Draft Submission to the BCG NEHTA Review from Dr David G More.

Note: This is a draft – any comments from readers will be considered and may be included in final submission to the BCG – Due on 27 July, 2007

Executive Summary

E-Health in Australia is rapidly becoming a national disgrace and the opportunity cost of not addressing it in terms of both money and lives is rising relentlessly.

The following offers an expert, independent view of NEHTA’s performance to date and recommends two key steps to remedy the currently disastrous situation.

These are:

Urgently the governance of NEHTA needs to change. The Board needs to have 2-3 representative E-Health Experts (from ACHI, MSIA, Industry etc ) and one or two independent experts added with the Jurisdictional representation dropped to 3-4 members. The Board also needs a highly qualified technical and a highly qualified clinical advisory committee with real influence and teeth. Note: The Australian Health Information Council (AHIC) – which should also have broad stakeholder input - is the right entity to ensure NEHTA stays focussed on delivery in the context of an AHIC managed strategy which I recommend below.

Longer term – six months – A consultative, inclusive, national E-Health Strategy, Business Case and Implementation Plan must be developed. This will then need to be reviewed and properly resourced and funded – managing the state / Commonwealth divides etc. NEHTA should then be managed by the governance approach recommended in that strategy and take its priorities from there as well.

Once this is done some hope and certainty may return to the E-Health Domain in Australia.

(I look forward to discussing the contents of this submission with BCG. I can be contacted via my blog by e-mail)

Background of Preparer of Submission.

David MORE MBBS(Hons) BSc(Hons) PhD FANZCA FJFICM AFACHSE FACHI

Much deleted as irrelevant for blog post!

For the last 15 months Dr More has been writing a blog on e-Health in Australia. The blog describes itself in the following terms:

“This blog provides a commentary on the progress (or not) of e-health in Australia from the perspective of some-one who has worked in the field for over 20 years and has become a bit jaded with the lack of apparent progress in a very important field.”

The blog now has over 4700 page views a month and is widely read and discussed by many participants in the e-health arena.

Strategic Analysis of Australian e-Health

E-Health is an overarching term to describe the deployment of ICT to support the operations of and to improve the outcomes (clinical, operational, financial and administrative) of the health system.

Experience from all over the world has shown that the implementation of e-health solutions in the health sector is a major challenge. Writing in the British Medical Journal a couple of weeks ago (BMJ Volume 334(7608), 30 June 2007, p 1373) Joan S Ash got it as close to right as I have ever read when she wrote”

“Why is implementation of health information technology such a universally difficult process? It is because we are transforming health care through information technology rather than simply automating old processes. Workflow and work life must change, which means people must adapt. Such change is deeply disruptive. The related personal and organisational challenges are enormous, yet efforts to manage change receive inadequate attention and funding.”

It is my view that NEHTA, an organisation that has virtually no practicing clinicians working with it and manifests virtually no insight into the way the health system really works, has totally overlooked this reality and has so ensured it is essentially irrelevant to the Australian Health System at large.

NEHTA’s problems have been also made much more dramatic and intractable by the following:

1. NEHTA’s lack of any real customers. The private sector simply ignores NEHTA and the public sector merely pays lip service to NEHTA’s recommendations. They have to get on with business while NEHTA plans to offer some “building blocks” some time in 2009.

NEHTA seems to have an almost ‘Field of Dreams” approach to what it is planning and developing in terms of identity management and terminology. They assume if it is built, they will come. I really wonder how true that actually is?

2. The fact of the Australian Health Information Council (AHIC) vacating the field between 2005 and early 2007 – removing the last vestige of any peak Strategic Planning entity which could guide the technically orientated NEHTA in sensible directions and provide some real-time feedback as to the relevance and applicability of what NEHTA was doing.

There is considerable confusion about the division of responsibility between NEHTA, AHIC, Standards Australia and the e-health component of the Department of Health and Ageing.

3. The lack of clarity about just what NEHTA is a Pty Ltd Company which seems at once to be both a Standards Developer and a Standards Taker, as well as having no real governmental authority.

4. NEHTA was meant to be a core enabler of E-Health progress but its approach has resulted in the deferral in all sorts of potentially useful initiatives while its staff try to understand the complex tiger they now have by the tail.

5. The recognition among a range of stakeholders that progress in E-Health is important and has not gone anywhere near as well as might have been hoped. See my open letter to Minister Abbott:

http://aushealthit.blogspot.com/2007/03/open-letter-to-minister-tony-abbott.html

And the Departmental Response:

http://aushealthit.blogspot.com/2007/06/minister-abbot-responds-to-open-letter.html

6. The blunt, and occasionally almost over the top, media management tactics NEHTA is known to employ and of which I have first- hand knowledge.

7. NEHTA’s failure to appreciate just how sensitive citizens are to retaining control of their private health information. They have not addressed this issue adequately in my expert view.

I have recently (May 2007) summarised my views of NEHTA’s current performance.

See http://aushealthit.blogspot.com/2007/05/nehta-how-far-has-it-come.html

The relevant part of that post is the following:

I think the answer to the question of what NEHTA has achieved is that "It is too early to tell yet” as the probably apocryphal story suggests was said by the great Chinese revolutionary Chou En-lai when asked for his for his evaluation of the French Revolution.

This said there are two things that can also be said. First , what NEHTA is attempting is no doubt a major complex challenge and second that so far, from the point of view of an external observer, they seem to be going about their brief very incompetently. From where I sit the risk of overall failure looks worryingly high.

What have they and are they doing wrong?

The key things I see as mistakes are:

1. The failure to develop an operational Strategic Plan, Business Case and Implementation Plan to facilitated the delivery of the outcomes sought by Health Ministers in August 2004 when NEHTA was authorized (Based on the Boston Consulting Group work of the same year).

2. The decision to corporatize the NEHTA entity which has removed NEHTA from effective public scrutiny and review and has disengaged the body from many of its public sector clients.

3. The ongoing lack of quality in many of the NEHTA documentary deliverables. Other than the document relating to the adoption of HL7 there have – in the last year – been a series of either useless or incomplete or excessively impractical documents produced with have added minimum value to the Australian E-Health domain. ( A secondary problem is the ‘ex cathedra’ approach to document release).

4. The continuing lack of transparency regarding NEHTA internal decision making with commercial-in-confidence and secrecy being made an art form quite unnecessarily. Given the public policy and standards role NEHTA is meant to play there should be totally open policy development processes and all strategic advice received by NEHTA should be made public for comment and feedback. Equally the NEHTA Board should publish relevant and adequately detailed minutes of the policy aspects of their meetings.

5. The failure to seek proper engagement with the Medical Software Industry.

6. The failure to ensure the boundaries between the roles of DoHA, the Australian Health Information Council, the States and Standards Australia’s IT-14 Committee were well defined and able to be understood so roles and responsibilities were clear.

7. The tokenistic way much of the stakeholder consultation has been undertaken and the almost Joh like “don’t you worry about that” style of management. The privacy consultations undertaken so far are examples of listening at its worst.

8. The obvious “tail wagging the dog” mode of operation seen in the way the NEHTA Executive and the NEHTA Board interact. Given the public sector backgrounds of the Board members if they actually understood what was at stake and enough of what was happening internally within NEHTA to manage it actively I am sure it would be a different, more open, more consultative and much more useful organisation.

9. The failure of the NEHTA Board and Management to recognise there are urgent issues which need to be addressed at both State and Commonwealth levels. The time frames NEHTA is working to are excessively relaxed – especially given the level of resourcing and staff available.

10. The sectional focus – on Public State Hospital Issues and Commonwealth Issues with minimal focus on either the private hospital or private practitioner needs. The lack of a holistic Health System Wide vision and approach is a key failing.

11. The delays that are now becoming obvious in a range of the work program components. The worst apparent examples are in the Benefits Realization , Shared EHR and Medicine Terminology areas.

To date the only successes I can see are the acquisition of the national license for SNOMED CT and the decision to adopt HL7 as a messaging and possibly EHR content Standard. Not much really for the $20+ million NEHTA has cost to date – excluding the money being spent on the UHI projects. Progress on the needed extensions to SNOMED CT before it is useful has been slow and seemingly badly managed if the delays in delivery are anything to go by.

The bottom line is that what NEHTA is trying to do is very badly needed, but the way they are going about it is deeply flawed in my view and the direction needs serious modification.

I have also expressed what I believe are significant process issues with the present review. These may be reviewed at the following URL:

http://aushealthit.blogspot.com/2007/06/nehta-review-i-sure-hope-it-helps.html

With that broad overview of my concerns I offer the following specific comments in response to the specific questions asked by the review –while suggesting the scope of the review – which does not appear to address the entire national E-Health Strategy, and NEHTA’s role in it, is just too narrow to have a satisfactory outcome.

Responses to Specific Questions (See Appendices)

Section 1.0

1a. – NEHTA actually commenced operation in November 2004 and so has been in operation over 2.5 years. In answer to “Has NEHTA achieved what was intended for it?”
No – see details in the section above.

1b. “Was NEHTA tasked with the right objectives in the first instance”

No – The absence of an overarching national E-Health Strategy has meant there has been incoherent and unfocussed activity and not much in the way of real outcomes.

NEHTA should have been something like the delivery arm of an E-Health Strategic Implementation Office.

1c. See above

1d. NEHTA has slowed down progress and alienated many of the volunteers who used to undertake standards work. The quality of the work they have done has been excellent but must now be seen as being under threat due to withdrawal of corporate support and other gradual reduction in resources.

1e. See recommendation below

1f. The recent meetings involving the MSIA and others make it clear the engagement model is deeply unsatisfactory. The only ones who are happy are those who are being awarded lucrative contracts by NEHTA as best I can tell.

1g. Significant good outcomes in E-Health will not be achieved with the current investment levels. The investment is not coherent, planned and rational at present. A symptom of the lack of an agreed overarching national E-Health Strategy, Business Case and Implementation Plan.

Section 2.0

I do not believe any of these questions can be addressed in the absence of national E-Health Strategy, Business Case and Implementation Plan. To fiddle around with NEHTA without being clear where all the other actors fit is folly in my view.

Concluding Remarks and The Suggested Way Forward

In my view NEHTA has been a dismal failure which has been characterised the worst possible outcomes for all the key stakeholders.

As I argue elsewhere in my blog there is opportunity to make a real difference in health service delivery without waiting for NEHTA’s long term R&D program to deliver –if it ever does.

See http://aushealthit.blogspot.com/2006/03/australian-e-health-strategy-why-what.html

Urgently the governance of NEHTA needs to change. The Board needs to have 2-3 representative E-Health Experts (from ACHI, MSIA, Industry etc ) and one or two independent experts added with the Jurisdictional representation dropped to 3-4 members. The Board also needs a highly qualified technical and a highly qualified clinical advisory committee with real influence and teeth. Note: The Australian Health Information Council (AHIC) – which should also have broad stakeholder input - is the right entity to ensure NEHTA stays focussed on delivery in the context of an AHIC managed strategy which I recommend below.

Longer term – six months – A consultative, inclusive, national E-Health Strategy, Business Case and Implementation Plan must be developed. This will then need to be reviewed and properly resourced and funded – managing the state / Commonwealth divides etc. . NEHTA should then be managed by the governance approach recommended in that strategy and take its priorities from there as well.

Once this is done some hope and certainty may return to the E-Health Domain in Australia.

Appendices

Appendix 1 - Call for Submissions

The Boston Consulting Group (BCG) has been selected to undertake an independent review of NEHTA, and assess any future role that it should play. As part of the review, BCG would like to receive submissions on:

1. NEHTA’s effectiveness in meeting its objectives during the two years since its inception, including:

a. The consistency of NEHTA’s current role and function with its objectives as laid out in the NEHTA constitution[1] – “Has NEHTA achieved what was intended for it?”

b. The appropriateness of NEHTA’s objectives, given the needs of eHealth development in Australia - “Was NEHTA tasked with the right objectives in the first instance”

c. NEHTA’s goals, strategies and work plan, including any gaps or overlaps with the work of other bodies

d. Progress achieved in deliverables and outcomes, especially with regard to the development of standards and the establishment of core information infrastructure for eHealth.

e. NEHTA’s structure and governance arrangements

6. The consultation and communication process NEHTA has undertaken, including:

§ The engagement process that has been conducted

§ The completeness and quality of the content that has been communicated

§ The outcomes that have been achieved as a result of consultation

7. The funding for, and value for money achieved by NEHTA, including:

§ The balance of resources committed to different activities and objectives

§ The level and mix of sources of funding

2. Possible roles for NEHTA or a similar entity in the context of future eHealth reforms, including:

1. Roles and responsibilities for existing players and/or potential new players, including NEHTA, in eHealth reform going forward

2. Priority next steps in delivering eHealth objectives

3. Vehicles and sources for funding the next steps
   
   
4. Potential governance models
   
   
5. Ongoing operation and maintenance of standards and infrastructure established by NEHTA

Submissions should be received by the 27^th July 2007 by:

Email: addressed to nehta_review@bcg.com

Fax: Addressed to NEHTA Review Team – Fax No 02-9323-5666

Mail: Addressed to: NEHTA Review Team

BCG

Level 28, Chifley Tower

Chifley Square

Sydney, NSW

2000

In addition to collating written submissions, BCG will be scheduling interviews with a number of stakeholders to gather supplementary data.

Appendix 2.

Article 3 of NEHTA Constitution

Objects :

The objects of the Company are all or any of the following:

To provide the critical standards and provide and manage the development of infrastructure, software and systems required to support connectivity and interoperability of electronic health information systems across Australia;

To research, develop and implement national health information projects including (but not limited to):

3.1.1 clinical data standards and terminologies including the development of standards, and common terminologies for health information for clinical service delivery, planning, policy-making and research purposes and communication between health systems in Australia;

3.1.2 patient, provider and product/service standards and directories/indexes that contain information necessary to uniquely identify patients, providers, products and services and other relevant information across the whole of the health sector in Australia;

3.1.3 identification standards to define the data structure and specification for the capture and storage of information required or the identification of patient, provider and product/services in Australia;

3.1.4 a product services directory which contains information for identification of products and services;

3.1.5 consent models governing collection and handling of electronic health information;

3.1.6 EHR standards;

3.1.7 technical integration standards to define the structure and rules by which information is exchanged between systems and users;

3.1.8 supply chain efficiencies, including exploring options such as common forms of procurement, standard contracts and common purchasing processes;

3.1.9 user authentication and access control to ensure compliance with privacy laws and the consent models which have been developed;

3.1.10 EHR secure messaging and information transfer, including identifying and managing the development of a national security model for messaging and information transfer between health care providers' systems;

3.1.11 a knowledge centre, providing knowledge-sharing and expert advice to the public and private sectors on business case development and implementation requirements for health information systems so as to meet national standards and architectures; and

3.1.12 to encourage health information industry reform and to facilitate opportunities in driving technological reform in health information technology, so enabling consistent interoperability and implementation of national health information technology priorities.

Any additional object which 100% of Members determine should be included in this Constitution at a General Meeting.

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[1] A copy of article 3 of the NEHTA constitution is attached for reference