued in the last twelve months (in August 2006). I suspect those responsible have recognised that a national SEHR is much bigger and more complex than they ever envisaged when they were given the abandoned carcass of the HealthConnect project to resurrect in late 2004.

It is worth noting that the time frame for the review of SEHR Standards was twelve to eighteen months after the development of the original report on February 2006. Since that time very little progress seems to have been made with EN13606 (which is still not approved) and NEHTA has apparently declined the opportunity to further develop HL7 V2.x messaging templates as an interim clinical content transfer approach. Meanwhile there has been significant progress on the HL7 Services front and on CDA R2, CCR and CCD making much of the work done in late 2005 for the report obsolete and urgently in need of re-assessment.

5. The fifth project, which is only partially mentioned in the presentation is the development of Secure Messaging for the Health System and the associated Clinical Data Standards for a number of key messages (Discharge Summaries, Referrals etc).

Here we have the secure message providers (HealthLink, Medical Objects, Argus Connect, Promedicus.net, and others) essentially being forced into going their own ways – based on HL7 V2.x or PIT – and the Clinical Data Standards Project continuing on with work based on HealthConnect’s requirements of 2004/5 whilst essentially ignoring the now internationally standardised alternatives for practical health information sharing. It just gets sillier and more wasteful by the month.

What is to be done?

I think the first thing that is needed are the facts. For that reason, as I have suggested previously, I believe we need a professionally conducted enquiry into e-Health for the last decade to get out in the open all the secret reports and make transparent just what has gone well and what has gone badly. The enquiry should also include a thorough audit of the status quo in regards to NEHTA's activities, work-plans, project management structure(s), budgeting and financial controls. This is particularly important in order to see behind the corporate veil which NEHTA has constructed that enables it to avoid being subjected to the rigours of public accountability.

This enquiry would be like the independent enquires conducted in the UK by the Audit Office or in the US by the Government Accountability Office. It would be hard to argue that such a review is not warranted – even on the basis of the obvious facts that the initial vision of 2000/2001 has not been anywhere near delivered some six years later and to ask why.

Another reason an enquiry is needed is that I would argue we have never tried a real model of an AHIC (clinician and expert led) governing a technical execution arm. This is what I took the Boston Consulting Group report as aiming to set up. What happened is that the Government set up the technology component with largely only technology leadership and then moved it away from direct DoHA control and placed control with a non-expert (in Health IT) board.

To show how far implementation has slipped one only has to return to the April 2004 Boston Consulting Group Report. Three years following the report it was intended that:

“ Connectivity building blocks largely in place

- 'Critical mass' of new interoperable clinical and administrative systems

- Key standards agreed and implemented by authoritative body

- Significant broad band/required infrastructure roll-out across country

- High-system users aware of consent issues and electronic benefits

- Significant numbers of providers have experience of clinical messaging and order entry applications

- Expanded information available for research, policy purposes and administrative uses.”

How close are we now to this happy state? Look closely at what was recommended and compare with what we presently have.

Source: BCG April 2004.

It is only when armed with independently acquired facts that a really rational and workable forward plan can be developed.

For what its worth I believe that essentially the technologically driven 'tail' needs to stop wagging the health sector 'dog'. If the revised Australian Health Information Council (AHIC) had executive authority, a relevant mix of Health and Health IT experts and appropriate funds, it would be the ideal entity to take direct control of the NEHTA agenda and work plan. As this does not seem to be the case an alternative approach is required.

As I see it, the problem is that there really needs to be a holistic strategic and low level integrated approach i.e. all the aspects from identifying the problems, finding approaches and solutions, then doing the actual work [differentiating what should be done by the market and by Government(s)] in a co-ordinated way at the technical, standards and strategic levels.

Having a non-strategic 'tech shop', which operates in a strategic vacuum, and which claims strategic responsibility for Australian E-Health is a real problem - they (the Council of Australian Governments) have created a strategically 'headless chook' and we are now seeing the results.

So NEHTA has become the answer to a question that was not properly framed by the Boston Consulting Group - and this has led, combined with the dismemberment of AHIC, to the dysfunction we now see.

The reason we have gone down this path is that the business case, which should have been acceptable to Government to initiate a reasonable level of investment, was never done (as it was in the US, UK and Canada) and so, without any real investment co-ordination and scale, nothing has happened. And nothing will happen until that changes and this joke of an effort which masquerades as a business case from NEHTA (see the two colour slides) is redone to really get us there. There is good evidence available and this effort does not exploit it at all.

NEHTA does not see the gap between what it is doing and the need to have a real, achievable and immediate impact on health services (which is, I believe, huge).

We need a fully funded strategic e-Health entity which has the role of driving NEHTA down a more health sector focussed role and setting priorities for the whole sector - with a mix of vendor and home developed solutions and an openness to working with industry, academia, clinicians, and others.

It might be possible to add to NEHTA a strategy unit and a decent health sector liaison unit and change the CEO to someone more fitted to the role. The present leadership have shown an absence of strategic nous and health sector understanding and should only continue in operational delivery rather than strategic planning roles.

We also need to get real political accountability back - so heat can be felt and reacted to for the betterment of all! NEHTA really needs to be back under normal public sector management and accountability.

At HIMMS 07 (a few days ago) we had NEHTA deliver a presentation entitled “Successful E - Health Transitions: Australia's E- Health Initiatives”. Given what NEHTA has failed to deliver over the last three years or so, I would hate to know what failure looked like if this is success!

A major strategic change is needed, based on real independent evidence of what is working and what is not, and it can't come soon enough. The bureaucrats who are fond of their jobs really need to get a reality check, and initiate major change of the sort I outline, or suffer a pretty nasty fate once the Minister realises just how badly things have really gone, how many lives have been damaged or worse, and how much money has been wasted.



Anonymous said...

While many more than likely agree with most of your comments few will be prepared to do so in Public for fear of repercussions of one form or another at a political level.

Sad though this may be - it is understandable. Even so, it is to be hoped that the Minister and his bureaucrats are paying more than a little attention even if distracted by the politics prevailing in this election year. It is not beyond the realms of possibility that NEHTA and the whole e-health business could quite easily become tied up with the Access Card debate thus ending up well and truly on the political agenda.

Happy first birthday.

Anonymous said...

It is probably fair to say that the bottom line question which seems to be underpinning most of the aushealthit blogspot commentary which is now coming through loud and clear is something like:-

'What has NEHTA done, or what is NEHTA doing, that can be put to good use (ie used to advantage) by the community of health software vendors - now, not in 10 years time?'

Once we have a precise answer to that question it is to be hoped the way ahead will become clear to all.

Dr David G More MB PhD said...


With respect to the previous comment - close but not a cigar!

The core message is there are a range of e-health initiatives which if implemented today can make a difference to the quality and safety of our health system. It is really only incidental that software vendors may have more to do.

I want a safer, higher quality and more efficient health system and what is going on at present is not getting us there any where quickly enough or with enough urgency or investment!


John Johnston said...

I don’t think the clinical software vendor community will be having sleepless nights. We are too busy reacting to the requirements of the clinicians and patients that use our systems during the day. The challenge that most of us face is prioritising the software development workload within the support revenue and project budgets we have.

Progressive alignment with emerging standards is in side-show ally where we stroll occasionally on the day off. When we take those pleasurable forays we look at the various approaches on display and we make choices based on international developments, Australian efforts that include NEHTA views, and intuition.

There is no doubt that the clinical desktop vendor community sees the value in adopting standards-based approaches. We will all be disappointed if the key deliverables around Person, Product, and Provider Identifiers are not forthcoming from NEHTA. Failing here will mean that there will have been a destructive effect on e-health development in Australia from its formation.

The terminology stuff around SNOMED-CT was already happening before the establishment of NEHTA and most clinical desktop vendors had made some commitment to understanding where and how it needed to be applied in their systems. Where a NEHTA (or a DoHA) can really help is to assist the vendor community have license fee free access to the terminology with some insulation from international courtrooms if we should falter on the implementation journey.

There may be no flaws in NEHTA aspirations. It is the risk around the implementation pathways for clinical desktop vendors, their customers, and particularly the consumer, that needs to be mitigated by a series of implementation experiments with collaborative funding between vendors and government to prove the concepts as we go along.

It’s a pretty obvious strategy isn’t it? ..or have I missed something?