This is probably the most important blog entry I will ever write – as what is decided at the Council of Australian Government (COAG) Meeting on Saturday will decide if we will ever see the full value that e-Health can offer delivered to the Australian public and, incidentally if I will bother writing this blog anymore.
Can I say the reporting over the last few days gives me great concern that there is about to be an awful mistake made.
From yesterdays Australian Financial Review we have the following:
COAG set to give e-health shot in the arm
Wednesday, 26 November 2008 | Ben Woodhead
State and federal government leaders are slated to assess plans for the national introduction of potentially life-saving electronic health records when the Council of Australian Governments meets in Canberra this weekend.
Proponents of the business case -finalised by the National E-Health Transition Authority (NEHTA) in September-are waiting for COAG members to sign off on the plan, which would help implement an individual electronic health record (IEHR) for every Australian resident.
IEHRs are expected to cut the rate of medical error and improve efficiency in the health system by making patient information such as medications and allergies available online to authorised clinicians.
Supporters of the technology had hoped the business case would receive approval at October's COAG meeting, but the discussion slipped off the agenda in the face of the spreading global financial crisis
It is understood the business case is on the agenda for this weekend's meeting. But sources cautioned the number of issues up for discussion meant the planned review could again be bumped.
Nevertheless, a spokeswoman for NEHTA said the organisation was hopeful state and federal leaders would consider the business case.
More here:
What concerns me it the focus on the mythical and poorly defined IEHR and the desire of some (undefined and clearly non-expert individuals) to develop and implement such a system – with the associated reduction on the emphasis on solving the real problems we have at present.
COAG and the Government have had the final version of the Deloittes National E-Health Strategy for month or two. This document is a pragmatic, well thought out, deliberately incremental approach to the development of e-Health in Australia.
It suggests we invest in getting basic infrastructure, secure communications and terminology right (as NEHTA is trying to do at present) while we commence work with both private and public sectors to implement, develop and certify the appropriate applications for each of the sectors of the Health System (Hospitals, GPs and Specialists, Pharmacists, Allied Health and so on). It is at the local ward and clinical desktop where the majority of benefits in terms of quality and safety can be achieved!
The release of the Garling Enquiry today (27 November, 2008) makes the point forcefully regarding the need for operational systems, with him commenting over pages on the inadequate capacity and utility of the information systems in use in NSW Public Hospitals and the negative impact this is having. Mr Garling does not want a slow pace of progress either – he wants full implementation of all relevant applications completed in all hospitals within 4 years. (See pp50-51 of the Executive Summary and Recommendations document)
See:
http://www.lawlink.nsw.gov.au/acsinquiry
There could hardly be more compelling evidence that we need to get the local information technology properly deployed and utilised before we embark on mega and privacy conflicted shared electronic records. Walking before running has always been a sensible approach.
It also suggests we focus on messaging so we can share the information contained in referrals, results, discharge summaries, specialist letters etc and so we can also develop a national e-prescribing environment that goes beyond ‘prescription printing’.
Once this is all working it is then suggested we move progressively to formal health information networking (starting locally and gradually scaling in size) and eventually, maybe, develop shared repositories of crucial clinical information for access where needed and when the public is fully comfortable with the risk benefit profile of such initiatives.
NEHTA on the other hand – desperate to survive after its present funds run out in June 2009 – is pushing that it be allowed to continue its present work – a good idea if better managed – and to undertake this huge national IEHR project – where all the evidence from around the world is that such huge projects inevitably fail unless led and instigated by clinicians (and the public) not technologists – of which NEHTA and Government has very few!
Deloittes also fully addresses the issues of governance of e-Health and ensuring we have appropriate balanced Health Sector input into e-Health with the clinical driving the technical and not the other way around as it has been to date.
If what comes out of COAG is the funds to implement the Deloittes approach over the next few years I will be a happy person. If we see approval for the nebulous IEHR and NEHTA retaining a lead role (with its cultural problems and technological focus) I am out of here and will find something that has a higher chance of success to focus on.
It is my view that this is a significant test of the competence of the Federal Government and Health Minister that the flawed vague and poorly thought HealthConnect Mark II (IEHR) is seen for what it is – a very bad idea.
Of course the option of no new investment in these difficult times also exists. If this happens we will know for sure we have a totally clueless, or worse impotent, administration of the Health Sector.
We will know next week I guess just where we are and whether hope and common sense can prevail.
David.
David, one of the key recommendations of the ALRC's inquiry into privacy laws is the NPPs and IPPs be unified.
ReplyDeleteSee http://www.privacy.gov.au/act/alrc/index.html
Others are hot on the trail of national and state reforms to speed up health information flows, eg,
http://www.privacy.org.au/
NSW Law Reform Commission has only just released a big report on privacy legislation.
So, it seems both the wishes of NEHTA (via COAG) and Garling may be highly dependent on work yet to done in reform of national privacy law. Putting an arbitrary time frame on EHR, at NSW or national level, seems highly presumptuous without input from the Attorney-General's office. Bob Debus knows NSW and he's at the A-G office as Minister Home Affairs.
On a related matter, I volunteered to have blood taken for a clinical trial. I was contacted through my private health insurer, and took it up out of altruism. An appointment was made at a bleeding station where I met up with the trial nurse. Consent form signed, we proceeded into a questionnaire on medical and health history. We didn't get past the "Do you identify yourself as aboriginal ...". I jacked up at answering any questions, especially since I had not been asked to produce ID. All of that stuff, past what-not, should be available for access if I consent to its release, for public health or research. What a waste of time and to think that research grants pay for the collection of unreliable data. At the very least the form should have been completed before the blood was collected, perhaps on-line.
Well said David, let's hope common sense at last prevails,
ReplyDeleteTom
I think everyone must hope that the if the announcement on Monday is for the delivery of an IEHR that this set as the ultimate goal dependent on the delivery of the infrastructure and local information management issues you have highlighted in your blog.
ReplyDeleteNEHTA has changed a lot in the past 12 months with a considerably higher level of consultation and openness. They have some smart people with new leadership. My hope is that commonsense will prevail.
If not...then your blog is more important than ever...
You raise three inter-related issues. The first is the Deloitte National E-Health Strategy, the second is the role of NEHTA and the third the IEHR.
ReplyDeleteIf the Deloitte document is, as you say, “a pragmatic, well thought out, deliberately incremental approach to the development of e-Health” we should be well pleased; more so if it receives COAG support. Your comments suggest you have some insight into the direction the report has taken!
No-one would argue with getting basic infrastructure, secure communications and terminology right and you seem to support NEHTA’s activities in those areas.
You advocate “we commence work with both private and public sectors to implement, develop and certify the appropriate applications for each of the sectors of the Health System (Hospitals, GPs and Specialists, Pharmacists, Allied Health and so on).” That is a very generalised all encompassing statement. The different “sectors” as you list them may require quite different approaches. Surely you agree it is folly to use the rather crude one-size-fits-all approach?
It is not apparent how you propose addressing the needs of each ‘major sector’; in fact you do rather seem to have them all wrapped up in one great big package! We have been there before.
Your strong support of the Deloitte document would suggest the “sectors” you mention have been specifically and individually dealt with in the document in terms of the strategies required to approach each of these major “sectors”. Let us hope so.
You conclude with a compelling argument that there is a “need to get the local information technology properly deployed and utilised before we embark on mega and privacy conflicted shared electronic records”.
On the one hand that makes very good sense. But we do not live in a perfect world. The states will continue to do their own thing, in response to the pressures of their local environments, whilst engaging nationally on e-Health when and where appropriate. The vendors will continue selling their e-health solutions into every nook and cranny of the health industry. Enormous pressures will prevail all around - be they financial, cultural, organisational, political.
“Messaging, referrals, results, discharge summaries, specialist letters, e-prescribing, etc” are all closely interwoven and interdependent one way or another; and from that perspective, with the IEHR.
This puts the IEHR in perspective and begs the question - if the IEHR is so elusive and difficult to design and develop, and it is - be it one “huge national project” or ‘multiple regional implementations’ - then in order to be ready, when everything else is in place, surely some work needs to be undertaken in parallel along the way.
There is another reason for so doing. If we don’t make some headway now we will, by default, be surrendering the IEHR [PHR-EHR] spaces to the likes of Microsoft, Google and others, and you have presented nothing to suggest that would be in the communities or the nation’s interests. The fact of the matter is that this is such a highly complex area there is a need to encourage multiple activities in this area to facilitate cross-fertilisation and learnings until something evolves which works and is acceptable to the community at large.
You suggest that NEHTA be allowed to continue its present work. You may want to see NEHTA better managed. That should not be problematic and we have already seen some improvements since February and there is nothing to suggest that will not continue. In effect, these arguments support the hypothesis that NEHTA should be cautiously encouraged to continue with some design and development work on the IEHR; probably in collaboration with the private sector.
Finally, you suggest that IEHR projects inevitably fail “unless led and instigated by clinicians (and the public) not technologists”. Whilst your argument has some merit it is also equally valid to note that clinician led projects are not immune from failure either! Individuals with a healthy mix of skills across the entire spectrum are needed to overcome the imbalance of one or the other.
My view is that there are three major tasks. First to get the basic - NEHTA planned, largely MA delivered - infrastructure in place. Second to have appropriate quality applications for each business function (hospital, GP etc etc) and third to improve information flows between all the various actors.
ReplyDeleteAn aggregate IEHR can come once we have that sorted. I have also no concern if we have a PHR provided by Google, MS or even Medicare Australia. That PHR with a doctor contributed core information set (allergies, medications etc) essentially makes the IEHR unnecessary. It is also fully voluntary and patient controlled - unlike the fiasco that is Healthelink in NSW.
David.
Medicare Australia is keen to get as much of the critical infrastructure bedded down as quickly as possible by working with other departments and agencies to that end. Medicare already works closely with NEHTA on the UHIs and an IEHR would complement our relationship quite nicely. So it makes sense to have some work progressing on that front in simmer mode - so to speak.
ReplyDeleteA good outcome from COAG would be a sign-off on the Deloitte document, on-going funding support for NEHTA's current workstream and approval for moving forward to the next stage of the IEHR initiative.
ReplyDeleteOnly on the basis that we move from a nebulous vague IEHR pseudo-proposal to the next step forming up the details of just what is proposed, how it will work, how privacy and security will be addressed, how it will be delivered and what it will actually cost.
ReplyDeleteIf the funding is to get that detail into the public domain for proper discussion - OK. If not - not a cent until that is the plan.
David.
Well it looks like COAG chose the fork in the road with a dead end for e-health.
ReplyDeleteIn an interview with Colin Barnett:
"COLIN BARNETT: The areas that will be disappointing will be cancer treatment and E-health. And that amounts to stopping the amount of paper and records flowing from GPs to hospitals.
The idea was to put that all into an electronic form to improve the efficiency of our health. I'm sure that will come, but it's not going to come as quickly as we might have hoped."