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Thursday, May 10, 2007

NEHTA Really Gets One Right!

On May 8, 2007 NEHTA released a report entitled “Standards for E-Health Interoperability, An E-Health Transition Strategy Version 1.0 – 08/05/2007”. As someone who has been involved in assisting NEHTA in developing reports in this area in the past, and so has considerable familiarity with the issues and difficulties that surround the area, I must say I am genuinely impressed.

It seems to me the key messages contained in this document are all very robust and sound and should be strongly supported by the e-health community. It would be of much benefit to everyone concerned with the future of e-health in Australia if the vendor community at large and anyone else took a little time to lodge their comments in that regard on this blog site - anonymous or otherwise. I repeat, I am genuinely impressed.

The key messages I draw from the report – in my words - are as follows:

1. Clarity and clear differentiation is required when thinking about and deciding how to approach health messaging and the internal structure of electronic patient records.

2. There is a recognition that e-Health in Australia is going to be largely delivered by commercial off-the-shelf software and that any approach to standardisation of interoperation needs to recognise this fact.

3. NEHTA’s customers (the Australian jurisdictions) are interested in deploying web services approaches and SNOMED CT in future systems, but right now they are wanting to implement and utilise what they already have and to consider such steps in parallel with future upgrades.

4. That Australia does not have sufficient critical mass (too small) to try to be a global standards trend setter given the investments in e-health standardisation that are now occurring in the rest of the developed world. We need to be a contributor and ‘quick learner’.

5. Just as the CEN / ISO EN13606 standard was unfinished and incomplete 18 months ago it remains so today, and with the progress being made by HL7, it is increasingly becoming practically irrelevant.

6. For the present the incumbency of HL7 V2.x messaging should be recognised and supported – and extended where appropriate – while planning commences for ultimate migration to HL7 V3.x when that is assessed as appropriate. There are still some concerns about the technical viability and implementation complexity of V3.x, but with the evolved NHS approach to its use it is highly probable useful results will be obtained in the medium term.

7. The Healthcare Services Specification Project (HSSP) seems to be an initiative with a lot of intellectual and practical fire-power behind it and looks likely to deliver highly useful outcomes over time.

8. Efforts to persuade Health Information System Vendors to change key underpinnings, internal structures and design approaches in their software are likely to be resisted unless a very compelling business case is provided.

9. The report sees no substantive place for openEHR type approaches in Australia’s e-Health future.

10. To have actual full scale implementations before standards are agreed is essentially a sensible approach wherever possible

On the basis of these insights and findings – the following conclusion and recommendation seems both rational and sound:

“On the basis of this assessment, migrating to a Document/Services-Centric HL7 v3 approach was selected as the preferred longer-term direction, complemented by support for continued use of HL7 v2.x and development some limited extensions in the short-to-medium term.”

This clearly defines the long term future as being based on migrating to a document/services-centric approach using HL7v3 CDA R2 and HSSP. (and I presume successors). This is certainly a choice I endorse.

Implicit in all this is a new sense or practicality, pragmatism and a recognition of the reality that actual achievement of goals such as ‘semantic interoperability’ are very much more difficult and complex than may appear even at a third close look – let alone at first glance. This change is to be welcomed heartily.

If I have one problem with the report it is that in deciding not to utilise openEHR it failed to make clear the complexity of openEHR deployment at any substantial scale which I remain convinced is a major problem.

Overall it seems to me this is an excellent review and heads in the right direction.

It seems on this basis we can now adopt some of my other pragmatic suggestions from previous blogs given the place we now, at long last, find ourselves.

Steps might include:

1. A major pragmatic review of the current further standardisation priorities (in conjunction with industry and Standards Australia).

2. A review of how best to get short term improvements into the field ASAP – again in conjunction with industry.

3. Re-shaping of the NEHTA work plan to be more aware of outcomes and clinical needs.

4. A new work program to ensure appropriate information flows between the major actors (GPs, Specialists, Hospitals and Service Providers).

5. Suppression of initiatives which do not conform to the directions defined above (e.g. the money wasting activities in South Australia and Tasmania under the dead HealthConnect banner).

6. A careful review of just what Information Infrastructure is required with this direction now so determined. (Where does the Commonwealth Government single-sign-on initiative fit, and also where do the Access Card project and the Medicare e-Prescribing work now fit, etc.)

7. A re-assessment of just what may be a practical and useful SEHR that offers utility and value for money and is politically and financially acceptable. A study of the quality of the present document on that topic would be invaluable for all concerned.

8. Utilise the same, or even wider QA processes, to ensure deliverable quality is at the level seen in this document.

I see this report as a watershed – I wonder whether it can be successfully built on?

David.

One small nit:

“Each of the approaches and the strengths and weaknesses of each are discussed in Section 0.” Page 12. This needs to be Section 4.1 I think.


2 comments:

Dr Ian Colclough said...

This is good news David. Deaf ears make for closed minds. This development would seem to indicate that someone has been listening. You have been prepared to stick your head above the parapet with your ‘blogspot’ and voice your opinions. If your efforts have helped contribute to this report - then may I say - well done.

As a passionate believer in the need to harness the expertise of health informaticians working at the coalface, and as a past contributor to your blogs, I ask myself - Do I see a glimmer of light at the end of the tunnel? I think so. It has taken a long time and cost a lot of money to get to this point at last. I might be wrong, but perhaps of recent times there has been some collaboration with the vendor and software development community which has ultimately led NEHTA to this point.

If so, and if NEHTA continues down that pathway, there is every possibility the light at the end of the tunnel will shine still brighter. I look forward to reading the document in detail over the weekend.

Dr Ian Colclough
Integrated Marketing & eHealth Strategies.

John Johnston said...

It is relaxing for us to see our esteemed blog-host, Dr David More, in a happier frame of mind with respect to NEHTA’s recent document, “Standards for e-Health Interoperability version 1.0”.

It could be that David has been an inadvertent architect of behavioural change within NEHTA. It seems to be operating a more “collaborative” engagement with the implementers of health information systems in this country, rather than being a perceived, if not actual, concocter of a brew from the cooks within its own galley. Whatever the truth is, I congratulate David for his fearless commentary and NEHTA for its apparent change of heart.

If you trace the NEHTA publications on the topic of Interoperability we have:-

1. Towards an Interoperability Framework v1.8 21st August 2005
2. The Interoperability Framework Version 1.0 1st April 2006
3. Interoperability Fact Sheet 19th August 2006
4. Interoperability Maturity Model Version 1.0 26th March 2007
5. Standards for e-Health Interoperability Version 1.0 8th May 2007

That’s a lot of Version 1 stuff and the latest document confirms a standards pathway that most of the implementation community were already striding along. It is good, though, to have that confirmation that there is no nasty fork in the pathway ahead to create indecision or a slowing of the journey. We just need to get to that destination in health informatics that Australians need in order to support good health programs and those that seek to reduce the impacts of disease or injury.

Two or three years ago, with a modest investment of $7m, the GPCG were funded by DoHA to deliver on their Phase 1 and Phase 2 work programs in health informatics. These were a bunch of useful projects that delivered practical experience in the implementation of the same interoperability standards that have now attracted a NEHTA badge of approval.

Most of these GPCG projects were executed with industry engagement and collaborative workshopping with a good cross-section of health providers, standards proponents, professional associations, academia and the health systems vendor community. While NEHTA’s focus is not in the primary health domain, many of the key requirements of its jurisdictional stakeholders were reviewed, tested, or applied in these projects.

From my vendor perspective, and from an MSIA perspective, I hope that NEHTA takes a leaf out of the GPCG book and follows through with increased industry engagement in projects that build confidence and capacity. There are benefits for vendors in subsidised development, benefits for NEHTA in practical proof of its choices, and the benefits that flow from working examples of the technology for the benefit of providers and consumers of health care services.

It was interesting to see the SA Government HealthConnect tender for a State-wide Care Planning solution appear this last week. This document has a pervasive requirement for NEHTA compliance yet its specifications and diagrams reflect that agency’s awareness that there is not much to comply with at this stage and that “interim solutions” will be required. This may be the sort of tender we will see for some to come from State Governments seeking new health information systems.

So, we are going to have to lift the pace, but a cautious “pat on the back” to NEHTA and our continuing recognition of David’s watchful eye and commentary.