Given this could be the most important blog I write this year, I felt it needed to be started by a relevant quotation. My chosen quotation is 'Those who cannot remember the past are condemned to repeat it.' This is one of the notable quotations from George Santayana and can be found in the work entitled Life of Reason, Reason in Common Sense, Scribner's, 1905, page 284.
Why is this relevant? Let me explain.
On the day the NEHTA Review by the Boston Consulting Group (BCG) was released the Australian published an article – clearly prepared well in advance – informing an unsuspecting populace that they were about to all have a Shared Electronic Health Record (Shared EHR) made available to them within four years, if they wanted one! Clearly an attempt to distract from the bad news of incompetence in the BCG report and to obscure what they planned for the future.
From the press release associated with the release of the BCG Review of NEHTA we also learned that the Board has been busy. In their words:
“The Board of NEHTA also endorsed a business case for developing a national platform for personal electronic health records to be put to the Council of Australian Governments (COAG) early next year.”
The Australian article makes it pretty clear the information to be held on the Shared EHR will be (to quote):
“ Core elements of most profiles would include:
* Allergies, alerts and adverse reactions.
* Current and ceased medications.
* Problems and diagnosis, active or persistent disorders.
* Family and social history and immunisations.
* Implants such as pacing wires, joint prostheses and medication implants.
* Screening results such as the last date and outcome of Pap smears and mammograms.
* Key physiological measurements, height, weight, body mass index.
* Planned activities, care plans and history of recent and past procedures.”
What does all this mean. It means that NEHTA imagines (fantasises) that it is ready to approach the Council of Australian Government (COAG) with a business case to implement a quite advanced Shared EHR over the next four years!
Implied in all of this is that NEHTA has worked out
1. the details of how the Shared EHR will work.
2. how the planned record will interact and communicate with hospital, specialist and GP systems
3. how the data will be stored and secured
4. how privacy will be protected and
5. how much it will all cost and what the benefits are that will flow from the recommended spend.
Even more amazing is that the business case apparently suggests this can all happen within four years – i.e. by 2012.
If COAG buys this megalomaniacal hubris, and agrees to this, it will be a total disaster and set back E-Health in Australia for a decade in my view.
Why is this initiative doomed to fail (Here is where recent and more distant history comes in)?
First, as we learn from the recent BCG report, NEHTA does not seem to be able to manage even quite simple projects effectively (can’t get staff, can’t spend what is needed and lacks implementation expertise for starters). Doing a project of this scale is clearly way beyond them – even with partners such as IBM and Telstra which you can bet they are hoping will do the heavy lifting.
Second, again as we learn from the BCG report, NEHTA has virtually no capability to engage with the Health Sector and simply does not ‘get health’. A project of the scale contemplated by NEHTA is not doable in that circumstance.
Third, when similar ideas were trialled in the years 2002-2005 by the Commonwealth, under the HealthConnect banner, the pilots were such dismal failures that not a single one was continued with in its planned form and ultimately the whole program turned into a ‘change management strategy’ having wasted $100 million +.
Fourth, to have a Shared EHR it is vital that the data that is shared from operational systems is of high quality and integrity – i.e. is ‘data for sharing’. NEHTA does not even have a plan for GP and Specialist data quality enhancement (it has cost the UK hundreds of millions of pounds over many years to make progress) and so ‘garbage in, garbage out’ will be the order of the day.
Fifth, the UK, Canada and the US have has EHRs on the political agenda for 4-5 years to build public support for a Shared EHR project – we have had one article in the Australian two days ago after a hiatus of years.
Sixth, it seems that we have had a collection of NEHTA boffins who, according to the BCG are not seen by practicing Health IT experts as being of much use, invent this business case in secret away from the public eye as well as those who actually understand the risk and complexity of such undertakings. So much for the new open NEHTA and for any substantial chance of success!
Seventh, any maturity analysis of the Australian status in E-Health would quickly show we are a full 5-7 years away from being able to successfully conduct such an ambitious project – lacking the people, implementation skills and technical infrastructure to make it work.
Eighth, Australia does not have a National E-Health Strategy that positions a proposal of this type sensibly. All elements including the doctors and nurses, support staff, technologies, partners and training need to be co-ordinated and managed. This is a strategic national effort which will take many years – not something to be rushed through COAG on the opportunity of a Government change.
Lastly, from what is known of NEHTA’s benefits work, there are a lot of assumptions based on effective Clinical Decision Support. Systems with these capabilities are still largely aspirational at this point of time in terms of widespread use and it seems likely NEHTA’s benefits case will be little more than wild guesses dressed up with flash graphics. COAG beware!
How should NEHTA actually be proceeding?
First NEHTA should engage with COAG to fund the development of a genuinely inclusive and practically based National E-Health Strategy. This could address many of the present uncertainties about what is practical, what is possible and what might work.
Second it should review, refresh and release all the documentation associated with HealthConnect Version 1.
Third the reality of the costs and benefits case needs to be subjected to hardnosed analysis through proof of concept implementations that can be shown to deliver in the real world. Hand waving assumptions should simply not be accepted.
Fourth NEHTA should release, for public review and discussion, the current business case so we all know what is planned, what will be the outcomes and can bring the Health IT Communities expertise to bear on the entire project to maximise the chance of cultural, technical and financial success. This should lead to a much more robust plan being approved late in 2008 – and having some chance of success when implemented.
Fifth – at the very least – the Shared EHR should be piloted in one State (it needs a pilot of that scale I believe to be credible) and once all the issues are resolved – a move to national implementation can be commenced. Just jumping in with the whole country is clearly crazy.
Shared EHR’s have been very problematic in large countries with success seemingly being confined to the smaller states such as Denmark etc.
Before I conclude I need to say I would really like a Shared EHR to proceed in a planned strategically rational fashion – just not in the unsound and ill considered way proposed by NEHTA which I feel is doomed. I know how hard this will actually be and I fear NEHTA does not have a clue.
If NEHTA goes ahead with its present plans, and COAG is silly enough to approve the request, I am convinced it will be an un-remitting fiasco some 2-3 years out and there will be blame and blood-shed everywhere.
See if I am not right.
David.
David, the article on NEHTA in ComputerWorld http://www.computerworld.com.au/index.php/id;1017466143 quoted a very significant point in the BCG report - "For example, all three major pathology messaging hubs in Australia currently claim to be HL7 compliant, yet they are still not interoperable".
ReplyDeleteI'd say this is a key target for NEHTA to tackle. They could inquire why pathology systems, public and private, do not communicate with each other, when pathology is a section of medical practice that has been computerised for a long time. Inefficiencies here lead to needless re-ordering of tests, which in turn drive up costs, as reflected in health insurance premiums.
BTW, I reckon the article in The Australian was fed by Telstra, see http://webdiary.com.au/cms/?q=node/2239
“If COAG buys this megalomaniacal hubris, and agrees to this, it will be a total disaster and set back E-health in Australia for a decade.”
ReplyDeleteLet's face the facts. COAG will depend on the recommendations of NEHTA’s Board. NEHTA’s Board is made up of very busy senior executives who are dependent on the CEO for advice and guidance.
Therefore, the megalomaniacal hubris to which you refer must come from one man - the CEO.
But what does it mean?
The dictionary defines megalomania thus:
megalomania (meg•a•lo•ma•nia) (meg”ə-lo-ma´ne-ə) [megalo- + -mania] unreasonable conviction of one's own extreme greatness, goodness, or power; the ideas in megalomania are known as delusions of grandeur.
Megalomania is an unrealistic belief in one's superiority, grandiose abilities, and even omnipotence. It is characterized by a need for total power and control over others, and is marked by a lack of empathy for anything that is perceived as not feeding the self.
http://www.wisegeek.com/what-is-megalomania.htm
en.wikipedia.org/wiki/Delusions of grandeur
The dictionary defines hubris thus:
Noun1.hubris - overbearing pride or presumption, excessive pride or arrogance, haughtiness, hauteur, high-handedness, lordliness - overbearing pride evidenced by a superior manner toward inferiors
Delusions of grandeur are defined thus:
http://en.wikipedia.org/wiki/Delusions_of_grandeur
Once I read this and explored deeper the information in the URL links I understood why you are so concerned.
There is no-one on the NEHTA Board that was close enough to or who goes back far enough to remember what really happened and why $100 million went 'puff' in smoke. If there is no-one on the NEHTA Board and no-one in COAG (politicians have all changed) who can remember what happened five years ago then it is up to the Good Lord to help because no-one else will. It is fast becoming clear the past will be repeated.
ReplyDeleteMegalomania is:
ReplyDelete- an unrealistic belief in one's superiority, grandiose abilities, and even omnipotence.
It is characterized by a need for total power and control over others.
It is marked by a lack of empathy for anything that is perceived as not feeding the self.
This doesn't sound like the sort of leadership that's needed to fix the problem. No bloody wonder things are in such a mess.
I think that your powerful and relevant criticisms of NEHTA are diminished by your unfair criticisms of the BCG report. The BCG report doesn't directly condemn NEHTA as you hoped it would, but it does point to a large number of serious weaknesses in clear terms.
ReplyDeleteThe fact that they included the opinions of NEHTA staff in their report shows that the report was fair, and adds to the weight of its recommendations.
My feeling (as a programmer working in the private side of health IT) is that what NEHTA needs to do is to implement the recommendations of the BCG report, which clearly states that they shouldn't be attempting an EHR at this time.
"Implement the BCG report" is also a nice, simple message, and we know how much politicians like those ;)
This says it all - from page 41 of the BCG Report.
ReplyDelete"In the absence of physical examples of SEHR, none of these can really be resolved. Our high-level assessment suggests a very high level of quality, comprehensiveness and attention to detail in the (unpublished) documentation, but there is little that could be used to convince health service executives to commit to implementation.
Furthermore, many stakeholders believe NEHTA has stopped actively working in this area altogether because of the paucity of published materials released. We believe that the design and specification dimension of this workstream has progressed as far as it reasonably can without intensive engagement and building of consensus around the impacts it will have (objectives e. and f.), and this, together with building the case for funding, needs to be the sole priority.
We would therefore support the recent switch of focus of this workstream towards building the business case for SEHR. This will be a wholly different exercise to the specifications work done thus far, however, and will require resources with practical clinical experience and keen political sensitivities. In the UK and Canada, there has been a significantly higher level of engagement with the medical and broader communities around SEHR.”
NEHTA has just ignored this need for engagement and developed their SEHR business case in secret. What a fiasco!
David.
From an organisational perspective a very interesting and extremely complex situation has been illuminated by the release of the BCG Report and NEHTA's response, both of which I have now carefully examined.
ReplyDeleteI see that a couple of your earlier commentators have highlighted what I suspect is at the core of the issue and the reason why you have so many concerns - which I think probably have a great deal of substance.
As a psychologist and organisational consultant in human behaviour I would sum the situation up this way:----
Houston, you have a problem. A competent occupational psychologist is very urgently required to join the NEHTA Board.