Quote Of The Year

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

or

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

Thursday, March 25, 2010

A National Expert Speaks out on the Looming Disaster NEHTA is Guiding Us Towards.

Dr Andrew McIntyre let me know (via Skype) he had posted this blog on the Medical Objects Web site about 12:20am this morning. Needless to say I was asleep at the time and picked up the instant message when I came down to the office this morning.

This is very serious stuff indeed I believe.

Over to Andrew.

NEHTA – On the road to nowhere?

National Health IT programs do not have a good record of success in general, and Australia has been a good example of that to date. I don’t think anything is about to change.

The reasons for this will no doubt be well understood in time, as history looks back and shakes its head in dismay at the wasted resources and opportunities. It’s hard to pinpoint the reasons for failure until you have success to contrast it with. I think a large part of the problem is the top down approach to a problem that can only be solved bottom up. By many measures Australia has been a leader in eHealth to date, but I don’t think any of that can be attributed to government policy or support as its mostly been bottom up. Certainly the National eHealth Programs of the past have failed to progress the situation and have in many ways just distorted the market for the worse.

While some will say the issue is “Change Management”, I think this is wrong. To have change management you need to have a change worth implementing and to date the quality has not been there to justify change. The quality needs to be in the software and eHealth is a complex beast to tame. To progress it we need to have the foundations to build on and currently they are sitting on swamp. Netha appears determined to adopt the tunnel vision of its “Stakeholders” i.e. The state health departments and ignore the bigger picture of the international markets and standards bodies. Despite ample evidence that the existing infrastructure is cobbled together and working in the most fragile manner conceivable they want to march on and implement national programs without any compliance agenda on the horizon for at least 2 years. Building anything on the current infrastructure without a resolute compliance program is a recipe for disaster.

Australia currently has good penetration of HL7 V2 messaging, but the quality is patchy and the interoperability extremely fragile. Any change to messages results in failures and in effect we are locked into a situation where only a few systems can handle compliant data. This is interconnectivity and is a long way from interoperability, it’s a road to nowhere and in reality the known errors in existing lab messages cannot be corrected because of the fear of breaking existing systems. Despite Australia having compliance testing available there appears to be a complete lack of understanding of its importance by Nehta. Rather than underpin the cracking foundations before trying to renovate the building Nehta is determined to add another 3 stories to the building. The earthquake in Haiti demonstrated the dangers of a city built without adequate building regulation. Nehta’s plans will result in major loss of life at the first sign of a tremor, even if they manage to build something (which they have failed to do to date).

Interconnectivity without interoperability is a recipe for disaster and this appears to be the agenda. Delivery at all costs appears to be the political motivation and I think it’s time to reject the short term political goals and try and attack basic compliance and quality now. The software term “Design by Contract” was never meant to mean a business contract, but a compliance contract. Nehta appears not to get this and wants to substitute “contracts to deliver a business plan” for “contracts to comply with standards”. Computers are quite bad at being politically correct and will reject business plans that lack credibility at the binary level.

The real issue in eHealth is a lack of quality, and subsequently a lack of interoperability and safety. There are fundamental engineering deficiencies in the real world and a lack of realization that only standards, and good compliance with standards can fix the flawed foundations. Foundations are not sexy, but getting the structure out of the ground is always the biggest hurdle on a building project. To improve the situation we need a focus on good software engineering practices and in the world of complex systems that means testing and more testing. The reality is that HL7 V2 is going to be around for many years to come and rather that march on with grand plans the priority needs to be getting a compliance program for existing standards up and running now. Moving to something new is an expensive diversion that will make the problem worse, not better. Someone needs to stand up and stop claiming they will deliver the 10 story masterpiece “next year” and start work on a compliance program for what is already in use. We need some solid foundations or the Haiti style devastation of eHealth will surely descend upon us within a few years.

The Nehta plan, as it stands will deliver fragile single purpose interconnectivity with little or no interoperability. It’s time we turned our existing interconnectivity into interoperability by a deliberate compliance agenda. Once that’s done we will be out of the ground and ready to do some real work. As it stands they are on a road to nowhere. We have been down that road and we know where it leads.

The original full posting is found here:

http://blog.medical-objects.com.au/?page_id=44

For those who don’t know here are a few words about Medical Objects:

About

Medical-Objects is an eHeath company dedicated to standards based EHR applications and messaging. Born out of frustration with the lack of progress we are working hard to get the standards and infrastructure in place to make the care of patients easier and more efficient. Our focus is clinical medicine and decision support and any missing infrastructure needed to implement this. While we are best known for our secure messaging, this is just (an important) building block that we need to enable our vision for advanced decision support.

----- End Quote

See here:

http://blog.medical-objects.com.au/?page_id=2

For more information see here:

http://www.medical-objects.com.au/Aboutus/tabid/105/Default.aspx

MO are one of the very few who have made major strides at a state-wide level making a difference in improving clinical communications and for them to be this worried should ring alarm bells everywhere.

It seems to me NEHTA is focussed on destroying working properly standardised clinical messaging providers (Argus, Healthlink, eClinic and MO to name a few) – while having nothing of their own to replace it while failing to work with what is already working and can do more, if allowed.

Read carefully and be alarmed, very alarmed!

David.

13 comments:

Dr David More MB, PhD, FACHI said...

Posted for Geoff Sayer - HealthLink

The analogy of the mobile phone is often used when it comes to messaging in health. That is, for interconnectivity you want for example your Optus user being able to speak to your Telstra user. The problem is, as Andrew points out, with interoperability versus interconnectivity is users are speaking in what ever language works for them (e.g. French, English, Pidgeon English, Mandarin) without regard to what the end user can use. There would be significant improvements if all concerned were using the same language (eg. HL7 v2) and had to undergo compliance to be able to operate that language.

HealthLink supports the notion of getting the job done through effective use of standards in the message types and providing support around that integration. We would argue you will get greater safety and patient outcomes much sooner by working with compliance around the message type rather than spending a number of years around the inter-connecting part. The problem with the the current approach is you are still being faced with compliant message types in years to come because while the payload is "agnostic" and allows flexibility that flecxibility is itself part of the problem.

The creation of the SMD standard appears to be mostly concerned about reducing the number of messaging applications on doctors' systems. It is often pointed out as the number one reason. I suspect that that you will actually end up with more applications on doctors' systems. Why, because the SMD process will faciliate more companies and jurisdiction with messaging applications. If we accept Andrew's argument that compliance is not really happening over the next few years there really is no driver for the existing applications to be taken off as many senders will be quite happy with the way things are.

If you had a compliance program around message type, market forces would reduce the number of applications as some companies exist because they are able to deliver work arounds for the use of non compliant message types. If message type was standardised and compliance around that, messaging companies would need to have alternate benefits for using them like integration services, decision support applications, quality of service and support to exist.

Anonymous said...

Dr Andrew McIntyre deserves loud applause. He is not alone. How many of his colleagues have tried in vain for a long time to get government and Nehta to listen to, and comprehend. a similar message to that so eloquently espoused by Andrew? There are far too many for all of them to be wrong. So what is the problem?

The problem is that government and Nehta do not want to know, they have gone too far, they have spent too much capital and they have achieved too little. They are entrenched and intent on preserving the status quo for reasons of self interest, self preservation and dare I say self delusion.. And as they hold the money they hold the power and they will therefore continue doing what they have been doing well into the future.

SME’s, like Medical Objects and many others, either have to live with that or take a stand to do something to ensure they are taken seriously. If they opt for the former, Andrew’s predictions will be prophetic. If they opt for the latter, it is just possible they may be able to navigate the battleship in the right direction.

Anonymous said...

My brain must be wearing out because I am having some difficulty interpreting what your commentator Geoff Sayer "Friday, March 26, 2010 8:38:00 AM" is trying to say. Perhaps his core message is scrambled in the discourse. What is the essence of his message?

Geoffrey Sayer - HealthLink said...

Sorry anonymous: The simplified core message is there is a NeHTA push for message players and clinical systems being able to technically send messages to each other (inter-connecting) without ensuring (compliance) that they are all using the same form and structure of message (interoperability).
If you focused on interconnecting alone you won't achieve much. You need compliance and interoperability to achieve positive patient and practice outcomes. If Andrew is correct, these appear to be down the road somewhere.

greyarea said...

"compliance and interoperability...appear to be down the road somewhere". Not if users (e.g. clinics) start basing their purchasing decisions on product compliance to the published standard.

Anonymous said...

Thank you Geoffrey Sayer (Friday, March 26, 2010 10:42:00 AM) much much clearer, precisely so - inter connectivity is good, but without compliance there is no interoperability.

Friday, March 26, 2010 11:41:00 AM has a good point provided the users (clinics) know how to purchase products which comply with the published standard. Ahhhhh - therein lies the rub does it not?

Anonymous said...

Geoff, Australia already has an accredited service that can test compliance of message type: http://www.ahml.com.au/. The AHML profiles have already brought us some level of interoperability.

Anonymous said...

Web clients (browsers) and servers are compliance tested in the field. Those that do not interoperate do not last in the market place. The only possible exception is Microsoft Internet Explorer, which is able to take advantage of a dominant market position, but even that has been changing of late.

How did we get to this stage of maturity without spending a lot of money on intermediaries that add no value to our web browsing transactions or spending huge amounts of money on compliance testing?

We established some basic standards (layered on even more basic standards like TCP/IP) and allowed the "ecosystem" to evolve. We now have rich interconnectivity and mission critical applications delivered over this apparently anarchic medium.

I think it the height of self serving arrogance that middleware vendors who want to charge us a per message fee for every transaction are attempting to pervert our standards development processes for no good reason.

Interoperability will depend on end point systems, not middleware. Using end user systems in a ubiquitously connected environment will quickly lead to the development of appropriate and practical interoperability standards. This will not occur unless basic conditions for health care connectedness are met. This means that identification of patients and providers, privacy, security and auditability need to be assured.

The very last thing we should be trying to do is dictate the content of the secure transactions taking place between well identified users about mutually identified subjects. Users will agree on content standards very quickly once they can actually communicate with each other in a trusted environment.

I believe that NeHTA is attempting (albeit with many false starts and following some blind alleys) to establish the required infrastructure.

I do not appreciate being preached to by people with significant vested interests about how badly NeHTA are doing because they are failing to pander to their business needs.

Dr David More MB, PhD, FACHI said...

Hi,

Bit of a pity, since you obviously have very strong views, you can't use your name?

David.

Anonymous said...

It seems to me that if a few leading, quality software developers focused on working together in a critical sector of the marketplace on behalf of their clients they would surge forward, demonstrate compliance and interoperability, and as a consequence expand through market demand leaving others to wallow in their wake.

Andrew McIntyre said...

I have heard people in Nehta say "Some people think you need standards for interoperability" suggesting you don't, and I nearly fell of my chair. To see it repeated here is a little amazing as anyone with experience in the area would never ask that question.

The fact is that it has taken 20 years to get web standards to where they are today and cost huge amounts of dollars and I am sure the amount of testing done has been huge. Finally its almost to a point where it works well.

To suggest that we go through 20 years of evolution and failures with critical patient data is an amazing statement.

The fact is that the standards support by the majority of GP systems is far from good and interoperability is brittle and this is preventing progress. One issue is that they do not know enough to know their failings and appear to feel no pressure to improve it as no GP systems have AHML compliance and are often not interested in suggestions to improve things. I the current environment they need a business case to improve their quality and compliance. The testing is actually cheap, its the work to make it so that costs dollars and Nehta is not giving them a business case. This is the fundamental concern I have, they may well have similar ideas to "anonymous" and "anonymous" is unlikely to have much experience. Every one of our junior support people got it after a month and software developers understand that you need reliable interfaces.

The Nehta analogy to the statements is "write your browser to support our website and we will pat you on the back. We don't care if you can support any other website and we only care if our website displays OK".

The semantics of medical data are actually more complex than most of the web and yes it will cost dollars to make it work well, but not having a compliance agenda, which is actually not expensive, will just create an impression that something is working without it actually working in a safe or robust way. Its scrificing patient safety in the name of public relations. Its basically spin without substance.

Some people are suggesting Medical-Objects are advantaged by the need to act as an interface engine due to lack of standards compliance, while others suggest that standards compliance is in my "Vested Interest". Both cannot be true. The fact is its in my "Vested Interest" to try and increase the uptake of eHealth. A road to nowhere is what I want to avoid. I know that the only way to achieve that is to get the basics right. As a first step, AHML accreditation which cost around $2000 last time I checked, does not seem like a hugely expensive direction. That would only get us so far, but it would be a good first step.

Geoffrey Sayer - HealthLink said...

Hi Anonymous (Friday, March 26, 2010 8:45:00 PM) you do seem be anonymously passionate. We must assume that you are serving your own interests by remaining anonymous.

In regards to:

"I think it the height of self serving arrogance that middleware vendors who want to charge us a per message fee for every transaction are attempting to pervert our standards development processes for no good reason."

You should get your historical facts right.

"Middle ware vendors" have been participating in standards processes long before NeHTA got involved with Australian standards processes. I think you will find that it was only in recent times that they joined the Standards Australia process despite NeHTA being in operation for some time.

To suggest that middle ware vendors are perverting the standards process is ridiculous as middle ware vendors have been the ones attempting to implement standards long before NeHTA existed and contiunue to give considerable amounts of unpaid time to contribute to this important process. NeHTA people are paid as part of their jobs (tax payers money) to be involved in standards - vendors are not.

The opinion expressed by myself and covered by Andrew is compliance will be the key to deliver benefits. We are concerned that the focus on interconnectivity without the next steps will not deliver benefits in a timely fashion.

Market forces have not delivered interoperability on its own to date - so to suggest that once interconnectivity is sorted out market forces will take over is not taking into consideration history.

You also must remember it is not totally clear at this stage how compliance will be implemented for different parts of the NeHTA program (HI Services, NASH, SMD, AMT, SNOMMED-CT) hence Andrew's original concerns.

The AHML has served us well in interoperability to date for those companies that make use of them. It will serve us even more so in the future when it is mandated by tender processes, IHE initiatives, clinic purchases, PIP incentives etc that force vendors to have AHML compliance or other accredited agencies compliance if they wish to take part. To date that has not really happened on a wide scale.

Bruce Farnell said...

At the outset I'd like to support the views put forward by Andrew McIntyre and Geoffrey Sayer. The views put forward mesh well with what I see at the coal face of clinical messaging in primary health care/general practice every day. If NEHTA truly believe that interconnectivity is all that is required and that compliance is optional then I cannot see how we can advance beyond the current state of play.

Currently, I see a failure of market forces to arrive at an optimum solution. Instead, what we have are many messages flying around which aren't necessarily fit for purpose. Also, many of the clinical record systems interpret these messages in different ways. Unfortunately, there are no clear mechanisms in place to ensure that everyone cooperates.

For example, I still see some pathology companies delivering reports in PIT format or HL7 where the results aren't atomised. To me, this represents a lost opportunity for value adding activities with this data later on. It is a cost to the GP in additional manual data handling, it's a cost to the patient with chronic disease and represents a major cost to the health system borne by all of us. I have another example at the moment where a message type from one pathology lab works fine in one GP system - but not in alternative GP systems. It's a mess and market forces cannot fix this due to market distortions and barriers to change. Firstly, the choice of pathology provider is supposed to be the choice of the patient - not the clinician. I can't see too many patients selecting a pathology lab based on their HL7 readiness - can you? The pain and barriers involved in changing clinical software is such that moving a GP clinic from one system to another will not be based on HL7 messaging compliance alone. At least that has been my experience. I believe that compliance needs to be mandated in some way if interoperability is to be achieved. There is no way around this.

It seems to me that mandatory AHML (or similar) compliance by all messaging participants (senders and recipients) would be a positive way forward. Personally, I think there also needs to be a mechanism linking Medicare payments to diagnostic providers to their messaging compliance. That would shake things up a bit.

All of this started me thinking about market forces and the "invisible hand" of free markets. The following is an extract from Wikipedia which I thought was relevant.

Adam Smith, the father of modern economics, is often cited as arguing for the “invisible hand” and free markets: firms, in the pursuit of profits, are led, as if by an invisible hand, to do what is best for the world. But unlike his followers, Adam Smith was aware of some of the limitations of free markets, and research since then has further clarified why free markets, by themselves, often do not lead to what is best.

Whenever there are “externalities”— where the actions of an individual have impacts on others for which they do not pay, or for which they are not compensated — markets will not work well.