Friday, April 28, 2017

A Really Long Saga That May Just Have A Happy Ending For Secure Messaging, Or Not.

This appeared a few days ago.

Are Sonic and Primary sitting on digital health progress?

The wonders of modern digital connectivity are there for the taking, but there are elephants in the e-waiting room
By Jeremy Knibbs
21 April 2017
This is one of those stories that as a GP you won’t, on spec, be interested in. But only because you’ve never been told “what lies beneath” the story: the unnecessary, and potentially significant, retardation of better communication between the various important hubs of health information in this country, and therefore the slowing of delivery of much more efficient healthcare, via GPs, to their patients.
Ask most GPs what they think of the big private pathology providers and your response will be usually be somewhere between indifferent to unusually positive. One GP we asked is literally thrilled with the new mobile results service that Sonic Healthcare now provides through its path labs. To GPs, path results arrive through their patient management system with relative ease. What is there to be bothered about?
If you ask a practice manager, or a practice IT contractor, you get a degree more of concern, but still nothing catastrophic. The issue for them is there are so many different systems talking to their patient management systems. That is a hassle, but once they are downloaded, they are usually robust and work. Some combinations still won’t work, however, no matter how hard you try to jam them together, and so, in some cases, the IT manager has to buy in another messaging solution, or develop a costly and frustrating workaround.
The problem is, unless you’re an immersed GP owner, or one of those GPs who are into their IT systems, you never see these issues, and generally won’t be aware of the additional cost. Over time, there is a lot of additional cost.
For the majority of GPs, these gateways are magically working, so never given a second thought. Which is normal behaviour. Does anyone know how their mobile phone works, or how Facebook targets those ads at you?
This article is largely about you giving everything that happens down the messaging and IT interoperability rabbit hole a second thought. Because our whole healthcare system is being slowed down currently by what is a mess of spaghetti-like communication protocols, that don’t talk easily to each other.
This situation has been created by a mix of poor planning, ineffective regulation, vested interests doing what they do best, and bad luck.

So what’s the fuss about?

Here are a few things:
• The messaging systems of the major private pathology providers are antiquated and proprietary. They aren’t up to the messaging standards being laid down by the government for a modern e-health messaging environment, and, in some instances, they aren’t even secure to the standards required. Also, there are lot of them, and they still change from time to time and remain proprietary and basic. In the case of Primary Health Care, the system can be dependent on which region you are in and the labs that are serving that area.
• Add to this a host of private, independent messaging systems, such as HealthLink and Argus. They are often a little more interoperable, secure and can provide better sources of data analysis if you want to tweak a system, but they, too, don’t talk to everything. Part of that is that the private pathology providers don’t want to talk to them, because if they do then these independent providers can move in on their referrers more easily and facilitate easier change of pathology providers. So long as they don’t talk to the private path systems, these independent systems aren’t that efficient either, so they never get to take hold of the system, like they have in NZ.
• The effect of this, and other techniques used by the big pathology providers, such as pre-printed branded and bar-coded pathology forms for doctors to use, and buying up all the real estate in large practices where pathology can be co-located,  is that these big labs can stay more strongly attached to their referrer base – which essentially is you,  the GP. They want to be very sticky to you because you are their reseller even if you don’t realise it.
• The result is you don’t have any hassles, so you don’t question anything and patients don’t know they can use alternative pathology providers. So the big pathology labs hold on strongly to their long term client base.
• But it’s what you don’t get that might be hurting you. Reverse the saying, “You don’t know what you’ve got till it’s gone” to “You don’t know what you’re missing until you’ve got it”, and you might start being a little more interested. No one is telling GPs what they might be missing.
Lots more here:
The rest of the article makes a great read so is worth it. The only point I would make is that it seems the GPs who work with Sonic and Primary seem pretty happy and lack a major stimulus to change.
While that is the case you can be sure commercial interests will prevail and little change will result unless there is a buck in it. It is up to the Government to work out just how much the really interoperable system is worth to them, or alternatively to attempt to mandate a solution – which you can be sure will be less good than incentive driven one.
Somewhere in the middle is the sweet spot I reckon! Note that Jeremey also has some commercial interest in the outcome of all this I believe.
p.s. In full disclosure mode, I have a few Sonic shares.


Andrew McIntyre said...

Its amazing how clueless some of the commentators are. Somehow messaging interoperability is all we require to make things work? really?

Does anyone remember when Internet explorer and Netscape were competing on that great platform of interoperability - the internet and http. Web sites would only work with a specific browser or there were basically 2 websites, one for IE and one for Netscape and browser detection was all the rage.

We need message interoperability before messaging interoperability becomes achievable or even desirable because without that all we would have is systemic failure at endpoints, lost data, crashing systems and a support nightmare. The pathology companies customize messages for the endpoint to avoid this and know that if they lost control of the messaging their results would not reach their users in a safe readable form. If that happened the users would blame them and they could lose business, because of lack of solid message interoperability.

Until we have support for receiving standards compliant messages reliably messaging interoperability is not even desirable and certainly not safe. Senders like to be sure their results are rendered reliably by the receiver and having control of the messaging allows them to achieve this.

Despite 15+ years of government "help" and over $2B spend there has never been any attempt to even encourage, let alone mandate systems to reliably handle standards compliant messages. This is the elephant in the room, but seems to be over the event horizon for the non technical "managers" of the eHealth space. No matter how glossy your pdfs are or how plush your office is, the technical level interoperability issues will refuse to go away unless you actually do something to address them. You can keep trying to drive that square peg into the round hole all you like, but all you will do is damage the playing field and expend a lot of energy, create noise and frustrate everyone.

Internet browsers are now much more standards compliant and that has allowed the web to flourish. We need compliant end points in healthcare so clinical decision support and high quality rapid information transfer can flourish. Meanwhile the ADHA keeps insisting that cars are not the way to go, but we need to build better horses. Horse riding commentators agree?

Anonymous said...
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Michael Legg said...

Andrew is right. Those same big pathology companies came together with the public providers and offered to provide, as a cooperative, a universal health messaging platform to government for just 12 million dollars... and then along came the PCEHR.

Anonymous said...

Good old Toxic Tim, take it from me, he has created probably the biggest mess possible and the most disfunctional and disenchanted workforce any country doing eHealth could achieve. The best thing would be to remove him and his leadership team and hit the reset button.

Anonymous said...
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Anonymous said...

Sounds to me as though ADHA is in a hole and is furiously trying to dig its way out. All we have to do is wait and it will kill the MyHR on its own. That or bring the whole edifice down on its head. Pick your own metaphor.

Anonymous said...

Not the surprising when you look at the language if that strategy slide. It was all ME no underlying WE, Tim and other went out on their own, and was again me, me, me, I, I, I. Not really a language of cooperation. I think they are digging in a sand dune, will take a strong board to randomally and confidentially talk to current and recently departed staff to find the true, that is if they care about the people and not just their own self worth.

Anonymous said...

Perhaps nice but dim is powerless to do anything? He seems a nice enough chap and there are darker forces left stirring in the ADHA that he inherited. It all plays nicely into APS and Accenture hands. I am not excusing anything, for the money we are paying I do expect more, the embarrassing and harassing mess of the ADHA and incompetency of so called upper management is embarrassing?

Dr David More MB PhD FACHI said...


This thread is really grim and I am wondering if the comments are not just part of an echo chamber (those who are negative talking among themselves), or do they reflect that we all have a really difficult situation that is really not being addressed.

Comments that might help sort this out would be especially welcome!!



Dr Evelyn Hovenga said...

I suggest we nominate a leader (or small group to lead) and get our National experts together (ACHI, MSIA etc, conduct a forum and replicate the work undertaken in Sweden recently refer . We could even consider adopting theirs? Once we have an agreed national strategy regarding a national health industry high level reference architecture and a set of key standards everyone must strive to be compliant with by a certain date, then get Gov't support and get the right legislative changes. We would be happy to manage such a project via the Global eHealth Collaborative but this not-for-profit needs financial support to do so. Perhaps the key stakeholders can pitch in?

Anonymous said...

Michael Legg, that is a good reminder, so much noise has happened since, where can historical material be found? And has this been tabled as part of the current secure messaging discussions of late?

Andrew McIntyre said...

I must admit Evelyn I could not support any attempt to try and move to a "new" standard as the problem is that we have much invested in what we are using and its not as if its not fixable with a little effort, its just that there never has been any effort or incentive and vendors have been pushed around to implement what Healthconnect/NEHTA 1 & 2/ADSA want. They all wanted to implement someting "new" and its led nowhere. However the real work is done with HL7 V2 and its the only thing that is working. Electronic pathology, warts and all is a success story despite the lack of support and distractions by government. Its also working for clinical documents now, on a large scale. Surely a little effort to try and get everyone up to standard with that is long overdue as its not going away. Given the big squeeze on pathology I can't see them lining up to implement new unproven systems. They would like to produce one standard message and have confidence that it will work, rather than producing pms specific versions that continually break when receiver systems are updated. That would save $ and allow messaging system interoperability.

Bruce Farnell said...

I agree with you Andrew - 100%.

I don't often comment and only do so when I when I think I have something to contribute. A couple of times it was on the topic of clinical messaging. I refer you all to:

These comments stated the problem, from my perspective, and suggested a way forward. I feel that they are still valid.

The really sad thing is that these comments were made over 6 years ago. Aside from some interoperability improvement between messaging vendors what has improved. Not much. We still need a workable process for ensuring message interoperability.

Anonymous said...

12:51 PM "This thread is really grim” . …. “Comments that might help sort this out would be especially welcome!!"

The reader's comment (questions) at the end of Jeremy's article is a pretty good place to start. Tim Kelsey and Paul Madden have a responsibility to answer the questions raised and should be able to do quite quickly - say 2 weeks at the outside.

1. What is the purpose of the MyHR and why?
2. Is the MyHR fit for purpose and if not, why not?
3. Who is the primary beneficiary of the MyHR and why is that so?
4. Is the MyHR the ‘right’ solution and if so why, or if not, why not?

Anonymous said...

Might I add one question? How does the current design of myHR and frameworks surrounding it add value to the now emerging transition to a new medical paradigm that is predictive, preventive, personalized, and participatory? How will PDF store enable P4?

Bernard Robertson-Dunn said...

I'll suggest an answer. It doesn't and can't.

Assuming MyHR is a source of data on a patient that is accurate, up-to-date, complete, trusted, extensible, tagged (e.g. xml, so that an app can identify the data), machine readable, sortable and clinically searchable (and it's none of these), where are the models, processes, applications and workflows into which the data would fit?

Data is useless unless it is used. As we have been saying for ages, MyHR is just a dumb records management system. It was designed that way and can never support P4.

MyHR has to be read by humans. The more data in it, the harder it is for humans to make any sort of sense of it and get any value from it.

IMHO, it's a backwater, a dead end, a relic of a bygone era of GP/hospital records.

Apart from that it's a wonderful source of patient data for other, non-health purposes that governments will find most useful when linked to all the other data they have.

Dr Evelyn Hovenga said...

Andrew I'm not suggesting something 'new'. Current technologies that work are in use but in a fragmented way. We need a national vision to work towards so that interoperability schema can be developed as a transition building on current systems but eventually meeting our collective agreed vision of what we would like to see within the health system as a whole. We need an agreed big picture view to work towards.

Anonymous said...

Evelyn, that is what the National Strategy is suppose to deliver, a comprehensive and inclusive big picture, one that places the patient at the centre of an affordable and forward thinking healthcare system where patients needs are catered for and healthcare workers are remunerated appropriately for their skills and services and not turned into data entry clerks. This needs to create a society that fosters a culture of sharing.

Dr Ian Colclough said...

Evelyn, we've had 'more' than one 'big picture' vision in years gone by; all the way back to the days of Health Connect.

The devil lies in the detail; further compounded by the temptation to develop the 'vision' and subsequently the 'solution' with the establishment of numerous 'committees' which together comprise 'every' conceivable stakeholder each riddled with their own 'conflicts' and 'vested' interests. Such an approach very quickly goes off-the-rails and we have seen repeatedly where that leads.

Bernard Robertson-Dunn said...

Anonymous April 30, 2017 11:48 AM
Totally agree, but with some reservations.

Nobody has ever done proper eHealth. It's a new concept and paradigm, largely based upon P4 (above)

There are two strategic directions:

1. Use existing tools, technologies and solutions to marginally improve what happens already (e.g faster horses, faster cottage industries in previous times)

2. Radically change the way healthcare is conducted and delivered (e.g the combustion engine and automation/industrialisation in previous times)

DoHA/NEHTA in the past have tried option 1 and pissed their money up against the wall.

DoHA/ADHA look to be doing exactly the same.

Option 2 is far harder but eventually will be much more productive. However, it will take investments in research and development, trial and error, gradual change, true innovation and leadership. I've seen no evidence of anyone anywhere (let alone in Australia) tackling this option.

The two strategies are fundamentally different in approach, but there is no reason why they can't be part of a single vision and overall strategy.

Having said there is no reason why it can't happen, in Australia there may well be a lack of true innovation and leadership.

The ADHA strategy will tell all. If it's more of the same, then they will have chosen option 1. This will be like driving down the road but steering by looking in the rear view mirror. It gives the impression of movement but getting anywhere useful is rather difficult.

Anonymous said...

10.56 AM It sounds like Eleanor is describing a 'schema' which is antagonistically-vendor neutral.

Anonymous said...

12.42 PM I think you mean agnostically-vendor neutral. Even so, whatever Evelyn (not Eleanor) is describing and whilst 12.02 pm is right on the mark it needs to be appreciated right up front that government and its public servant bureaucrats somehow have to be taken right out of the equation. Because, as we have seen all too often as soon as they become involved they exercise their muscle power to steer, own and direct competent technology vendors along a hugely rocky road towards failure.

Anonymous said...

David @ 12:51 PM it might be the Government's problem today but from memory I think Labor (Rudd-Roxon) were responsible for putting the Personally Controlled Electronic Health Record (PCEHR) on the table as an afterthought when it became painfully obvious that the National Health & Hospitals Reform Commission (NHHRC) had made no mention of information technology in their initial report which they quickly followed up with an Appendix (Addendum) to the Report promoting the concept of a PCEHR.

It benefits Labor to point the finger at the Government Coalition Parties for the great muddled Digital Health mess today, but it won't be long before Labor have to carry the can once again when they are re-elected. Both parties seem content to blame each other and keep kicking the can down the road at the taxpayers' expense.

Dr Evelyn Hovenga said...

There is international agreement that the primary hurdle to gaining maximum benefits of digital health is effective and semantic information exchange. This needs to be resolved to enable the provision of person-centric care as the use of integrated EHRs and sound data analytics have great potential for cost savings. Our National experts should provide the necessary leadership. There is a need for implementation pathways to be developed to reach cohesive solutions which are safer, more cost effective and technology agnostic than is currently the case. One positive European example is from the epSOS (Smart Open Services for European Patients) project that achieved technical interoperability between the 17 countries. Another is Northern Territory’s comprehensive shared electronic health record (EHR) based on Ocean’s openEHR platform or the New Zealand’s national programmes that share a common operating environment, a national infrastructure, secure connectivity, ICT capability and health identity information systems supported by telehealth initiatives and a set of nationally endorsed IT standards.
A key issue for many eHealth systems is the governance and management of Health data, information, knowledge and their interaction with computing and communication technologies (information standards). Storing information in a computable format have been shown to provide a source of new knowledge discovery. The World Health Organisation (WHO) published a most useful circular graph representing the data use ecosystem[] This has the potential to be used by any national to map their specific data flow requirements from a national perspective and develop the national infrastructure accordingly. New digital trends require a greater focus on integration, collaboration, data sharing, patient empowerment, quality healthcare irrespective of location, supported by a comprehensive national infrastructure, incl. wifi and broadband access. The use of mobile devices has the potential to improve care processes and outcomes but these too need to be integrated. Australia has a desperate need for a clear data driven national business model to achieve a sustainable health system. We can't leave this to Governments or pubic servants to sort out, we've tried that. It needs a expert team approach.

Anonymous said...

April 30, 2017 5:49 PM It all sounds very knowledgeable but I don't detect much pragmatism in your commentary.

Dr Evelyn Hovenga said...

Examples given represent pragmatic solutions.......

Dr Ian Colclough said...

Pragmatic is best described as dealing with things sensibly and realistically in a way that is based on practical rather than theoretical considerations.

By all means it’s a noble objective to have a system that works as Evelyn describes, such as in NZ or in 17 countries across Europe, or in the NT. That’s aspirational and quite acceptable, but it’s not pragmatic thinking.

A pragmatic approach involves having one’s feet firmly planted on the ground and overcoming the huge number of obstacles that lie ahead in order to reach the aspirational goal. In other words, dealing with the problems that exist in a specific situation in a reasonable and logical way, instead of depending on ideas and theories.

For example, Andrew McIntyre at the beginning of this blog thread (7.49 AM) said:
1. “It’s amazing how clueless some of the commentators are. Somehow messaging interoperability is all we require to make things work? really?”

2. “We need message interoperability before messaging interoperability becomes achievable or even desirable because without that all we would have is systemic failure at endpoints, lost data, crashing systems and a support nightmare.”

3. “Until we have support for receiving standards compliant messages reliably, messaging interoperability is not even desirable and certainly not safe.”

4. “Senders like to be sure their results are rendered reliably by the receiver and having control of the messaging allows them to achieve this.”

5. “Internet browsers are now much more standards compliant and that has allowed the web to flourish.”

6. “We need compliant end points in healthcare so clinical decision support and high quality rapid information transfer can flourish.”

Andrew’s points 1-6 are excellent examples of pragmatic thinking. Thank you Andrew.