Quote Of The Year

Quotes Of The Year - Paul Shetler - "Its not Your Health Record it's a Government Record Of Your Health Information"


H. L. Mencken - "For every complex problem there is an answer that is clear, simple, and wrong."

Monday, March 29, 2010

The Australian National Health and Hospitals Network - Where Does E-Health Fit? - Draft

The following is a Draft of a Short Paper for a Trade Journal – Comments and critique are welcome!

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In the report published in early March on the Commonwealth Government’s National Health Reform Plan there were a major set of structural reforms announced.

In brief these are (taken from page 9) of the report the Commonwealth Government:

  • becomes the majority funder of public hospitals;
  • takes over all funding and policy responsibility for GP and primary health care services;
  • dedicates around one third of annual Goods and Services Tax (GST) allocations currently directed to state and territory governments (referred to throughout this document as ‘states’) to fund this change in responsibilities for the health system;
  • changes the way hospitals are run, taking control from central bureaucracies and handing it to Local Hospital Networks; and
  • changes the way hospitals are funded, by paying Local Hospital Networks directly for each hospital service they provide, rather than by a block grant from the Commonwealth to the states.

As with many such large scale reform proposals the more detailed revelations as to what is actually planned seem not to come in the initial document release and in the case of e-Health the report specifically notes that there are more detailed announcements in this specific area to come.

That Information Technology is an area to be addressed is seen on page 19 where “improved integration of information technology across our health system” was a key element of feedback received from the consultations held following the release of the NHHRC Final Report. This is confirmed in the press release associated with the report’s release where we find the following.

“On the basis of these reforms, over the coming weeks and months, the Government will announce critical additional investments to:

  • train more doctors and nurses;
  • increase the availability of hospital beds;
  • improve GP services; and
  • introduce personally-controlled electronic health records.”

As I write this, in late March, 2010, we have seen the additional clinical training announcement but are still waiting for the other three.

The final plan to introduce “personally-controlled electronic health records” is apparently the major thrust of a relatively imminent announcement. Just what these actually are and the implications of this plan are totally unclear at this point.

Before commenting specifically on this proposal we need to flesh out the other aspects of the plan a little. The reform plan talks of small networks of public hospitals of 3-5 or so hospitals. (It is mute on how these will relate to primary care and the private service sector (hospitals, radiology, pathology etc). According to the AIHW there are 736 public hospitals so we can assume that there will be around 170 Local Networks formed.

On the basis that we do not as yet have an e-Health plan announced what needs to be included?

First, any new plan needs to closely review the directions which have been agreed by the States and Territories to date in the form of the National E-Health Strategy which was released late in 2008.

Second any new plan needs to recognise that there are significant ‘facts on the ground’ already in place and in process and these, where appropriate, need to continue on uninterrupted.

Third the plan needs to properly address coordination of care and information flows between all the various elements of the health sector. It needs to be genuinely inclusive of the public, private and community health sectors.

Forth there is a major issue in e-Health regarding just what should be addressed at a national level and what is appropriate for local decision making and governance. My preference here is for a high degree of local autonomy within a pragmatic, flexible and responsive national e-Health standards and governance framework. If this is not addressed the risks of all sorts of failures is very high. Careful decision making will be required to determine the correct scope of national versus local provisioning and infrastructure etc.

Fifth any concept of shared personal health records needs to be deferred until the automation of all public and public care providers, and clinical messaging is well advanced and consistently standardised. Once this is achieved is the time to take the next steps of clinical information sharing with very high levels of consumer consultation around areas such as security and privacy. This is very much a walk before you run, essentially bottom / middle up approach rather than top down in most aspects.

Even with this limited ambition there are a range of problems that will need to be addressed.

An obvious one is that even if the number of local networks is only half of what seems to be planned there are a range of infrastructural elements which will be too small to be efficient and practical. E-Health is very likely in that basket.

A possible solution to address what is needed may be to adapt the Health Information Exchange (HIE) Model which is seemingly being quite successful in the US. In this model primary care computing and care co-ordination is central – empowered by secure information flows, with patient consent, between health care providers.

Appropriate aspects of the information flows can also made available to consumers via clinical portals and a Personal Health Records (PHRs). Everyone needs to realise PHRs are still a very unproven technology and may not actually prove to be all that useful or valuable in the longer term.

Appropriately sized Health Information Exchanges – maybe covering four or five local networks are both feasible and demonstrably effective.

If we do not see a proposal similar to this emerge from the Government in response to the NHHRC report and the National E-Health Strategy I will be very disappointed.


National E-Health Strategy – September, 2008


National Health And Hospitals Network Report – March, 2010


Ministerial Press Release – March 03, 2010


Primary Care Based Health Information Exchange (see for example).


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Thanks in advance for any comments!



Anonymous said...

The only problem with this is that separating e-Health infrasructure into multiple independent "Fiefdoms" is inherently inefficient. One only has to look at the centralisation of IT in South Australia or the NSW Radiology archive project to see that there is a need for entities bigger than local networks to derive economies of scale.

Adam said...

This is a good piece of analysis - health information exchanges servicing regionally based communities of practice is the way we will realistically tackle eHealth in this country. I agree that these communities of practice will need to be of sufficient size to drive meaningful economies of scale (serving a population base of say 250,000 - 1,000,000). The key issues will be the degrees of freedom that these projects are given (they must be made to conform to a minimum set of robust standards), establishing an appropriate funding mechanism for exchange implementation and ongoing support (which does not exist today), and ensuring the right project management, change management and technical capability is provided in support of these implementations. It is this last point that worries me the most - there are a lot of interested amateurs in this space in Australia, but very few people with robust and proven skills in these domains.