This appeared last week:
Australia’s most urgent digital health care issue is appalling interoperability
Severe interoperability problems in the healthcare sector are holding back efficiency, massive cost savings for government, and, most importantly, patient safety.
Each year it is believed that as many as 18,000 deaths are caused or at least expedited in Australia by medical errors. A lot of these errors have their origins in a digital ecosystem beset by bespoke secure communications systems that simply that don’t talk to each other.
In general practice, there are about 18,000 fax machines, which currently do most of the grunt work of secure messaging for things like referral letters to specialists and hospitals, and, at times test results. That gives a very clear picture of how stuck in the dark ages healthcare messaging and data sharing remains.
It’s become a high priority for the recently formed federal body, The Australian Digital Health Agency (ADHA).
The agency is attempting to pull together the various private sector software and secure messaging vendors and healthcare service suppliers in order to get them to ‘burn their boats’ in the name of jumpstarting significantly improved data sharing in the sector, and pave a road to significant improvements in safety and efficiency.
But where there is efficiency and gain for some, there is nearly always a loss somewhere in the system. And while the various software and messaging vendors and the major pathology and service providers, including Sonic Healthcare, our largest Australian healthcare company, are duly attending the peace meetings and making all the right noises, behind the scenes, the commercial strain on these organisations is already obvious.
It is hard to shake the feeling that something is likely to break, thereby dragging out the process even further.
High stakes
In a surprise recent move, Sonic appears to have declared strongly for the peace process, by agreeing with the ADHA to connect their pathology laboratories seamlessly over time to the AHDA’s mega health centralised communication project, the MyHealthRecord (MyHR).
The ADHA will pay for Sonic to do the development. But by agreeing to automatically release pathology data to a centralised live electronic medical record (EMR) of all Australians, Sonic is taking a serious potential step to releasing the hold it and Primary Healthcare have on general practice distribution channels for sending patients to their labs.
The MyHR is the government’s attempt to provide every Australian with a centralised electronic medical record for reasons of safety and system efficiency.
It’s a whole other drama for which the ADHA and its predecessor organisatons have copped a lot of flack. Current and planned investments are not likely to see a respectable ROI for some years based on failures of the program to date. But if the AHDA can get the MyHR fully operational, there will be benefits for the system and a basis for optimism moving forward. One of the benefits would like be helping to inject momentum into efforts to get healthcare interoperability sorted out quicker.
Theoretically, if Sonic rolled out their connection to the MyHR across the country, and if MyHR could connect properly to GP surgeries via their desktop systems, then up to 40 per cent of GP secure messaging might be sorted out. Pathology results could bypass the spaghetti like systems of multiple messaging vendors in between GPs and their various providers, all of whom fight in some way or another over talking to each other in order to retain some commercial stake in the ground.
But this is a very big ‘if’.
The MyHR has its own problems, and some more cynical analysts have suggested that Sonic might just be playing the game of being seen to do the right thing, when ultimately, they, like some others, have very little confidence the MyHR will get that far.
Lots more here:
I would argue we are far more advanced than what is suggested with secure (non-fax) messaging and that the myHR is the last thing you would want to place at the centre of our Digital Health initiatives.
What is your perspective?
David.
David at some point ADHA will have to think beyond messages and look at the interoperability of healthcare services. Message acknowledgement is just the start of the problems when it comes to agreeing to semantics and behaviour.
ReplyDeleteInteroperability is a multi pronged outcome that does not equate to maximising connectivity. Thousands of independent messaging communities just creates a mess and opportunities for market manipulation.
Eventually someone has to invest in shared meaning.
Calling it interoperability does not make it interoperability. They will be telling us some sort of dreamed up productivity/revenue loss figure next.
It still puzzles me how the messaging work, decommissioning of NASH and HI services is going to happen without negative impact on the government PHR?
David at some point ADHA will have to think - looking forward to that day
ReplyDeleteInteroperability is an issue because of the dinosaur vendors who want to "own" the ecosystem. They have no interest in actually "talking" to other systems, and have made a whole industry out of the HL7 model to perpetuate this farce. On the secure messaging, if a clinic has a privacy breach, secure messaging will not cut it, as it only confirms delivery from site to site - not clinician to clinician. This will not meet the Privacy Commissioner's view on what is secure and what is not secure.
ReplyDeleteFax over IP (FoIP) meets these use cases. I am not sure they are looking at a problem or marketing a solution.
ReplyDeleteI agree with you David, my personal experiences with various healthcare providers does not reflect this Stone Age picture some paint, is it perfect? Probably not, is it a disconnected communication free zone? Not in my experience. I think they over play the technology card and do a disservice to the human networks that work for the vast majority. That said I would be happy for a machine to replace the ADHA CEO, be less predictable and repetitive, might even generate some imaginative thinking that is currently in short supply.
ReplyDeleteOne of the issues with the decline in advertising revenue is the superficial analysis that gets published and this is a perfect example. To be critical of 20 years of atomic HL7V2 pathology transfer at no cost to the GP and suggested that they would be better off getting a pdf via MYEHR is quite silly. While the decision support done today is basic, atomic data such as HBA1C values are used and the pdf version of pathology is going to make this difficult.
ReplyDeleteA central hub version of messaging is also going to have scale-ability problems, especially when run by people not familiar with dealing with the load, which would be enormous. To paint fax over ip as an advance is simply incomprehensible and denies that electronic pathology is working today. Its as if the best way to hide your own failure is to bring down whats working to your level.
We have also dumped the individual PKI keys which did allow authentication of individual providers and was working, although HESA lacked the resources to sort out odd hardware incompatibilities and threw their hands up and said "Its to hard" even though we had it working well. It seems no one in authority has a bottom to top understanding of the problems. They have trashed NASH, standards, Identifiers, SMD, AMT/SNOMED-CT and now want to announce PDF healthcare as an advance. Its a retrograde step, taking us back 20 years to a prettier, resource heavy version of PIT.
Paul Fitzgerald,
ReplyDeleteDear Paul, as a director of the largest of the vendor organisations who you describe as 'dinosaur vendors who want to own the ecosystem', I strenuously object to that characterisation and the sentiments that underlie it.
We are working extremely hard on upgrading our systems to talk to one another, but it is challenging, with significant structural differences between our various systems and a plethora of "standards" to choose from, confounded by unworkable national infrastructure.
However we are working hard on sorting it out and we are getting there. Surprisingly to some, ADHA is being very helpful and we are getting there. We have already demonstrated the ability to exchange messages between systems and are working really hard on scaling it up so that we can solve the problem once and for all.
Kind regards,
Tom Bowden
,
Andrew McIntyre makes a lot of sense. Unfortunately Tom Bowden's comment which follows seems to be contradicting a lot of what Andrew said. They are both experienced in messaging. I wonder who has allowed the politics of the situation to undermine objectivity in the face of some commercial imperative.
DeleteHope you succeed Tom and people know when to stop being helpful. If you can keep it on the agenda as the MyHR takes centre stage that will be great. Secure messaging has almost been across the line several times, the PCEHR has always been its achilles heel.
ReplyDelete5:07. Thought leadership is a great natural ability, no room in Digital Health these days I am afraid.
Claiming that sticking pathology reports on the myHR as interoperability is a joke. A very bad joke. Shoving more pdf's on a web portal is not interoperability.
ReplyDeleteHere is an idea, let us all have a shared understanding of what the term interoperability really means. Then look at potential solutions which tick all of the boxes. No, shoving more pdf's on the myHR does not tick any of the boxes.
As for faxing. Yes, it needs to evolve into something else. However, the new lowest common denominator for communication needs to work with our state funded medical establishments. Despite their relatively large technology spend (compared with general practice) they are still 'banging the rocks together' from a technology perspective. I could go on about lack of accountability and how easy it is to spend other people's money.... perhaps another time.
@Tom Bowden, Tom, I was not referring to your company, or any of the plethora of more modern players in the healthcare space. I was talking about the ones that Government's continue to implement at costs in the hundreds of millions that have technology build in the nineties, and fail to progress with the times. It is these who want to own the ecosystem. Whilst the talk about interoperability, they have little interest in doing this. I heard just this morning of a hospital group in West Coast USA that has a paediatric hospital and an adult hospital - they run two different versions of the same EMR, from the same vendor, but the two systems cannot talk to each other.
ReplyDeleteA couple of years ago I did a review, for a client, of a number of large IT implementations in the health area. Things like Fiona Stanley and Royal Adelaide but also going back to the Victorian HealthSmart initiative. It was remarkable how the same three issues were identified in just about all cases, in multiple reports over a number of years:
ReplyDelete1. Poor understanding of how long a large IT project takes. Hence time and cost overruns and rushing the tail-end to get it out on time with insufficient testing
2. Little or no change management. Users not engaged with the new system and thrown in the deep end with no training or, in some cases, warning.
3. Interoperability. Multiple systems across a hospital which simply didn't talk to each at all, let alone work together. Admission systems that were incapable of sharing data with Intensive Care etc. This is not unique to Health care (I am currently working in the Education sector with vendors who don't understand modern architecture practices) but it seems particularly prevalent there.
Note that interoperability is NOT just sharing data, there are several other aspects required to get applications to play well together.
Surprisingly the client I did the review for changed their selection procedures and ended up with a set of systems that could at least share data, even if they were still very silo-ed.
One seems content to facilitate the syntactic interoperability while the other is after richer feeding grounds of semantic interoperability. As our national entity lacks leadership the path of least resistance will be taken.
ReplyDeleteAs we can see from your post yesterday David for the taskforce to consider the world has moved on having understood syntactic interoperability is a minor stepping stone which is relatively simple to achieve, to make a difference we must be embracing the wider interoperability challenges. Sadly Tim for some reason has failed to grasp this and instead retreated to a comfort zone of stories and tweets. Not exactly the thought or any other kind of leadership qualities I was expecting from tax payer investments. Still with that exectuvive overseeing government and industry it was always going to be an adventure and success free zone.
Part of the original concept for the PCEHR was to create a virtual health record comprising and linking repositories of data help by various health care providers and to deliver to those who needed it a consolidated view of all a patient's health data.
ReplyDeleteThis, if implemented properly, would have gone a long way to solving the interoperability problem. Unfortunately there was no coherent information architecture that would have identified the components that were required to make it work.
An information architecture would have identified that it is the content held in the repositories that matters, not the documents that contain that data. This, as others have pointed out, is the real problem of health data interoperability.
NEHTA, in its wisdom decided to ignore the hard problems and concentrate on what it thought was easy and deliverable - a centralised document store of hard to manage pdfs. All the talk now is of uploading data to MYHR.
Because there was no information architecture, which everyone could understand and agree on, and against which the PCEHR/MYHR could be assessed, it was/has been difficult to recognise that what NEHTA delivered is nothing like the original vision, nor is it even remotely useful.
We are now in the situation which is much worse than before the PCEHR/MYHR was implemented. Not only has the interoperability problem not been solved, but we now have a system that the bureaucrats are desperately trying to justify and which cannot be modified (they would have to start again from scratch), to make it anything like what is needed.
Far from leading the world, which is heading towards true interoperability and giving patients access to existing medical record systems, Australia is rapidly moving backwards with its dumb, centralised, patient controlled, privacy invasive, summary, secondary, very expensive, unused, document store.
Unfortunately the bureaucrats, who don't understand information systems, let alone the complexities of health information, don't recognise this.
Bernard, taking up the original starting point of network-based access, I would add a couple of points:
ReplyDelete1. We actually need Information and Information Flow Architectures; and,
2. We need NORMS, developed by healthcare for healthcare, to inform, guide and hold to account (in comportment terms) the exchanges of health-related information.
These reflect that healthcare operates under the Duty of Care as well as the need to recognize and address actual and emergent medico-legal liability considerations.
John,
ReplyDeleteand to add to what is needed, and why the problem is so complex, the end points need to perform some quite significant data analysis on the data they hold.
The Concept of Operations section that discussed the information model (and it was only a discussion, not a model) said "The PCEHR System enables the collection of information from participating organisations, individuals and the Department of Human Services Medicare program within a series of conformant repositories. Information will be collected in the form of a clinical document."
The PCEHR was/is just a set of documents, some meta-data and an index of documents.
True interoperability involves the repositories managing and analysing the data at a clinical/medical level, not at a template/meta-data level. That's why they would need to go back to scratch.
We are not even there on the syntactic interoperability level, but I fear that if we push the pdf everywhere solution we might even lose the base semantic interoperability we have with pathology. The problem is a bit like an episode of Utopia. The spin doctors have already announced a grand plan that the minister loves and anyway they can plaster over the failures with more PR.
ReplyDeleteDoing what is needed at a low level is just hard work without any flashy announcements but until its done we remain waist deep in the swamp. PDF is like trying to build the castle in a swamp on rubber dinghies roped together.
Andrew, I agree totally. Going down the wrong path makes it much harder to find and go down the right one.
ReplyDeleteBernard has highlighted some very important facts which ADHA (&NeHTA)and the Federal and State Health Departments seem to have completely lost sight of. In my opinion We should never lose sight of them. They are:
ReplyDelete1. @9.37 AM Part of the original concept for the PCEHR was to create a VIRTUAL health record comprising and linking repositories of data held by various health care providers, and to deliver to those who needed it a consolidated view of a patient's health data.
2. @11.17 AM The Concept of Operations section that discussed the information model was ONLY a discussion, NOT a model.
3. @9.37 AM An information architecture WOULD HAVE have identified that it is the content held in the repositories that matters, not the documents that contain that data.
Had these 3 essential concepts remained alive and at the forefront of PCEHR MyHR development we would have a very different outcome from that which we have today. However, that necessitated informed, enlightened, competent, pragmatic leadership which was and has been lacking in every respect.
DeleteYou should all keep in mind that what we built was heavily constrained by realities that would not go away if we paid more attention to those principles. In particular, I went and created FHIR because it was evident that we didn't have the standards base to build the system those principles imply.
ReplyDeleteAnd it has proved to be a great movement Grahame, are those constraints still valid? If so are they now artificial? Why should people accept the constraints of the past? I think others are correct to question and remind others that change is an option, a set of options that need to be debated before we get locked in.
ReplyDelete"You should all keep in mind that what we built was heavily constrained by realities that would not go away if we paid more attention to those principles."
ReplyDeleteI'm sorry, but if someone asks you to build a rocketship that will get them to the moon and back and do it by the end of the week for $100, you have a duty of care to explain that it can't be done because of the constraints of reality. If you don't or can't and then try and do it you are as culpable as the idiot who asked for it to be done.
"I was only following orders" is not a valid defence.
an extension to 9.05 AMs question that the Father of FHIR is well positioned to answer is ...
ReplyDeleteHow mature is FHIR?,
Is it ready, proven and stable, to be embraced by major developers and embedded into their product portfolios now as the bedrock of their future offerings?
Andrew @12.00PM said ".. the spin doctors have already announced a grand plan that the Minister loves .."
ReplyDeleteI think this Health Minister might surprise you. He's alot sharper than his predecessors. He's not averse to asking some very hard questions. Time will tell.
Time will tell.
From what I see and hear FHIR is ready to be adopted into planning and development as much as any of it predecessors, the makeup of the FHIR communities and its mode of operations I believe far exceeds other alternatives. My concern is the ADHA which bend it to be CDA by another name. It is like watching kids play with matches. We have or had the talent and leadership, such a unnecessary delay IMHO
ReplyDelete10:12AM. I believe many are, certainly those invoked in project Argonaut. That leaves a few questions:
ReplyDelete1. What are you looking to solve with FHIR?
2. What role does ADHA have in FHIR if any?
3. Could ADHA add anything of value to FHIR? And would anyone care?
12.19 PM Ready to be adopted? Heresay is not good enough.
ReplyDeleteWhere has it been adopted, tried, tested and proven?
Hopefully Graham Grieve will throw some light on the questions now being posited on this blog.
1:37, are you serious? I hope you are not part of the new generation the ADHA is scrapping together.
ReplyDelete@1:56 PM I am not part of the new ADHA generation. Even so, my questions were valid. If I were considering investing in FHIR I would be asking a lot more questions along those lines. So my suggestion is that you stop avoiding the issues and get on with answering the questions.
ReplyDeleteAnon 1:30 PM
ReplyDeleteGood questions.
Looking at
http://hl7.org/fhir/overview-arch.html
at least they use the usual definitions of conceptual/logical/physical architecture, but it is a bit of a problem that there are now two different architectural approaches fundamental to MyHR.
FHIR is positioned at "the Platform Specific Specifications layer of the Information Models and the Behavioral Models Viewpoints, respectively. "
The answers to Anon 1:30 PM's questions should be in teh deliverables that would normally have been completed well before getting to the platform specific layer.
i.e. TOGAF Business Architecture and the nine boxes above where FHIR is positioned.
AFAIK the deliverables that belong in those nine boxes have never been created by NEHTA, Health and/or ADHA. In other words, the answers to Anon 1:30 PM's questions do not exist.
Could I also point out that the ADHA strategy Executive Summary says:
"By the end of 2018, a public consultation on draft interoperability standards will confirm an agreed vision and roadmap for implementation of interoperability between all public and private health and care services in Australia. Base-level requirements for using digital technology when providing care in Australia will be agreed, with improvements in data quality and interoperability delivered through adoption of clinical terminologies, unique identifiers and data standards. By 2022, the first regions in Australia will showcase comprehensive interoperability across health service provision."
and, the Con-Op of September 2011 said:
"Access to the PCEHR System will be based on Australian and International
standards for ensuring interoperability of eHealth systems as well as other
relevant specifications."
In other words, they implemented a system in 2011 without having delivered the core interoperability requirements and don't expect to do so until at least 2022.
The .pdf based solution that we have at the moment and will probable get as part of the "death-to-the-fax" movement are clunky work-rounds which will need replacing sometime after 2022. Transitioning to a FHIR based solution will impact all aspects of the system from user behaviour right down to the data. That's going to take a huge chunk of money, at least as much as has already been spent.
FHIR isn't the problem, it looks like a good architectural approach. ADHA's problem is that they have got this far without it
And one final comment, Zachman and TOGAF are Ok approaches for complex and simple problems. Healthcare is acknowledged as a wicked problem for which Zachman and TOGAF have major failings.
If anyone is really interested see my paper "Beyond the Zachman framework: Problem-oriented system architecture" which was published in the IBM Journal of Research and Development. Volume 56, Issue 5, September/October 2012
A copy is available here:
http://www.drbrd.com/docs/Problem-orientedSystemArchitecture.pdf
12:51, you ask an open ended question, what context are you asking? Is it in the area of Orion Health Rhapsody Integration Engine, or the areas Intermountain apply it? You could always try the fair community on Zulus.
ReplyDeleteI did look on the HL7 Aus website but could not find the Strategy that AHMAC commissioned which was intended to provide investment guidance for V2, FHIR, CDA etc, but then the current chair is a bit of a wet fish so it probably is sitting under his stool.
@4.23 PM you demean yourself by demeaning the current chair of HL7 Aus with your pathetic insult.
ReplyDeleteHere is another question that a potential investor would right fully ask. What are the barriers currently preventing the generalised adoption of FHIR?
Hi 5:53 PM What is the investment you are looking into? It might help the discussion on where FHIR would deliver the most benfit, like all standards it does not live in isolation.
ReplyDeleteOr were you referring to the Chair of AHMAC and not HL7?
ReplyDelete7.06PM A consumer-centric-controlled SEHR partly funded by government but arms-length removed from Government control.
ReplyDeleteNearly everyone in Australia today is registered for Medicare and they receive benefits under the MBS and the PBS
ReplyDeleteWhen these 24 million people are compulsorily registered for a My Health Record what additional quantifiable benefits will they receive?
Why doesn't the MyHR use the Medicare Number? Isn't the Medicare database being used as the root ID source for registering every Australian with a MyHR? Why is everyone being given another 16 digit number for the MyHR? Isn't that perpetuating the further fragmentation across the health system?
ReplyDeleteIt should help insurance companies and other patient shoppers.
ReplyDeleteI do question the need and relevance of the ADHA, they had a really good go at making Digit Health attractive so that it drove and awareness and informed takeup by citizen ( rather than healthcare professions). Unfortunately it has failed to make any impression, I am not clear what additional value this framework for action will add, except it will be the same select group going over the same old ground.
Fundamentally it's ethos is that of a marketing entity not problem solving entity. The difference lies well beyond culture. The former tells and promotes, the latter analyses and solves.
ReplyDeleteRe the Medicare number.
ReplyDeleteIt has long been known in government that it is not very trustworthy. There are more Medicare numbers than Australians and much of the identifying information and addresses are wrong.
In 2007 they tried to replace it with the Human Service Access Card but messed that up.
There is a school of thought that the only possible justification for the $1.5billion that the government has spent with little or no health care benefit is because it will turn the IHI into a default National ID number.
When people create a myGov Account and link it to their MyHR they will validate their IHI and provide a lot of other information which will make tracking citizens so much easier, e.g. phone number, email address, GP etc. Every time they go to see a GP their details can/will be updated.
MyHR is a strange beast. There is far less to it than the government claims and far more than they are letting on.
Oh!? I hadn't realised that when the government compulsorily registers everyone for a MyHR an individual will not be able to access it unless they are first signed up to MyGov which in time will happen through the online lodgement of tax returns.
ReplyDeleteThe government is moving towards a single sign-on through myGov. At the moment you can get to Centrelink via a direct log-on page but that will change soon. You have to have a myGov account to get to MyHR. It makes it much easier for the government, sorry, for you to link all your accounts.
ReplyDeleteThis page shows you how to register for a MyHR:
https://myhealthrecord.gov.au/internet/mhr/publishing.nsf/Content/before_you_register_yourself_or_your_child
Step 1. Get a myGov account.
@10:40 am
ReplyDelete“Why doesn't the MyHR use the Medicare Number? Isn't the Medicare database being used as the root ID source for registering every Australian with a MyHR? Why is everyone being given another 16 digit number for the MyHR? Isn't that perpetuating the further fragmentation across the health system?”
A person’s Medicare Number may change over time. For example, when you turn 18 you can choose to have your own Medicare Number, and to no longer be a row on one or more of your parents’/carers’ cards. Also, if you get divorced/separated, you may wish to remove yourself and your children from your partner’s card, and start a new Medicare Number for each affected person.
The 16 digit national individual health identifier (IHI) is essentially static over time (although there may be instances where due to error - an IHI is merged or unmerged with another IHI). The IHI is used by uploading systems to identify which person’s MyHR record the uploaded information is intended for inclusion.
A person can have a number of associated identifiers in different contexts. They may have one or more medical record numbers in each hospital or healthcare facility they visit. They will also have one or more Medicare Numbers which identify their benefits/claims made under Medicare. The 16-digit IHI is a way of linking those different identifiers. One way to think of it is that the Medicare number identifies a record (a record of claims/benefits under Medicare), but the IHI identifies a person.
Thus the intention of the IHI is not to further fragment, but rather to reduce fragmentation, by providing a linking number. There are significant constraints in the way it can be used (see Healthcare Identifiers legislation).
6:07, well summarised. There are 10 health identifiers used across the Australian health sector that I know of, only 4 of which would be known of by a citizen.
ReplyDelete> Hopefully Graham Grieve will throw some light on
ReplyDelete> the questions now being posited on this blog.
back from having a life during the weekend - I'll try.
> And it has proved to be a great movement Grahame, are
> those constraints still valid? If so are they now artificial?
>Why should people accept the constraints of the past? I think
> others are correct to question and remind others that change
> is an option, a set of options that need to be debated before
> we get locked in.
1. thanks
2. yes, the lack of standards was only one of the constraints. There are others; merely changing the standard - but following the same everything else - will lead to a similar outcome to what we have now
3. it's always good to debate approaches. But hindsight is 20/20 - I think it's useful to bear that in mind when discussing the past, and trying to draw lessons to apply to the present
> you have a duty of care to explain that it can't be done because of the constraints of reality
as I said, hindsight is 20/20. Also, subsequent decisions led to where we are. It's unfair to judge like this.
> How mature is FHIR? Is it ready, proven and stable
we're mid-way through the standardization process - starting to settle, but still responding to implementation experience.
Our process is well described, and ADHA, like many other players, keep close track of where we're at. The counter question is, 'how mature does it need to be?' for a particular use - and that depends on the use
> embedded into their product portfolios now as the bedrock of their future offerings?
The answer is probably 'nearly yes', in that companies are now doing it - *if it's the right point in their life cycle* - but they'll still have to deal with the latter part of our maturity process.
Use in MyHR evolution/development etc would be subject to the same issues - FHIR release 3 is enough to support known use cases, but using it would require a strategy to deal with ongoing change.
> 1. What are you looking to solve with FHIR?
> 2. What role does ADHA have in FHIR if any?
> 3. Could ADHA add anything of value to FHIR? And would anyone care?
I think it's not really the right time or place for me to comment on these, except to say that ADHA can definitely add things of value to FHIR - and they already are (though like with every participant, there's always space for more contributions...).
David, Bernard, Andrew
ReplyDeleteTo David' original question about the article:
Andrew, the article is superficial. My guess would be it's outright wrong in parts. It's certainly and been misunderstood.
A couple of things:
* I didn't set out to write to the audience of David's blog, who are clearly far more knowledgeable on this topic than I am. I set out to write it to a much broader community - clinical, technical and public interest - who seem to have no buy-in, indeed, hardly any understanding of this huge and vital issue in the future of efficient delivery of health in the country.
* This is an great blog. But it does have the whiff of an echo chamber at times. You all know what you are talking about but you are also all discussing some highly technical issues, with views that no one understands as a result. Your views here aren't made meaningful or relevant to important influencers in the professions of tech and health or government because there is a lot of dismissiveness and cynicism with all the good thinking.
* When I visit the ADHA I get the feeling they view you and this blog as an anti MyHR terrorist cell. That is not a good place to be no matter how hard lots of people may have tried to get people to listen in the past.
* I understand a lot of you must have been fighting this for a long time, and I'm new to it. But If there is a huge breakdown between the technical community and the government on the MyHR and other issues like interoperability, then someone in the tech community should be formulating a plan to bridge that gap, no matter how much that might involve swallowing pride. Yes, the government should be making that effort as well.
* Would a little mediation between the two parties be a bad thing given what is at stake?.
* Couple of minor points on some of your comments:
- I didn't ever set out to suggest the MyHR should be a central hub of interoperability. The ADHA doesn't even think that. Bad writing potentially. I did suggest that the MyHR talking to path and hospitals might pressure the private path labs if it opens up the possibility of an 'open' channel on results. That would be something good the MyHR does.
- Yes, there is already some advanced interoperability, and it's been free to primary care so far, on the back mostly of private pathology. But it's pocketed and a mess. And perhaps it shouldn't be free to GPs and that is part of the issue. It's not a tech issue anymore. It's a complex series of vested interests and those vested interests can't be blamed. The problem needs help from everyone.
- The march of certain connected technologies does raise the very real question that the MyHR isn't the best way to go. But how do we hlep get that looked at.
* If this blog isn't in some way to significantly help the healthcare community I'd be surprised. It's not doing that to full effect at the moment.
I am very interested in taking some of the views and arguments made on this blog outwards to the grass roots GP, hospital consultant, government influencers, where ever I can. With a view to making the debate decently informed at the least.
At Wild Health Summit you can ask these questions personally of Tim Kelsey, Tom Bowden and the like directly. We are having a day where we just have Q&A panels. One is on interoperability, another on the MyHR. I'll front the comp tickets if you can't afford them. We need all views to be aired fairly. If you can afford them pay something - see journalism below.
Re: Andrew's point of a lack of good journalism: yep, we're struggling to fund journalism these days. But we sure as hell need to try to fund it. At Medical Republic we're trying hard and we're optimistic. I think we can help the healthcare community in Australia if we manage to succeed.
Jeremy Knibbs
jeremy@medicalrepublic.com.au
Hi Jeremy - nice to have you here.
ReplyDeleteOne point I need to make is that the ADHA has been repeatedly offered the opportunity to respond to issues on the blog in articles or comments - but have thus far only asked for two comments to be removed for inaccuracy - which was done.
Cheers
David
Jeremy, I agree that it is good to you have here.
ReplyDeleteI agree that the Blog can appear like an Echo Chamber. That is, at least in part, because we are trying to work out how to go forward and how best to make our individual and professional contributions. Certainly, a number of us go back a long way.
Equally, I would agree that the issues raised on the Blog are predominately technical because the Department of Health and, to some degree COAG, have given us no alternative framework within which to make a considered contribution.
At the heart of this strategic challenge is the fundamental question of e-health paradigm.
The current paradigm of Centralized Electronic Health Records dates back to the days of Tony Abbott as Health Minister. It also dates back to the Information Economy and the fascination with the Web.
The Commonwealth, to the best of my knowledge, has never asked the fundamental question: What is the likelihood that the knowledge and assumptions that underpin this strategy are correct?
If there is someone who recognizes the disaster that is the now-called MyHR and would like to hear about a new way forward, I for one would be very interested to have such a chat. This can be as confidential as it needs to be.
In making this offer as a place to start, I have the advantage on my colleagues in that I actually led the national strategy for 5 years in its very earliest days. We were moving successfully until the Howard government came to power in 1995 and abruptly closed the COAG-endorsed collaborative initiative down and sold off the collaborative entity to the private sector. The rest is history.
Finally, I appreciate the efforts you are making in trying to get the e-health agenda onto more solid ground. I suggest that you might begin by asking the question I raised above regarding the Likelihood that the knowledge and assumptions that underpin the current strategy are correct?
Jeremy,
ReplyDeleteHi, and welcome.
In my commentary yesterday I tried to steer clear of the technicalities of the MyHR and focus on what it actually is or isn't.
As I pointed out, MyHR is full of treatment data. All the Medicare data is about visits to GPs specialist etc for treatment; the prescription data is also about treatment.
I posed the question, if the MyHR is an "online summary of your health information”, why does it contain little or no information on standard health indicators and risk factors?
If I want my MyHR to include my height, weight, blood pressure, resting pulse rate, that I exercise regularly and don't smoke, there's nowhere for that data to go. The Shared Health Summary can contain a medical history (i.e. treatment) but not health indicators. As I said, MyHR is primarily a treatment record, not a health record.
IMHO, the fact that MyHR obviously isn't what the government claims is rather serious. Maybe you could inform your readers of this discrepancy?
I find the reference to followers of this blog as being an anti MyHR terrorist cell, in this day and age there is no humour in that and reflects more on the culture in the ranks of ADHA and certainly does little to build bridges IMHO. If those who might have differing views are slapped terrorists then we are heading in a dangerous direction. I do agree that there are at times some interesting comments from supposedly ADHA staff, and I am sure as with all public blogs some trolling occurs.
ReplyDeleteI do appreciate that parts of the community might find clinical informatics a mind boggling subject, but then it is a complex field. Is it a fear of smart people? Or a failure to invest properly in coming to a common understanding. Other international entities seem to realise investing in problem solvers and thinkers.
It is probably also worth pondering why with the emergence of the ADHA and the promise of openness, transparency and a new hope for change, the following of this blog has skyrocketed?
Do keep writing and engaging, you will be surprised how generous many are with sharing their knowledge and learning from others.
Personally I found your article an interesting perspective and hope you and the ADHA have a great event, it's a bit far for me to fly but look forward to the you tube or transcripts.
The area of eHealth deserves a proper investigation because its has consumed > $2 Billion of taxpayers dollars and has delivered nothing. It affects everyone. There is a need for a proper in depth journalistic investigation. Perhaps the rest of government is just as bad and that is why no one takes any notice? I hope not.
ReplyDeleteIn the last 2 decades many people on this list have tried to advance the cause, but increasingly no one is listening, and if "they" are so right why has there been no progress. Its a matter of looking at outcomes and saying there are none. We are entering a dangerous phase where there is a mood that the ADHA needs results and will push for some success at the expense of longer term functionality, which has been the crux of the problem all along. There has never been any attempt to fix the lower level issues of standards compliance, modelling or terminology and we now have the situation where the ADHA thinks that sending around pdfs, and only pdfs, is the solution and will "eliminate the fax". This has been taken up by users. We could have eliminated the Fax by sending around PIT reports 15 years ago, and in retrospect should probably have done that then as a first step, but it was felt that the benefits of transmission of human only readable reports was not enough to make a significant difference to quality health care. Pathology has been sending out mostly atomic data (Except for histopathology) for 20 years and with MyEHR even that has been reduced to pdf reports with no access to the underlying atomic data.
The potential saving wrt medication side effects/decision support etc are just not there with this solution and your fax can turn reports into pdfs if thats all you want.
If after $2 Billion spend and 20 years of effort government eHealth has failed to deliver anything you would have to ask if they are approaching the problem the wrong way and do they actually have the intellectual ability to understand, let alone solve the problem. They will potentially set back eHealth by 20 years if they are allowed to succeed. The infrastructure to support eHealth, which government said they would provide is all broken with inadequate provider and practice identifiers, a brain dead medication terminology and no effort to model common clinical reports etc etc. There is no governance of message quality, despite the existence of standards for 20 years. At some point you have to ask is government "help" with eHealth actually the problem, rather than the solution and I would postulate that it is.
I am sure they will present a slick PR face to journalists, but is there anything behind this "Ban the fax" rhetoric, and I have not seen any evidence that there is. I have no idea what the 300 people working for the ADHA do, but I suspect that many of them are frustrated that they are constrained from doing anything useful. When I try and and help develop useful specifications for projects they demand that we dumb it down to pdf only or they will find someone else. That fact that we are no further ahead after 20 years demonstrates a failure of leadership and I think its time we demanded government "Find someone else" or if they won't, stop trying to "help". This is a worldwide issue and reflects the failure of generic management, an issue that journalists should look at in depth.
Jeremy,
ReplyDeleteAFAIK, nobody who comments on this blog has a problem with the use of information technology to improve health care. Neither does anyone have a problem with electronic medical records, health records or the goal of improved interoperability.
The view of many commentators on David's blog (me included and I've had a lot of experience with public sector IT) is that MyHR is yet another failed government IT project.
That it is a failure is not yet apparent to most observers because it isn't being used and is not delivering value - but that's its failure.
One day, the hard heads in PM&C, Finance and/or ANAO will realise this and do something about it. I have no expectations that ADHA will change their views - as Upton Sinclair said "It is difficult to get a man to understand something when his job depends on not understanding it."