Senate Estimates Gets Tetchy on E-Health and NEHTA. Some Truths Come Out!

There were some fun and games at the Community Affairs Senate Estimates hearing on February 10, 2010.

The full transcript is here.

http://www.aph.gov.au/hansard/senate/commttee/S12751.pdf

The cast was made up of Senators and the following luminaries from the Department of Health and Ageing.

Ms Jane Halton – Departmental Secretary

Ms Rosemary Huxtable, Acting Deputy Secretary

Dr Penny Allbon – Director of the AHIW.

Ms Jan Bennett, First Assistant Secretary

Ms Liz Forman, Assistant Secretary, eHealth Branch

The full exchanges are below for your reading pleasure:

My comments, on what we have learned, are as follows.

Comment 1: Good news it seems – at least the AIHW and NEHTA are working to get basic information standards in place.

Comment 2: It is now totally clear that on July 1, 2010 there will be marginal to no change in the Australian Health System and that July 2 and many days and weeks to follow will be the same as June 30, 2010. The HI Service is to be phased in – timing unclear and not disclosed.

Comment 3: Medicare and NEHTA have set up a sandbox to play with the HI Service but essentially have no idea how it will go when subjected to the real world. This is really not the way you conduct a national program implementation I believe.

Comment 4: The commercial software providers have not really been brought into the tent and assisted as much as is possible to get their end of the service done.

Comment 5: DoHA has actually no idea who will want to use the identifiers – no-one has committed – all saying it is a good idea etc.

This says it all.

“Senator BOYCE—I guess the question is: how do we know when that enthusiasm is likely to turn into action? You do not have any sense of that, Ms Forman?

Ms Forman—I do not have a sense of that, no.”

Comment 6: There is clearly some fear the legislation might not have a totally smooth passage through the Senate.

Comment 7: Senator Boyce has clearly had some software vendors express concerns about how NEHTA is going about impinging on their commercial rights and trade secrets. I suspect, in fact, the level of trust between NEHTA and the software providers is pretty low right now. That again can hardly be a good thing for any national roll out.

Comment 8: The way private hospitals and private providers and practitioners are out of this loop is pretty spectacular.

Comment 9: We now know the secure messaging program will have a major test in April and an IHE Connectathon that is being funded by DoHA (not NEHTA).

All the following is worth a browse for if only so that expectations can be adjusted – way down.

Page 26

“Senator BOYCE—Unfortunately, it seems indicative of a lot of areas in Queensland Health. We have NEHTA and all sorts of work going on around developing e-health identifiers. Has the institute been involved in any of the development of standards for NEHTA or any of the NEHTA work?

Dr Allbon—Yes, we certainly have. We regard it as a really important leadership role on our part to ensure that the development of e-health will ensure that the data that we collect and the information remains compatible and that we keep time series. There are some risks from e-health which we are guarding against, as well as enormous benefits for the richness of statistical information.

Senator BOYCE—I am trying to think of how to phrase this. Does this include not just straight health data but the standards around the processes of developing the software and using the software?

Dr Allbon—We do not get involved in the software side of it. What we do get involved in is really the data supply chain—how that data will be collected, what the standards and definitions are and, therefore, how they will flow through into collections.

Senator BOYCE—Would you expect that, in all cases, they would meet international standards?

Dr Allbon—The standards that we have in relation to data are national standards, so we are looking very much for continuity with the information that has been collected in the past. In terms of the software and remaining developments of the interoperability, my understanding is that international standards are being used, but that is not my field, so I cannot comment on it.

Senator BOYCE—Okay. I may have some more questions put on notice around that depending on what NEHTA tells me this afternoon.”

Page 124 on – For 29 Minutes:

“[9.14 pm]

CHAIR—We are now moving to outcome 10.

Senator BOYCE—I put some questions on notice and asked some questions at the last estimates about ehealth.

I was told in the answer to question E09-245:

NEHTA is … working with the primary care sector and primary care software vendors to develop an implementation

pathway.

Would you be able to give me a list of who in the primary-care sector are the primary-care vendors that NEHTA has been working with in terms of developing an implementation pathway?

Ms Bennett—I am sure we could provide that information, though we may have to go to NEHTA to get it and then provide you the detail in follow-up, if that is all right.

Senator BOYCE—So you would provide that on notice?

Ms Bennett—Yes, if that is okay.

Senator BOYCE—That is fine. My next question was, when we have that list: when did the work on implementation which each of these organisations in the primary care sector and the primary care software vendors begin?

Ms Forman—That work and that collaboration is still very much at the discussion stage I think.

Senator BOYCE—So has the work actually commenced or are they talking about working?

Ms Forman—They are talking about working. They also have a working group relating to secure messaging where quite a significant amount of work has been done with the vendors.

Senator BOYCE—Is secure messaging being undertaking or is talk about secure messaging happening?

Ms Forman—Talk and development of software so the vendors are able to work towards bringing their software in line with the NEHTA specifications and then testing that.

Senator BOYCE—So is that being trialled?

Ms Forman—That is underway.

Senator BOYCE—Are there actual trials happening? Is software that has been developed to meet the NEHTA specifications actually being trialled right now?

Ms Forman—It is being developed, and we are expecting there to be a testing workshop in April.

Senator BOYCE—Can you explain to me what happens at a testing workshop?

Ms Forman—I can. In fact, the department is assisting in sponsoring this through IHE. They develop a system that sets up all of the specifications and the vendors are able to come together and test their product and see where it is meeting the specifications and where it is not.

Senator BOYCE—So who comes along to this meeting? NEHTA is there and anyone who would like to be a software vendor?

Ms Forman—That is correct.

Senator BOYCE—This is happening in April where?

Ms Forman—The location?

Senator BOYCE—Yes.

Ms Forman—I would have to take that on notice.

Senator BOYCE—And this is just around secure messaging?

Ms Forman—That is right.

Senator BOYCE—It is not in Canberra?

Ms Forman—I do not think so. I am not sure of the location.

Senator BOYCE—If you could take that on notice, that would be good. Does this assume that all those software vendors want each other to see what they have done? Are they all going to be in the one room demonstrating how they think they have dealt with the issue?

Ms Forman—I would have to take the fine detail on notice. I can get a description for you.

Senator BOYCE—Wouldn’t part of this be that some of those vendors would be hoping to get a commercial advantage over other vendors by having thought of a way of doing it in a way that other people are not doing it?

Ms Forman—It is very much around meeting the standards. There are a number of ways that vendors can meet the standards.

Senator BOYCE—But the standard is not prescriptive, is it? It does not say you have to do this, this and this. It says, ‘This is what the outcome has to be,’ doesn’t it?

Ms Forman—A standard does give a range of ways of achieving the outcome.

Senator BOYCE—Would any of those vendors in your view be concerned about confidentiality issues at that workshop?

Ms Forman—I am not sure. I can certainly ask NEHTA for advice on that issue.

Ms Bennett—Just to be clear: the workshop is a NEHTA workshop. It is not something the department directly—

Ms Forman—No, we are actually funding IHE to run the Connectathon.

Senator BOYCE—If NEHTA are not going to appear themselves, there has to be a forum in which we can ask questions regarding what NEHTA is doing. The minister today introduced the Healthcare Identifiers Bill 2010 into the House of Representatives. This is to bring NEHTA from a transition to a reality. Is it intended that all the healthcare identifiers would be rolled out nationally?

Ms Halton—When you say ‘all the’, the healthcare identifier nominated in the legislation would be national, yes, Senator.

Senator BOYCE—But we have the individual, the medical provider and the organisation—that is what I mean by ‘all the identifiers’.

Ms Halton—Yes.

Senator BOYCE—There are three categories of identifier.

Ms Halton—Yes, but basically you will have one and it will be relevant nationally.

Senator BOYCE—Who will have one?

Ms Halton—You would have one. I would have one.

Senator BOYCE—As an individual consumer?

Ms Halton—Yes.

Senator BOYCE—But all the medical providers also have to have one—

Ms Halton—One.

Senator BOYCE—and all the hospitals would have to have one.

Ms Halton—The thing about this is that it sounds so simple, but, boy, when you try and crash your way through the existing arrangements, you realise it is not simple. I am sure the minister next to me would have some views on this from when he was Minister for Human Services. With the way we currently classify ‘location of practice’, for example, an individual practitioner may have multiple identities because they practice in multiple locations. What we will do here is uniquely identify the practitioner, regardless of where they are, and uniquely identify locations and, dare I suggest, you and me.

Senator BOYCE—There are three categories of identifier, but it could get even more complicated for medical practitioners who are patients as well, couldn’t it?

Ms Halton—Yes, but let’s be honest—

Senator BOYCE—But we will not worry about that one.

Ms Halton—They are allowed to have two identities, Senator, because they are not inconsistent.

Senator BOYCE—With these three types of identifier, each—oh dear, we get into the organisational side of things there—individual entity within each category will have a unique identifier.

Ms Halton—That is right.

Senator BOYCE—It is intended that this be rolled out nationally through all three categories by when?

Ms Huxtable—Subject to the passage of the legislation, the health identifier service comes into effect on 1 July this year. As you will see in the legislation, Medicare Australia is the HI service operator from 1 July.

Senator BOYCE—And you would expect an operational national identification service—

Ms Huxtable—There has been a very significant amount of development work leading up to this point, both in crafting legislation and in ensuring that the appropriate structures are in place. The actual testing of the identifier service cannot happen until the legislation is passed, but that will set us on train to implementing the HI service.

Senator BOYCE—The states, in the main, already have their various independent health identifier systems. How is that brought into alignment? When will that happen?

Ms Huxtable—Senator, the states and territories are very much part of the development of this legislation. In fact, the legislation has been worked through in a subcommittee of AHMAC, the Australian Health Ministers Advisory Council. The Commonwealth legislation establishes the HI service and the identifiers will apply to state organisations also. It is only in regard to privacy that there is some state legislation that will need to be passed in time. However, the Commonwealth legislation has pre-eminence in that regard until that occurs.

Senator BOYCE—So what you are saying is that the states will stop using their current identifier systems and start using a national one? Is that what you are saying?

Ms Halton—Yes.

Ms Huxtable—Yes, the states, as you would know, have a range of identifiers that are currently in use. The major issue that the HI service will address is where patients, as they present at different settings, are identified in different ways. That leads to all sorts of discontinuity and impediments to continuity of care, increases duplication and leads to time being wasted in trying to match the record with the patient. These unique identifiers will apply nationally and will be incorporated into state systems as they are into private practice, effectively.

Senator BOYCE—Ready to start being used by patients, hospitals and medical practitioners by 1 July.

Ms Huxtable—The way in which it works for the individual patient is that when a patient presents for a GP consultation, for example, and provides their Medicare card, that Medicare card enables the provider to draw down the unique identifying number for the patient, so patient records will be populated over time as people present at a practice and have a consultation.

Senator BOYCE—So the time of population starts on 1 July, is that right?

Ms Huxtable—Yes, subject to the passage of legislation, of course.

Senator BOYCE—Obviously, yes. Are live trials of these systems being conducted with real patients now?

Ms Huxtable—I would need to get the details. NEHTA and Medicare Australia have worked together very closely in establishing the service. I can be corrected if I am wrong, but my understanding is that the systems are in place but will not be fully tested until the legislation has been passed. I can correct the record if that is incorrect.

Ms Halton—Essentially, Medicare Australia have set up a model health community and they have been doing—

Senator BOYCE—What is a model health community?

Ms Halton—It is a demonstration of what the e-health—what the capability is—

Senator BOYCE—It is a virtual community, so to speak.

Ms Halton—Yes, but in test, if I can describe it that way. You know how a lot of things are done in test environments to demonstrate capability and capacity. In much the same way, the health identifier arrangements have been set up to ensure that they are robust, they work et cetera. They have not been doing it in respect of real people, if I can put it that way, but they have done it in such a way that we have confidence that it will work if the legislation passes and we can push the ‘go’ button.

Senator BOYCE—Would you go into a bit more detail as to what gives you that confidence? What have you seen?

Ms Halton—There are a number of things that give me that confidence. Basically, this is a project that we have been working on for a good number of years—as you know well because you keep asking us questions about it. Medicare Australia are the agency who have had responsibility for running the Medicare arrangements for a long time—they understand these issues particularly well and they have had phenomenally close working relationships with NEHTA as part of this. We have had state and territory jurisdictions and the IT providers crawling all across it—it has been a very open and transparent arrangement. Medicare have put the proposed arrangements into a test environment so they can demonstrate the capability actually works.

Short of going live—and as you understand full well, until you actually do push the green button you cannot give a guarantee—but to the extent you can test, retest and practise these things—

Senator BOYCE—But you could do a live test in a contained environment, for want of a better term.

Ms Halton—That is effectively what we have been doing, without real people in it. Does that make sense?

Senator BOYCE—Real people are always the scary bit of any equation though.

Ms Halton—Indeed, but we have, sort of, dummy people—can I put it that way, Ms Forman?

Ms Forman—Yes.

Senator BOYCE—You can, Ms Halton!

Ms Halton—This is going to look terrible in Hansard. Notional people! I am corrected—notional people.

Senator BOYCE—The reason I was asking about that is that I have been told by people in the industry that the full specifications for the universal health identifier and how this testing has taken place are still a secret to people in the industry. They do not know what the full specifications are for the UHI and other identifiers— these have not been shared with people in the industry.

Ms Halton—The legislation is pretty jolly clear.

Ms Huxtable—We have consulted significantly. As to the specific discussions that may have occurred between NEHTA, Medicare Australia and others, we would need to take that on notice—if you are talking about the technical specifications of the service.

Senator BOYCE—So who does know the technical specifications—Medicare and NEHTA?

Ms Huxtable—Medicare and NEHTA are the ones that have worked collaboratively to get the service up and running. The work that we have done is around the legislative framework which, basically, is the umbrella under which the service operates, and there has been very significant consultation in respect of this legislation.

Senator BOYCE—Yes, but my questions here are going towards the more technical specifications.

Ms Halton—Yes, I understand. Medicare, as the deliverer, can answer those very particular questions. If I sit here with effectively two hats on—as a director of NEHTA and also as a portfolio secretary—I can say to you that I do have confidence in this.

Senator BOYCE—And as a director of NEHTA, presumably.

Ms Halton—Absolutely.

Senator BOYCE—Let me just confirm with you, Ms Forman, that anyone who wants to come is invited to your workshop for software companies that are interested in this.

Ms Forman—That is correct. It is the IHE Connectathon.

Senator BOYCE—A connectathon! Okay!

Ms Halton—That will go into the lexicon, Senator!

Senator BOYCE—Again, I have had concerns expressed to me that, even with this sort of development, six months would be a quick and short time frame in which to assure yourself that the software and the interfacing of all these identifiers worked. But you are saying that it can be done in the period from when the legislation is passed until 1 July.

Ms Halton—Senator, we have been working for a lot longer than six months on this.

Senator BOYCE—Sorry, but it has been said to me that you would want six months from when you first did live testing to get it right.

Ms Halton—We know that providers—I am not allowed to say ‘in the space’, because I will be fined—

Senator BOYCE—Sorry—what are you not allowed to say?

Ms Halton—‘In the space’, but, if I acknowledge that I am not allowed to say it before I say it, I do not get fined.

Senator BOYCE—I would have thought that was a double fine, personally, Ms Halton!

Ms Halton—This is a really large industry and a large part of the health system. There are a whole series of issues about rolling this out. We do not expect that on 2 July, miraculously and all of a sudden, capability will appear across the health system. We know that some people are preparing themselves now and will be in a good position very early while some people will take longer.

Senator BOYCE—When you say ‘some people’, do you mean software vendors or organisations or GPs or what?

Ms Halton—All of the above. Some people who put software onto doctors’ desktops are already looking to make sure that they are NEHTA compliant so that they are in a position to use this capability whenever it becomes available. Some people will be slower to react. That is an issue for the market. My strong advice to software providers is that this is going to happen, subject to passage of the legislation, and they ought to be thinking about NEHTA compliance, because we all know that, inevitably, e-health is going to happen. If they want to be part of that world they need to be looking at issues around compliance.

Senator BOYCE—Are you confident that they all have sufficient information to do that and to be compliant by 1 July?

Ms Halton—I cannot give you any assurance as to what level of attention they have paid to this.

Senator BOYCE—All the information is publicly available—all the specifications et cetera—that any one of those parties would need?

Ms Halton—We believe that there is sufficient information in the public domain for anybody who wishes to use the capability in the short term, subject to passage of the legislation, to be able to do that. We know that a couple of the big providers are already moving in this area. People have made investment decisions. We absolutely understand and respect that; that is their choice. Some people are making those decisions; some people are not.

Senator BOYCE—I am not talking so much about the investment decisions but simply the availability of information so that I, as an individual in any of those areas who needed an identifier, could satisfy myself that I have all the knowledge I need to be confident that I could be compliant on 1 July.

Ms Halton—I believe that is the case. Indeed, this workshop that we have just talked about is precisely part of people being able to assure themselves of exactly that matter. Ms Forman, is that correct?

Ms Forman—Yes.

Senator BOYCE—Could we just go back to the answers you gave, Ms Halton, when I asked, ‘Is it a national rollout from 1 July. Will all the identifiers for all the parties, all the stakeholders—whatever we want to call them—be ready from 1 July?’ The answers were ‘yes’, but now you are saying, ‘Not everyone will be taking part on 2 July.’ Can you try to explain to me what you think it will look like on 2 July, then?

Ms Halton—Probably very much like it does now, because, as I said, there will not be a revolution overnight. The capability will be there. Some people will get their identifier; some people will go to a provider who has, for example, picked up the software, which is already looking to enable this. So what you will have is progressive rollout over time, and what we expect it is that you will see some things happen more quickly: you will see point-to-point communication happen more quickly; there are some geographical areas that are already more prepared for this; we have some provider groups who are already working on these issues quite proactively. So I think what you will see is progressive rollout in different ways in different areas across the country. One of the things I genuinely hope, quite frankly, is that patients will go to the doctor and say: ‘Why can’t we get this stuff electronically now? I understand there is the potential. Why can’t we?’

Senator BOYCE—I am told that we have developed a standard here for the organisational identifier number that we have. Is that correct?

Ms Halton—There is a standard. There is a standard for all these numbers. It depends what you mean.

Senator BOYCE—I know, but I mean the one related to organisational identifiers.

Ms Halton—I am not clear how you are differentiating that from the other identifiers.

Senator BOYCE—Okay, so is there one standard for all identifier numbers?

Ms Halton—There is a standard. There may be some subtlety to your question which I do not understand.

Senator Fierravanti-Wells interjecting—

Senator BOYCE—No, we are talking about a national standard.

Ms Halton—Yes.

Senator BOYCE—But I understand that there is an international standard—it is on 8824:1990(e) for anybody who wants to know—that has been around for over 20 years now. On the basis of information I have—and I am certainly not an expert on this topic—it is considered safe and robust, and yet it was not used for our identifiers. Can you tell me why?

Ms Halton—We will have to take that on notice

Senator BOYCE—I would just like a fairly careful explanation of what we thought was wrong with the international identifier and what problems, if any, that could create in terms of international competitiveness for anyone developing software and the like here.

Ms Halton—On one occasion the media commentators took great offence to my use of the term ‘geek speak’ in estimates, so I will take great delight in saying again in estimates that we will give you an answer in plain English.

Senator BOYCE—Thank you. I will move through this a bit faster, shall I, Chair?

CHAIR—I think you should, and then Senator Siewert has some questions.

Senator BOYCE—Have any clinician groups yet signed up to use the identifier system from 1 July?

Ms Forman—The sense of it is probably not really one of ‘signing up’; it—

Senator BOYCE—Have any committed? Do you know who is going to be there on 1 July saying: ‘Give me my identifier. I am starting in this system tomorrow’?

Ms Forman—We have certainly had a lot of very positive feedback from the provider sector, particularly, during the public consultations. We had consultations during July-August and then again from November to January, and there was a lot of enthusiasm amongst a whole range of provider groups. We had a lot of the organisations represented there—surgeons, allied health, GPs, nurses—and a lot of enthusiasm. That is probably the best indication we have that providers are keen to get this and keen to use it.

Senator BOYCE—I guess the question is: how do we know when that enthusiasm is likely to turn into action? You do not have any sense of that, Ms Forman?

Ms Forman—I do not have a sense of that, no.

Senator BOYCE—Perhaps you would be the best person to answer this next couple of questions, Ms Halton. NEHTA is corporation limited by—

Ms Halton—It is a company limited by guarantee.

Senator BOYCE—You may or may not be able to answer this: is there any intention that NEHTA—when we drop the ‘T’ out, presumably—will function as a commercial entity?

Ms Halton—It is owned by the Commonwealth, states and territories so, whilst it is constituted as a company, it is a company with a particular purpose. We have not had, amongst the states and territories, a discussion about the future governance arrangements. I have to say my personal opinion is it is unlikely it would function in a commercial way. I cannot say one way or the other, but certainly given its function is quite specified and its owners are Commonwealth and state ministers, I cannot see why that would be the case.

Senator BOYCE—This concern has been put to me by people from private companies or who are stakeholders who are concerned that they are being asked to share secret commercial information with an organisation that they are not entirely confident may not at some stage be in competition with them.

Ms Halton—Yes. Let us be clear, whilst I cannot give you a categorical guarantee in relation to anything because it is not my guarantee to give, I think we do need to understand that NEHTA has been set up by the jurisdictions for some very particular purposes, most notably to ensure the efficient, economical rollout of electronic health across the country. If I, in my case as a director, with my state and territory colleagues were interested in basically building some vast monolith we would have indicated that. That is not what we are interested in. We are actually interested in the e-health world where the commercial sector actively has a role in delivering and driving adoption et cetera. The notion that we as governments could supplant or indeed play in that space, I frankly think is laughable.

As I said, I cannot guarantee that, but NEHTA has a very particular charter which is about ensuring that the investment that we are going to put in as governments means we do not get multiple rail gauges but we actually get the capacity of this system to deliver good outcomes for patients. State and territory colleagues are running very large systems and they want to get maximum value for dollar. I have the national interest absolutely front and centre in terms of patients and the dollars we are spending. It is not our business, core or otherwise, to be competing with the commercial sector.

Senator BOYCE—Thank you. I will put my other questions with regard to this on notice.

[9.43 pm]”

As I have said before these hearings are a gift that just keeps on giving!

David.