Over the last few years one of the very few success stories in e-Health has been in the area of secure messaging between healthcare providers – especially pathology and radiology practices – and their referring GPs and to a lesser extent specialists.
This messaging has been provided by a range of for (some variable amount of) profit (think HealthLink, Medical Objects, Promedicus, eClinic and so on) entities, and also some virtually non-profit (essentially cost recovery) entities (think ArgusConnect).
(I apologise in advance if I have mischaracterised provider’s status – let me know!).
Most have utilised HL7 Version 2 messaging standards with variable levels data content dis-aggregation.
ArgusConnect has also played a significant role in supporting developments with NT Health in its (still pretty embryonic) work in the Shared EHR and e-Prescribing.
ArgusConnect (http://www.medisecure.com.au/index.html) is also a key partner in the Medisecure e-Prescribing hub.
Additionally we have eRx (http://www.erx.com.au/) who is providing an e-Prescription hub with secure messaging.
From their FAQ they say:
What standards does eRx use?
eRx has adopted existing messaging standards through the use of web services technology, the utilisation of HeSA PKI certificates and conforming to privacy legislation. eRx will adopt to emerging messaging standards as they become available.
See here:
http://www.erx.com.au/PDF/eRx-FAQ.pdf
Now a month or so ago I published a blog pointing to some issues that were arising in the ePIP program the requires Secure Messaging to be on the agenda of software providers used by GPs for an additional and reasonably useful payment.
See here:
http://aushealthit.blogspot.com/2009/12/news-alert-serious-differences-seem-to.html
Well a new document has come to light from my various sources that rather makes it clear that NEHTA has been less than open with all those it has had working on the PIP Working group.
----- Begin Extract
NEHTA Web Services Messaging Application (WMSA) Project Plan – 30 Jun, 2009.
Project Definition
Background
In the Northern Territory, secure electronic messaging underpins the following ehealth services:
- Shared Electronic Health Record (SEHR)
- Electronic Transfer of Prescriptions (ETP)
- Electronic Transfer of Referrals
- Communication of clinical information
Currently this messaging is provided by the Argus Messenger application which is a commercial messaging application installed at each of the participating sites. The Argus messenger application uses the Public Key Infrastructure (PKI) encryption and POP3/SMTP technology for the transmission of messages between a number of systems as well as from source systems to the SEHR. Source systems interact with the functionality provided by the Argus Messenger through a number of API’s.
The National eHealth Transition Authority (NEHTA) has developed a set of specifications for securely transferring health information using web services technology. As a result, to meet current and future needs in the
Initially this will be a generic web services messaging solution, however as NEHTA specify each type of clinical service, e.g. pathology required, pathology test results, discharge summary, referral, ePrescribing, etc, these will be implemented as discreet web services endpoints and the generic web services endpoint will be used for unspecified payloads.
Aim & Objectives
The objectives of the WSMA project are to:
- Develop a secure messaging application compliant with relevant NEHTA specifications, utilising web services technology.
- Develop and implement a generic web services endpoint solution, which will later implement distinct endpoints for each clinical event as NEHTA specifies them.
- to replace Argus secure messaging systems for Communicare & Pen computing sites in the Northern Territory;
- to replace Argus secure messaging systems for the SEHR
Strategic Alignment and Outcomes
The expected outcomes of the NT secure messaging project include:
- Successful implementation of a production web services solution for securely sending messages from Communicare & Pen Sidebar to the SEHR, which is compliant with the NEHTA specification.
- Future releases of WSMA will replace “Argus Messenger” at all the NT DHF sites
- Addressing current administrative and performance issues associated with the Argus secure messaging systems.
- Provides a platform on which further interoperability initiatives such as identity management (UHI, ELS), electronic referrals, discharge summaries, etc can be leveraged.
- The IP for the software developed in this project will be owned by the Northern Territory of Australia, and will be made available to other jurisdictions under open source licence the details of which will be defined later. It is envisaged that WSMA will be progressively deployed across other jurisdictions. (Creation of an open source .NET SDK for use by other Jurisdictions e.g. SA Health)
- Cost savings as sites are expected to require less administration and maintenance as well as the removal of the reliance on commercial messaging systems.
----- End Extract.
So what we have here is essentially NEHTA and the Jurisdictions all but declaring war on, and planning to replace, the current messaging providers for totally unclear reasons – especially when this area is one that has been gradually improving and where there has been co-operation to a considerable degree – unpaid – between NEHTA and the messaging providers.
It seems its Argus for now but essentially all commercial messaging system are on the nose as far as NEHTA is concerned. Sadly the plan offers no clues as to just how such replacement might work and just who would provide the hand holding and support that is needed in this sector. Is NEHTA wanting to get into messaging support? I think not!
This has a very much the flavour of a ‘my way or the highway’ approach from NEHTA that I cannot imagine will be well received by the vendor community.
Sounds like NEHTA has been playing both sides of the street and I would be surprised if there are not some commercial or legal outcomes of all this.
David.
21 comments:
While Argus may or may not be "not for profit", it is the most expensive clinical messaging system in the country if practices pay for the optional (but not really optional) support. Having leveraged tax payers funds (via its relationships with misguided winner-picking divisions), Argus is still very poorly coupled with the various bits of clinical software that it is designed to connect. In short, Argus has promised a lot but delivered very little...and time has basically passed it by.
While what NEHTA has done here is disgracefully unethical and possibly illegal, it is important to note that third party messaging integration layers don't have much of a future in general and specialist practice in Oz anyway. Clinical software vendors are getting more web services savvy, and they are equally getting jack of dealing with the demands placed on them by messaging vendors.
So to answer your question, NEHTA won't have to get into secure messaging support because clinical software vendors will do it for them. Most of the hand holding, as you call it, occurs with the installation and configuration of messaging layers. Once doctors simply have to ensure they have a UHI for the recipient clinician, an ePIP lever will be pulled and secure messaging will just happen.
As a messaging Provider, our only demand is to produce and comsume standards compliant HL7 and the failure to do that is the cause of the messaging problems.
With some notable exceptions pms systems are very poor at this and in notable cases refuse to do it or demand payment from the messaging provider.
The demands made are for better quality, but even when glaring errors are pointed out there is little interest in fixing the problem in many cases.
This is the point that Nehta just don't get and its this failure that makes Nehtas "Messaging Solution" a joke. They are solving the tower of babel by giving the workers an iPhone and sitting back and smuggly saying "look what we have done" The emperor has no clothes and he is wondering why he is feeling cold as the storm brews and the blizzard approaches.
They just don't get it.
The messages I read here are:
(i) NT Health considers Argus secure messaging systems have administrative and performance issues which are so bad that NT Health wants to replace Argus Messenger
(ii) The IP for the software developed in this project will be owned by the Northern Territory of Australia, and will be made available to other jurisdictions under open source licence the details of which will be defined later.
This suggests that NT health is the instigator of this ‘initiative’ and NEHTA is the complicit bridesmaid.
(iii) Communicare and Pen computing are favoured by NEHTA in that successful implementation of a production web services solution for securely sending messages from Communicare & Pen Sidebar to the SEHR are compliant with the NEHTA specification.
(iv) NEHTA has been less than open with all those it has had working on the PIP Working group.
Really, what is this all about? Are there some other hidden agendas here? NEHTA cannot be going alone on this, who else is involved?
Without wanting to start a debate about the merits of the various current clinical messaging systems, I believe that the many thousands of health professionals who use Argus every day to make their clinical communications more efficient are likely to disagree that Argus has promised a lot but delivered very little. Certainly aspects of using Argus are not as automated as one would like (such as having to manually update our electronic clinical address books, and download the digital certificates of colleagues or practices that have started using Argus), but this is not Argus' fault at all or its fault alone.
The real problem confronting the vendors of all clinical messaging systems is the lack of enough standards - and who is responsible for these standards that still don't exist...?
I hope the various web services mentioned in the Background section will be discrete as well as discreet!
In my view NEHTA is failing to engage properly with the very companies that could help it achieve its objectives. NEHTA seems to live in a world in which it thinks that e-Health challenges will be magically solved by flicking a switch on with web services, enabling hundreds of applications across thousands of sites to talk to one another. You would think that after successive failed regimes and very little to show for several years and tens of millions of dollars they would realise that they are on the wrong track.
Andrew McIntyre is 150% correct. The key to success is ensuring that all parties engaged in eHealth are committed to standards conformance (especially EMR vendors, labs, hospitals etc). This means conformance testing and contractual requirements to conform.
Incidentally, companies like ours (HealthLink) are not focused on messaging alone. Messaging is actually a relatively small part of our business. As a Health-system Integrator we provide a range of services including web-services based e-Referrals, PKI, access to key government databases, we handle more than 3,000 customer support calls each month and we actively liaise with parties across the sector on all manner of related issues.
In nearby New Zealand, where we generally have quite a good relationship with government, we provide web-services based electronic referrals to whole regions of the country. We support online requests to key resources and have a number of projects in the pipeline.
Bickering with NEHTA over whether and how messaging should work, while at the same time no effort is made to address the key impediments is an extremely frustrating pastime. Some months ago I rang Mr Fleming to discuss the issues, he promised to follow up with an appointment to meet but I heard nothing from him.
I remain puzzled at the situation, but very busy, working in environments such as NZ and Canada where there is at least some high level understanding of what needs to happen.
Tom Bowden CEO HealthLink Ltd
I dont want to enter the NT/WSMA debate.
However the first 'Anonymous' comment is the sort of ill-informed clap-trap that is serious cause for concern for messaging in Australia.
The view that "third party messaging integration layers don't have much of a future in general and specialist practice in Oz" is facile, impractical and cant be based on experience at any large scale.
Clearly the comment "NEHTA won't have to get into secure messaging support because clinical software vendors will do it for them." must be based on a total lack of experience in the messaging space.
End user support is quite a burden in cost and resources, regardless of what technology is used and all messaging providers can attest to that. There is now a large range of technologies represented by the messaging vendors (including web services) but all mesaging providers will attest to the case that end-user support is a significant effort and must be provided to ensure the consistent interity of the messaging pathway. Internet goes down, firewalls are changed, someone re-gigs the doctor's network and so it goes on. It is seldom a reflection of the technology or the reliability of the messaging software.
Clinical softare vendors will not want to assume this responsibility because it will turn out to be pure cost! Their support costs will increase dramatically (I would suggest double) and they will not have avenues for charging for that extra support to recoup their costs. Saying clinical software will provide the support is a 'con job' that the clinical software vendors will eventually wear if they are not careful.
Tuesday, February 09, 2010 8:45:00 AM said “I hope the various web services mentioned in the Background section will be discrete as well as discreet!”
Absolutely, and whoever undertakes the development with NEHTA and NT Health will need to be very circumspect as well. Disturbing the wasp nest can be very disruptive and that will certainly drive change, but those involved in creating the disruption need to watch out when the wasps get into a real frenzy.
Well argued Ross Davey. It begs the question 'Is this perhaps an opportunity that BT can build upon now that it has its foot in Peter Fleming's door.' If he won't talk to you Tom we do have to wonder why in the light of NEHTA's recent manoeuvrings.
A good word for Argus. Argus has made significant progress over the last decade in sharing information across the very difficult interfaces of the health system (let alone the technical interfaces). It worked and it still works, and it is being used in a LOT of places to help with passing on the baton of care. Hands up - how many sites/initiatives first used or still use Argus to send their first electronic clinic referral/discharge referral/other transmission? I think people would be very surprised how widespread it is and how much it has pioneered any pogress we have today.
Good grief! 'Anonymous' said ".... Argus .... is the most expensive clinical messaging system in the country if practices pay for the optional (but not really optional) support".
Where did he get that from?!
I understand that it costs $99 per practitioner for annual Help Desk for support for GPs, specialists and allied health. Any cheaper and it would have to be free, and then how would they survive?
My practice considers this very reasonable.
OK - messaging, transactions, fees - are inter-related 5 cents per message? 10 cents? 25 cents? 75 cents? $1.00? $1.50 - hidden fees ........... stop right there. Government bureaucrats want to control this space, they are worried that if they don't get control they will be held to ransom. The thinking is to simplify it down to one major player, negotiate an acceptable fee to both parties and move on.
So the party which can provide a solution which works and which government can control (?own) is the party that will end up making the money. That is their thinking in a nutshell. It might sound nutty but that's how it is - silent, unspoken, deceitful,"disgracefully unethical" milking everyone for their ideas under the pretence of collaborating with some of the more gullible vendors but sadly not "illegal' as a previous commentator suggested.
"Government bureaucrats want to control this space, they are worried that if they don't get control they will be held to ransom. The thinking is to simplify it down to one major player, negotiate an acceptable fee to both parties and move on."
So the concept of establishing Standards and having a contestable marketplace to avoid being held to ransom through competition is a sham???? So the Standards agenda of NeHTA is a sham? That cant be true! Can it?
"I understand that it costs $99 per practitioner for annual Help Desk for support for GPs, specialists and allied health. Any cheaper and it would have to be free, and then how would they survive?
My practice considers this very reasonable."
But that's $99 more per practitioner than you pay for other messaging solutions - just so you know.
Thank you Tuesday, February 09, 2010 11:37:00 AM I agree. Why else would the bureaucracy be so difficult to deal with? Why else would NEHTA behave the way it does? Cooperation, collaboration be blowed.
"But that's $99 more per practitioner than you pay for other messaging solutions - just so you know."
OK genius. And who pays for support of the end-users?
Oh its the senders you say. And who is that?
Pathology practices, hospitals, specialists (They are rich they can afford it) Very equitable...Not!
And so what happens when GPs start to send messages in greater volumes? Who pays then??
“So the concept of establishing Standards and having a contestable marketplace to avoid being held to ransom through competition is a sham???? So the Standards agenda of NeHTA is a sham? That cant be true! Can it?”
In a strange kind of way, difficult though it may be to believe - it certainly can be true. Why is this so?
Standards have been bandied around for a long, long time. We all know that standards are important and in time they will become well defined, widely implemented and embraced by all, we hope. But it has been and will continue to be a long time before that day arrives. In the meantime standards will continue to evolve but they will not be the panacea to all of ehealth as some seem to hope will be the case.
What this means is that there is nothing wrong with advocating and pushing for the “concept of establishing Standards”. However, will that really provide everyone with the “contestable marketplace” you refer to and that many hope for? Probably not - good in theory, but in practice another world will prevail.
Hence the Standards agenda of NeHTA is not a sham, it is quite genuine. But do not overlook the other agenda a la one major player. Get the major player into place to deliver the infrastructure and the core processes, adopt open standards as and when they become available, and encourage ‘others’ to interface to the core processes via the major player with certain provisos (terms and conditions = control = not able to be held to ransom). The corollary applies ie. others can still be held to ransom.
As usual folks, I will not hide behind any veil of anonymity. There are a couple of points Pen Computer systems would like to make. Firstly, NEHTA is not a customer of ours. We have been formally engaged once, by NEHTA to provide a review of an Interoperability Framework document way back in the Reinecke era. Our customers are primary health providers, state governments, the Federal Government and a host of agencies that represent best practice in chronic disease prevention or management programs.Pen enjoys a contract with NT Health to maintain a link between its Ferret product and the NT SEHR Repository, and between HCN Medical Director and the NT SEHR Repository. This required a linkage between these products and Argus messaging. When we were asked to test WSMA as a webservice to do that job we helped NT Health massage the product so it would do the job. We did that on a goodwill basis and would do that sort of work for any of our customers. As most would know, Pen has contributed to the evolution of eHealth standards and applied them progressively over a long period of time to meet customer needs. We have been building solutions using web services for several years and it is not at all surprising that NT Health would be following that strategy. It never required a NEHTA to advise Pen to go down that path either..we were already doing it. There may be some unanswered questions about the NT Health WSMA initiative but my comments are purely directed to the right of a customer to "move with the times", and in this instance, I think that NT Health have been tardy, if anything, in pursuing a web services solution. Most of the eHealth vendors would be considering the power of the Web in framing their strategic direction. If WSMA is any good, and in the public domain, there will be those that use it and others will develop their own tools.
I agree that Argus is a good start and is working well for our practice. There is no per message cost and a cheap $99 per GP cost per annum (in my view). The support staff are generally good but Argus is expanding so rapidly that there will always be administrative hiccoughs when this is the case.
The savings in mail/stamp costs in my practice are huge, let alone the knowledge that
1) the 'READ RECEIPT" protects me medicolegally
2)No more last minute phone calls when patients lose or forget their referrals and present to the specialist.
It is clunky to have to update the Address Book manually but I am sure all these things will improve and its a START!! The letters from the specialists come straight into my patients files after they are read and I am saving a fortune in computer scanning staff time costs. My staff love it as well as it reduces scanning of letters-which they hate doing
A winner all round I would say and I wish NEHTA would fund the Divisions more and longer to implement it across Drs/Hospitals/Paramedicals.
I also wish "NEHTA would fund the Divisions more and longer to implement it across Drs/Hospitals/Paramedicals". Wouldn't it be wonderful if NEHTA, DOHA and the Jurisdictions, could see the merit of doing so. Oh, but they can't do that because that would mean they would be picking winners - it's not allowed. They prefer to seed fund a pilot until it just about gets going and then pull the plug and start again somewhere else. It's quite unbelievable that these people are permitted to keep playing such games year after year. They wouldn't last 3 months in the private sector.
"This suggests that NT health is the instigator of this ‘initiative’ and NEHTA is the complicit bridesmaid."
What is the situation here? Is NEHTA calling a tender? Are the specifications being made available to everyone or is this a closed shop? What is NEHTA's role - is it morphing into a software developer and implementer or what? Or is it a source of funding for developers to draw upon?
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