Wednesday, November 11, 2015

Just Why Is It That Everyone Seems To Think They Are An Expert On E-Health?

This appeared last week:

Improving implementation: the challenges facing development of My Health Record

Friday, October 30, 2015
The latest Health Policy Issues Brief from the Australian Healthcare and Hospitals Association (AHHA) and the Deeble Institute for Health Policy Research has pointed the way forward on developing a national e-health initiative.
Despite significant Government investment in the development of an electronic health record, the e-health initiative has proven difficult to get off the ground. Toward better implementation: Australia’s My Health Record by Krister Partel explores the development of the Personally Controlled Electronic Health Record and identifies challenges and opportunities for the rebranded My Health Record.
“The external review of the Personally Controlled Electronic Health Record went a long way towards identifying areas to improve upon,” said Mr Partel.
“However, experts have raised concerns that have not yet been addressed.”
The brief discusses potential issues with implementation and offers recommendations to assist with the process. Chief among these are the lack of registered users, the difficulties in transitioning from an opt-in to an opt-out system, and the importance of maintaining consistent and coherent governance arrangements.
“The Commonwealth Government’s attempt to reboot the failed Personally Controlled Electronic Health Record is admirable,” said AHHA Chief Executive Alison Verhoeven.
“But more needs to be done to ensure that the same mistakes are not repeated in the rebranded system.
“A well-implemented electronic health record has the potential to promote greater consumer engagement and understanding, reduce waste and inefficiency and improve quality and safety. This Deeble Institute Issues Brief outlines the steps necessary to ensure that My Health Record lives up to its potential.”
Toward better implementation: Australia’s My Health Record is available here.
Here is the link:
Here is the link to the report:

Deeble Institute Issues Brief No 13 (Krister Partel)

The Executive Summary is worth a browse:

Executive Summary:

A well implemented and fully utilised electronic health record system should strengthen a health system by improving quality and safety, ensuring continuity of care and improved health outcomes as well as reducing waste and inefficiency in the health system.
Australia chose to pursue a personally controlled electronic health record (PCEHR) system following a 2009 recommendation from the National Health and Hospital Reform Commission. A PCEHR is a special class of electronic personal health record where a consumer controls his or her record content and record access, which means only nominated health practitioners are able to access nominated information in the record.
Due to a lack of uptake and utilisation, in 2015 the Australian Government announced a system overhaul, which included rebranding the PCEHR to My Health Record and moving from an opt‐in to an opt‐out system. While the overhaul attempts to address the key problems identified in a 2013 external review of the PCEHR, a number of experts have flagged concerns with the new My Health Record, which should be addressed prior to implementation.
The following are three key and ongoing implementation concerns along with recommended actions to overcome these concerns.
Lack of registered users, system use and clinical utility
The following actions are recommended to accelerate achievement of My Health Record critical mass, system use and clinical utility:
·         comprehensive system security and privacy safeguard review with subsequent action plan to address concerns prior to opt‐out pilots, followed by proactive messaging to consumers and providers that technical security has been dealt with in the design of the record
·         comprehensive communications and engagement strategy with targeted and sustained consumer‐ and provider‐specific education and registration activities leveraging consumer groups, peak bodies, professional colleges and software distributors
·         Comprehensive and best‐practice provider training based on an iterative process to develop training modules and the training platform with stakeholders
·         registration incentives for both consumers and practitioners such as an increased Medicare rebate for system use as part of clinical activity
·         technological and business support, including financial incentives to service providers nudging uptake and use
·         software default settings linked into the interoperable national health record system
·         flexible and clear policy and technical frameworks that are adaptable to clinical need
·         structural change to the data sharing model where information necessary to the current treatment of a consumer is shared among the care team
Opt‐in versus opt‐out registration

The following actions are recommended to ensure a smooth transition from an optin to an opt‐out consumer controlled electronic health record with evidence‐based privacy and security protocols:
·         comprehensive system security and privacy safeguard review of the current architecture evaluated against a repurposed opt‐out functionality, which includes both threat and risk assessments as well as privacy impact assessments
·         action plan stemming from the review to implement a mix of technology, policy and process mechanisms aimed at strengthening security and privacy controlsto be completed prior to My Health Record’s optout trials
·         public education campaign demonstrating system security and privacy safeguards
·         engagement with software developers and distributors to ensure software compliance with necessary system changes and to ensure ongoing system interoperability
·         update current provider training due to opt‐out transition and work with the sector to develop and rollout revised modules
The following actions are recommended to ensure best practice and inclusive My Health Record governance arrangements:
·         key national and regional stakeholders as well as consumers should be part of My Health Record’s governance arrangements in order to secure buy‐in from the health and community sectors and key consumer groups
·         consideration should be given to the following building blocks for effective governance:
o   strong leadership, culture and communication
o   appropriate governance committee structures
o   clear accountability mechanisms
o   working effectively across organisational boundaries
o   comprehensive risk management and compliance systems
o   strategic planning, performance monitoring and evaluation
o   flexible and evolving principles‐based systems
·         the Council of Australian Governments’ Standing Council on Health should play a leadership role to ensure these effective governance building blocks become more than aspirational
---- End Extract
I note the author is the AHHA Advocacy Director rather than an e-Health domain expert and it certainly shows.
The key thing that is wrong with all this is an underlying assumption that the basic idea behind the PCEHR is sound, which sadly is plain wrong. Worse, there is no evidence I am aware of that  that confirms this model of National E-Health record will work - and be clear it has never actually been tried before.
(The basic idea behind the PCEHR is that it is a national E-health Records System created in parallel to the systems already in use by clinicians. In the PCEHR the information held is controlled by the patient and may not be accessible when needed.  The unproven assumption is that this sort of system will be useful and will improve system quality, safety and efficiency.)
Equally the benefits studies quoted for the PCEHR are not actually related to the model of the PCEHR as it has actually been implemented.
What we seem to have here is a classic example of a non-expert trusting that the Government has an optimal technical, functional, clinical, workflow and information design for the national e-Health system and that all is needed is some management, incentive and governance changes around it and it will all be wonderful, benefits will be delivered and all will be well. I know for certain there are many experts who would violently disagree - including myself.
As Sir Humphrey might say there is a very ‘courageous’ assumption buried here (that the basics of the PCEHR are not flawed) that may very well not play out and may result in ongoing waste of money.
Coming from an assumption that the Royle Review identified all that was wrong with the PCEHR is a very, very bad and unwise idea. The non-expert Royle Committee really did not grasp all the issues (especially the clinical, data integrity and workflow issues) that many expert submissions have since identified.
It would be really useful if the DoH actually listened to the many independent experts we have in this area!


Bernard Robertson-Dunn said...

What's even worse IMHO, is that, of the people who run NEHTA, there is not a single person with qualifications relevant to developing Information Systems.
[ref NEHTA Annual Report: ]

Lots of health people and some lawyers and commerce/business management. There is nothing wrong with these disciplines being represented, but without a balance of people who know how to define and develop Information Systems, they will probably make a few mistakes.

And the evidence is a) they've made a lot of mistakes, b) they don't understand what mistakes they have made and c) they don't understand the consequences of these mistakes.

Which just reinforces David's heading from yesterday:
"This Is A Classic Example Of The Vision Impaired Leading The Blind. What A Mess!"

Anonymous said...

Krister Partel, clearly has absolutely no understanding of eHealth and as a consequence has no understanding of the issues involved in designing, testing and implementing the PCEHR national ehealth record system.

It is presumptuous of him in the extreme to put himself forward as an eHealth domain expert.

The Executive Summary, as presented in your blog, David, comprises a lot of empty rhetoric reflecting the author's complete lack of any practical experience in the eHealth IT domain.

Anonymous said...

There is a well resourced reference list accompanying this report. The DELOITTE NATIONAL E-HEALTH STRATEGY document doesn't rate a mention presumably because it came before the PCEHR was ever thought of. How very convenient.

Best if the Deloitte document is forgotten about altogether, because it's very embarrassing. It marks the point at which eHealth lost its way in Australia. Had the government implemented Deloitte's Recommendations a great deal of progress in deploying eHealth would have been made.

Anonymous said...

The Deeble Institute Brief boldly claims to "outline the steps necessary to ensure My Health Record lives up to its potential".

!!!!! Are they for real?

The assumption here is that there is nothing much wrong with the product. The assumption here is that the implementers got it wrong. The assumption here is that a different implementation will make it work and everything will be well.

The problem here is that the assumptions are wrong and Partel does not know they are wrong. Perhaps the Deeble Institute has been asked by the Department to produce a report which the Department wants to accept to convince politicians all is well so they can keep doing what they have always been doing in the hope they will get a different outcome one day.

Michael Legg said...

As many of you would know I have been an adviser in ehealth to AHHA for many years. In case it should be misunderstood, I was not involved in any way in forming this policy statement.

Anonymous said...

Another member of the cargo cult... Its quite a popular movement these days.

Anonymous said...

Well, the Australian Healthcare and Hospitals Assn has won the $481,000 contract to design and produce the My Health Record "education package".

The Deeble Issues Brief was published on October 30; the MHR education/design contract was published on October 9 but is dated from Sept 15 to end of June next year. Let me make a guess here, it won't say anything new

Anonymous said...

Michael Legg said "I have been an adviser in ehealth to AHHA for many years..... I was not involved in any way in forming this policy statement."

Be that as it may Michael you are an adviser and you should speak your mind openly on the policy document. You either support its recommendations or you don't.

This is a responsibility that comes with the territory of being an adviser to the AHHA over many years. Let your views be known. Evil flourishes while good men remain silent.

Anonymous said...

The current Medical Observer has 'Mixed response on eHealth test' by David Rowley. The last paragraph quotes Jo-Anna Wood "former NEHTA and Medicare Local eHealth consultant, now an eHealth adviser to the WHO. She says Ms Ley's proposals are still just ideas and should be allowed to develop."
Ms Wood's bona fides are at and make interesting reading, in the context of the (presumed) skills & training required for "e" and "Health".

Bernard Robertson-Dunn said...

To save people the trouble of looking for Jo-Anna Wood's qualifications.

University of Melbourne
Executive Master of Arts (EMA), Public Policy, First Class Honours

University of Canberra
Bachelor, Communications; Public Relations; Law
Graduated with a Bachelor of Communications, specialising in Public Relations and majoring in Law.

This total lack of Information Systems development experience is not uncommon when it comes to government and large scale IT development.

In 2007 Joe Hockey tried to sell the country on the idea of an Access Card to replace the Medicare card. It was a miserable failure, one that I saw up close. I was part of a team advising the Minister and Departmental Secretary, my role being to provide Architecture Assurance. If the project hadn't died because of public pressure it would have died a technical death - it had no chance of working. The smart card technology and the networks they wanted to use were just not capable of doing what they wanted them to do. And they still couldn't.

The government appointed a Chief Technical Officer whose bio included this:

"She has a Master of Business Administration from the Melbourne Business School with a focus on ecommerce strategy and the strategic management of IT. She holds a Bachelor of Arts degree focused on international politics, has undertaken tertiary studies in law, and completed the Harvard University John F Kennedy School of Government Senior Executive Fellows Program"

And I'm told she still thinks the system would have worked if they had been allowed to finish it.

Michael Legg said...

I am a little surprised at being accused of silence here. I would have thought my views in this space are on the public record and with my name to them (unlike the commenter above). This includes previous policy documents from AHHA on informatics.

For the record on this blog though, I believe improvement in health and healthcare relies on informatics. I believe we are not getting the best value from our Government's investment in ehealth and that we would get better value from more involvement of those competent in health informatics and by better learning from research and history.

I contributed to and supported the first national ehealth strategy. It advocated a guided market approach improving existing clinical communications. This remains the soundest public Government plan but it is a plan that has, in my view, not been closely followed.