As regular readers will recall, on Monday I posted some commentary on the Australian Health Information Council (AHIC) Survey questionnaire, which is being conducted by the Nous Group.
The article can be found here:
http://aushealthit.blogspot.com/2007/06/ahic-survey-will-they-hear-what-they.html
What has been interesting, in discussing the survey with colleagues, is the unanimity on the importance of having a plan.
I think this is because it is recognised, and clear to all that developing ‘building blocks’ without knowing how you want the house operate and what appearance you want is quite silly.
While I don’t want to argue semantics - I see the focus on these building blocks - without having a concept of what the house is to look like and who it is to accommodate as extremely problematic.
As it happens every nation I know of that has thought about a national e-health strategy has come up with the same list (messaging, identifiers and terms) and I see all of them a critically necessary but not sufficient. We still need systems and applications to take advantage of what I see as just essential shared infrastructure
It seems to me that if the AHIC Board get only one message from the current survey this will be it – we need a plan! The next question that then arises relates to just what sort of plan is required and how is it to be developed.
I think it is important to respond to this question and a number of readers have suggested they would like to know what my thinking might be. Let me say first off I recognise the complexity and difficulty of this and am confident I have no unique hold on wisdom in all this. I will provide an opening view and would be keen to hear any and all comments.
The best way I can think of to approach the issue is to consider what I believe should be some of the principles that should underpin the plan and shape the approach and methodology of its development and subsequent implementation.
Before providing the principles I think it is important to note that we have now had a decade of grand plans (since the House of Reps report in 1997) and expensive trials which have not got us very far, as best anyone can tell. So grand detailed top down plans need to be treated with healthy scepticism.
What principles might lead to a successful plan and subsequent implementation.
First cab off the rank for me would be to get an accurate unbiased situation report of where we are. What is working, what is not, what are the reasons for success and failure etc. This is quite a large task and would require review of all the initiatives and trials from the last decade in a clear eyed and objective fashion. There would also need to be quantitative review of the success of the various adoption incentive programs to fully understand what value has been obtained from these initiatives.
Next it would be important to try an obtain a similar clear eyed view of just what was happening globally and the factors that could be shown to be leading to success or the opposite and what could be done to mitigate risk.
Once such situational information was available it would then be reasonable to develop a range of possible high level approaches and workshop and refine those with relevant stakeholders. This step needs to be conducted in an inclusive, open, transparent and consultative manner.
It is also important in undertaking this consultation to be clear that the technology needs to be the servant of the health system and to be implemented in such a way that assists the health sector achieve its objectives of safety, consistency, quality, effectiveness and value for money.
There are a range of strategic choices that will need to be made, and these choices need to be made on the basis of what suits the operation of the Australian health sector and those who work in it. Among the choices that need to be made are:
1. The balance between, and what will be, standardised nationally, at a state level and locally.
2. The priority to be placed on support of the primary, secondary, tertiary, investigative and public health / preventative aspects of the health sector.
3. The importance that is to be placed on information standardisation to assist in health system information aggregation and reporting.
4. How the distribution of benefits from the use of technology are going to be distributed and what incentive and adoption facilitation mechanisms are to be employed.
5. What level of investment will be made in developing health IT, who will invest and over what time period.
6. What of the current e-health infrastructure needs to be retained and what needs to be replaced. How can we best build on what is working today and ensure there is a future for those things that have proven to be useful and valuable
7. What approach to governance, reporting and evaluation should be adopted. What bodies are needed, what functions should they perform and what expertise needs to reside where?
8. What will be the optimal approach to develop and maintain public support for improved e-Health services.
9. How can enough skilled people be trained to address the needs of both plan development and implementation?
10. How best can the private sector be involved as both providers and vendors in a national initiative? What roles should each play?
This is a high level list which barely scrapes the surface, is certainly incomplete, but should provide an initial understanding of the scale of the effort required. A workable, practical, supportable, fundable and implementable plan will require a lot of hard work and good will. We have series of failures to recover from and we really should give it a very thorough and rigorous try!
I need to be clear here. I understand the risks of the grand plan and want a balance that works for Australia. I think we need to develop some organising principles and direction and then to get on with it – National e-Health Strategy Lite maybe! However we do need some clear sensible frameworks, standards etc and we certainly need to understand what has gone wrong in the last decade. The strategic vacuum approach has not been seen to work and we need not to continue down that path any longer.
David.
5 comments:
The list of questions to be addressed in an Oz Health Informatics Grand Plan are all perfectly valid. However, it will will be impossible to reach a consensus on the majority of those issues - everyone has a different opinion. Opinions don't matter if there is central control, but there isn't. Everyone will do what they see as best - they can't be commanded or ordered to obey an arbitrarily-determined Grand Plan. Thus it is a fruitless exercise. Better to concentrate on (and fund!) the building blocks on which there is broad consensus, and then let societal self-assembly take its course. That is not a nice concept for those accustomed to working in public-sector command-and-control organisations, but it is the way our wider society works.
Tim,
We must be very special then. Most other advanced countries have a plan and are moving forward at a reasonable pace. We are doing neither.
David.
I have to agree with Tim. I believe most of the "advanced countries" you talk about already have a national identifier and other infrastructure supporting their plans. We don't.
I think your analogy of the house is unfortunate, and would prefer a town planning analogy. We need to build a community.
To finally push the construction analogy past breaking point, I think the current situation in Health Informatics is similar to a group of people arguing over what their particular house should look like when the road is a muddy, rutted dirt track and there is no plan for the provision of essential services.
By all means have a plan, but plan for building the essential services first, and let everyone get on with planning their houses in the knowledge that the road will be fixed so the mail can get through. Maybe in the meantime we can have the arguments about which side of the road to drive on.
Jon,
I think it is worth having a look at the Monday and Tuesday posts for this week (Commencing 11 June). I simply don't accept that it is possible to get anywhere serious with-out a plan (forget the analogy - I could have used the fact you need a plan to design and build and ship or aeroplane and that to do that you need to understand what it is and what it is to do)
The US, Canada, Holland, Denmark and the UK have plans and seem to be moving forward and measuring progress against their plans - why do you want to be a plan free zone?
What the plan needs to do is align people and make a community that desires progress and put down markers on how to get there. Like you and Tim are saying I think - it needs to be simple, credible, focussed etc - not the classic Grand Plan..but it has to exist I believe.
The journey of a 1000 steps etc..needs a map.
David.
Hi David,
I want a plan too, there is absolutely no argument about that. My point (and I think Tim's too) is that we should not be planning to build something like a house, a boat, a ship or an aeroplane, but rather something like a town, a network or a grid. This is a very important, if perhaps subtle, distinction.
It is still possible to understand what it is and what it is to do - it's just that "it" is actually facilitating infrastructure and standards rather than a system intended for immediate use by end users.
"It" is to provide a standardised environment that will support sharing of healthcare information. It will allow the adaptation of current systems and the development of new systems that support the people who are providing and consuming healthcare in all its myriad forms.
I agree we need a plan - but it would be wise to agree on the strategy first, both within the health informatics community and, more importantly, with the broader community.
Jon
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