Thursday, November 07, 2013
Finally One Government Tells The Truth About Australian Government E-Health. Amazingly Comprehensive Coverage Of What Is Going On.
A link to the following report appeared last week.
Posted Wed, 30/10/2013 - 08:09 by Fran Molloy
The Victorian Health Sector ICT Review Panel have issued their report, which recommends changes in the three major areas of governance, procurement and investment in health sector ICT.
Here is the link:
The report makes wonderful reading on the Victorian sector but Section 9 is the one to read first.
The following describes those national e-health initiatives as they appeared to the panel at the time of this review.
A national e-health memorandum of understanding has been agreed in principle by the Standing Council on Health (SCoH) and endorsed by the Victorian Government. It is currently undergoing the process of formal ratification by all jurisdictions, including Victoria. Some priorities are to:
• develop a business case for the national e-health infrastructure and services, including the PCEHR
• harmonise reporting to the government
• implement national health identifiers for people and providers
• roll out a national information and data standards, to be adopted by all ICT vendors.
National E-Health Transition Authority
In July 2004 Australian health ministers recognised the pivotal role e-health plays in improving the safety and quality of healthcare services and controlling healthcare costs. They noted the need for cooperation on significant national e-health programs and established the National E-Health Transition Authority
(NEHTA) in July 2005. NEHTA is funded on a cost-share basis as agreed by the Council of Australian Governments (COAG) and is a private company limited by guarantee. The NEHTA board comprises all of the jurisdictional health chief executives plus one independent member and an independent chair.
In 2006 initial funding was endorsed by COAG for three years to develop national identifiers, for both providers and individuals, and standard clinical terminology for use in health applications, recognising that these are key dependencies to be able to achieve accurate and timely identification of patients and providers.
In 2008 COAG endorsed the allocation of a further three years’ funding to continue its existing work program, commence operation of the Identification and Authentication Services and to establish an Individual Electronic Healthcare Record (IEHR) Project Taskforce to progress related components of
other national programs into the IEHR work plan. The IEHR was initially a COAG initiative but the subsequent personally controlled electronic health record (PCEHR) program was a 2010 Budget initiative of the Australian Government administered by the Department of Health and Ageing (DoHA).
Following the cessation of COAG funding in June 2012, the SCoH agreed to a reduced funding program for NEHTA to manage its core operations until June 2014. These core services comprise the Healthcare Identifier (HI) Service, Clinical Terminology Service, National Authentication Service for Health (NASH), National Product Catalogue and e-health standards and specifications development. The HI Service and NASH are operated by the Commonwealth Department of Human Services under contract to NEHTA. To date Victoria has contributed over $50 million as its cost-shared contribution with other jurisdictions to the NEHTA work program.
The ongoing governance and funding of NEHTA beyond 2014–15 will be an important matter for consideration by the Australian Health Ministers’ Advisory Council (AHMAC) E-Health Working Group, which is due to report to SCoH by September 2013 for possible later consideration by COAG.
From 2009–10 to the present NEHTA has also received funding to assist DoHA in managing the progress of the PCEHR. Specifically this was for the development of the large volume of technical specifications and standards required for the PCEHR and to act as the managing agent to oversee DoHA’s industry partners and the three ‘Wave 1’ lead implementation sites and nine ‘Wave 2’ implementation sites funded to test and validate planned processes and technical foundations for the PCEHR that would inform the design and implementation approach.
The three Wave 1 sites tested three common information exchange mechanisms (discharge summaries, electronic referrals and shared health summaries) required to support the PCEHR and their ability to incorporate national identification and data standards. The nine Wave 2 sites were focused on more PCEHR components, for example, medications and consumer portals.
The role of the Victorian Department of Health’s Secretary on the NEHTA board is as a director of a private company, albeit nominated under its constitution as the member’s (i.e. Victoria’s) representative.
Consequently the position includes specific fiduciary obligations and liabilities with respect to the company. Departmental briefings are provided with respect to board matters but it remains the director’s responsibility for actions taken by the board.
NEHTA executives including the CEO also meet regularly with the National Health Chief Information Officers’ Forum (NHCIOF) to identify any issues arising from their work program and to draw on the available expertise to aid resolution. NEHTA also has recently established a Statewide Product Consultation Group, with clinical, consumer, industry and informatics representation.
National eHealth Information Policy
Governance over national e-health and information policy is complex. The national environment is presently in a volatile and dynamic state. A number of important reviews and decisions, each at a different stage of development but all due to complete in 2013, are currently underway, including:
• the SCoH development of a memorandum of understanding (MOU) in relation to developing an effective national e-health capability between all states and territories and DoHA
• the SCoH-sponsored review and update of the 2008 National E-Health Strategy and an associated national business case for potential consideration by COAG
• the SCoH-sponsored review and renewal of the National Health Information Agreement (NHIA) between the states and territories and DoHA and other Commonwealth agencies, including the Australian Institute of Health and Welfare (AIHW) and the Australian Bureau of Statistics (ABS)
• the independent review of the regulation and operation of the national HI Service that is required under the Commonwealth Healthcare Identifiers Act 2010.
The MOU, with respect to developing an effective national e-health capability, is the most advanced and documents existing arrangements and agreed financial commitments.
The review of the National E-Health Strategy and the associated business case will have the greatest potential impact. Its terms of reference include making recommendations on the overall national governance of e-health for the next decade. The business case will potential run to billions of dollars, although the terms of reference need to take account of the current fiscal constraints of all governments.
Beyond these policy and machinery-of-government changes there are operational factors that are driving a high level of need for collaboration between jurisdictions. Some of these include:
• the complex integration needs of modern hospital clinical systems environments to enable decision support, medications management and enterprise scheduling
• the increasing demand for solutions to support continuity of care across settings, requiring more rigorous and comprehensive standards for interoperability
• the introduction of new national reporting requirements by recently established bodies such as the Independent Hospital Pricing Authority (IHPA), National Health Performance Authority (NHPA), National Health Funding Body (NHFB) and the Australian Commission for Safety and Quality in Healthcare (ACSQC) – these requirements include reporting for activity-based funding and on national performance indicators
• the Commonwealth’s program for implementation of the PCEHR and associated legislation, which has impacted on the design and operation of information exchange between providers for all purposes
• an Australia-wide shortage of both clinicians and information specialists with health informatics expertise, as highlighted by Health Workforce Australia in a recent publication on the state of the health information workforce.
Memorandum of understanding
The MOU to develop a national e-health strategy and business case was agreed in principle by SCoH at its 9 November 2012 meeting.
The MOU provides an interim arrangement pending consideration of longer term national governance and future investments beyond 30 June 2014, which will be framed in the national e-health business case currently being developed, for consideration by SCoH in 2013 and possible subsequent consideration by COAG. The MOU does not propose any new funding beyond existing commitments for national e-health projects.
A schedule to the MOU describes the roles and responsibilities of the states and territories, which includes the following interim goals (current status shown in italics):
• compliance with standards and specifications when investing in new information systems The OCIO has documented the current suite of approved national standards for incorporation into tender specifications.
• incorporating SNOMED CT-AU/AMT into new clinical systems and upgrades and specifying the inclusion of standard terminology functions when procuring new systems or replacing existing systems AMT is already incorporated into the Cerner clinical system and is the standard expected for any other clinical systems. To date only a limited number of SNOMED CT-AU reference sets have been developed by NEHTA but these will be incorporated in the standards when nationally endorsed.
• plan for the implementation of an appropriate authentication service over the next three years (all organisations using PCEHR are to obtain an appropriate authentication certificate)
The National Authentication Service for Health (NASH) program is yet to deliver its full functionality, although a roadmap has been developed in consultation with the NHCIOF. The future approach to authentication will be dependent on what is finally delivered.
• the incremental adoption of healthcare identifiers for patients (IHIs) into electronic record systems of public healthcare services, such as when:
– new patients are added to electronic record systems (including new births)
– investments in new or replacement systems are made, such as new patient administration systems
Statewide adoption of IHIs is a government election policy. IHIs are being used in the national lead ehealth sites in Eastern health and Barwon. Victoria has also published, in collaboration with NEHTA, a best practice approach to the safe adoption of IHIs but is yet to initiate any more widespread adoption.
• take steps towards healthcare identifiers being used in public hospitals so that healthcare identifiers for healthcare provider organisations (HPI-O) are more broadly adopted across health sectors
Outside of the lead e-health sites this has been a local decision with no statewide policy position. There have been administrative difficulties in setting up HPI-Os. This has led to some change in the national approach and there is likely to be further change as a result of the current HI Service review of operations.
• supporting the incremental connection of the health information, within the services they manage and fund, to the information held in the PCEHR system, including progressive uploading of clinical documents, subject to the approval of the Rapid Integration Project by the NEHTA board The NEHTA board has approved $2.1 million in funds to extend the functionality of the existing Victorian lead e-health sites to enable posting of national standard discharge summaries to the PCEHR and provide their clinicians with access to the PCEHR. This builds on the work already undertaken to implement national standard messaging (including use of all national identifiers) for point-to-point messaging from hospitals to General Practitioners. There is also a possibility of this extending to Peninsula Health and Austin Health as further NEHTA funds become available.
• migration to the National Health Services Directory (NHSD)
The NHSD is built on the Victorian Human Services Directory (HSD), which has been sublicensed to the National Health Call Centre Network (NHCCN) to support its management of the NHSD. The NHCCN took over full management responsibility of the Victorian system at the end of February 2013.
• agreeing and adopting the Telehealth Technical Standards.
The standards have recently been endorsed by NHIPPC for adoption in all public health services and a policy directive will be issued to the Victorian Public Health service to that effect.
National E-Health Strategy and business case
The 2008 National E-Health Strategy was developed and endorsed by health ministers but only noted by COAG. Consequently, it was never explicitly funded beyond already committed resources flowing to NEHTA to develop the e-health foundations (identifiers, terminologies and specifications).
When the Commonwealth announced the PCEHR in April 2010, the $467 million funding was claimed to be equivalent to the first stage of implementing the individual electronic health record (IEHR) described in the strategy. This was not agreed by the states and territories not only because they disputed the costing but also because the scope and design of the PCEHR varied significantly from the IEHR proposed in the strategy. For this reason, Victoria’s official position is that it will not implement the PCEHR beyond supporting lead implementations (and then only if externally funded) until there is an agreed national business case.
The business case will cover the costs and benefits to the nation of future investment in e-health. It will address the level of recurrent funding required for ‘national infrastructure’ and address the issue of what programs and initiatives should be nationally coordinated, and what subject matters should be dealt with via national standards for e-health and informatics in support of each of the following:
• national governance, regulation and compliance
• secure message exchange
• healthcare identifiers
• clinical terminology
• medications management
• electronic transfer of prescriptions
• National Product Catalogue/eProcurement
• orders and results for diagnostics and imaging
• clinical decision support
• care plans
• healthcare reporting and research datasets
The business case should, for each of the programs and services, at the national level and for each jurisdiction, provide advice on:
• the disaggregated cost of ownership (capital and recurrent) including the cost of change and adoption, workforce skills development and ongoing maintenance and governance
• the costs of all components necessary to deliver the planned benefits, including the cost of central infrastructure and of supporting systems in the health services, and recommendations on how those costs should be shared between jurisdictions
• agreed measurable benefits for consumers, health professionals, the Commonwealth and states and territories, drawing on existing benefits analysis and evaluations – the benefits that are to be accrued must also be aligned with the investment required.
This level of detail will be essential as it is often the case in e-health that there is an inequitable burden placed on parts of the system in delivering an overall beneficial outcome. For example, preliminary modelling done for the PCEHR shows that hospitals bear a significant cost in implementation for which they receive little direct benefits in return. There will need to be close analysis of where the costs and benefits fall in any negotiations with the Commonwealth on sources of funding and incentives in the final business case. This may provide opportunities for complementary and mutually beneficial investment.
The development of the business case is being run by the Commonwealth with the support of a steering committee and working group (Victoria is on both). Central agencies are also engaged nationally through an EHealth Reference Group and both the Department of Premier and Cabinet and the Department of Treasury and Finance have been closely involved in Victoria.
Deloitte Consulting has been engaged with the report is due to SCoH in September 2013. The timing of subsequent referral to COAG will be affected by the September 2013 federal election.
National Health Information Agreement
The purpose of the NHIA is to ensure the availability of nationally consistent high-quality health information to support policy and program development, and improve the quality, efficiency, appropriateness, effectiveness and accountability of health services provided to individuals and populations. The agreement promotes the efficient, secure, confidential and timely use of information across the complete life cycle from development to use.
The NHIA will govern the structures and processes through which Commonwealth, state and territory health, national statistical authorities and national health reform bodies work together to improve, maintain and share national health information.
The scope of the agreement is all national health-related information, including clinical and statistical information, as determined by AHMAC. In order to ensure consistent national information, the scope of the agreement includes standards, definitions, classifications and terminologies for data collections and indicators.
The NHIA has existed as a policy instrument for over a decade but the current revision is much more comprehensive than previous versions, principally to accommodate the needs of the National Health Reform Agreement and the requirements of the new agencies formed under that agreement (IHPA, NHPA, ACHCQS and the funding administrator).
Specifically it has now taken a much broader view of the complete information life cycle from data capture to collection, collation, analysis and reporting and archiving, with an emphasis on principles such as ‘single provision, multiple use’ articulated in the National Health Reform Agreement, which is being progressed by the Standing Committee on Performance and Reporting (SCPR) for consideration by AHMAC.
The latest draft of the NHIA was been reviewed by AHMAC and is currently being finalised by the National Health Information and Performance Principal Committee (NHIPPC), based on advice from AHMAC for endorsement by SCoH. An issue yet to be determined is the role of SCoH in authorising updates to mandated national minimum datasets once it has initially approved them.
Health Identifier Service Review
Section 35(1) of the Commonwealth Healthcare Identifiers Act requires that an independent review is undertaken of the HI legislation and the HI Service after two years of operation. The aim of the review is to ensure the Act provides the regulatory support to enable the HI Service to operate efficiently and effectively and support the sharing of clinical information in practice.
The review is also to consider the implementation, operation, performance and governance of the HI Service and the HI Service operator. The Commonwealth Department of Human Services (DHS) is the service operator under contract to NEHTA.
The review has produced its draft report, which has a large number of recommendations for improvements to both the legislation and service operations. This reflects Victorian experience to date.
The legislation and its restrictive interpretation by DHS (despite legal advice to the contrary) has limited the level of functionality able to be achieved in interacting with the HI Service and in progressing change requests to make it more efficient.
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For once we see a real representation that we can believe about what is going on.
Unheard of in modern times. Read closely and really understand who is doing what with whom!
Posted by Dr David G More MB PhD at Thursday, November 07, 2013