Quote Of The Year

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

Sunday, October 29, 2017

AusHealthIT Poll Number 394 – Results – 29th October, 2017.

Here are the results of the poll.

Do You Agree With Grahame Grieve (And Your Humble Pollster) That The myHR Is Architecturally Fundamentally Badly Flawed And That This Needs Correction If The myHR Is To Succeed?

Yes 99% (146)

No 0% (0)

I Have No Idea 1% (1)

Total votes: 147

I think this is the clearest vote ever! The myHR needs architectural change to succeed. Tinkering around the edge is an expensive waste of time and money!

Any insights welcome as a comment, as usual, especially regarding what might be done to fix things?

I begin to wonder who the single clueless person is who just likes to vote for the sake of voting?

A really great turnout of votes!

Again, many, many thanks to all those that voted!

David.

51 comments:

Anonymous said...

Perhaps David that one person does not believe the MyHR could be made to work even if rearchitected? That to one side, how will the ADHA deal with the outcome of a great poll? Will they attempt to buy people off by contracting them and hoping for silence? Will they announce a replatforming of the MyHR in a vain attempt to be seen to be ‘rearchitecting? Or will they just march on and become even more inward focused and excluding of all but those who say yes.

Someone needs to do something I find the ADHA has lost it intellectual power it inherited, they in a vain attempt continue with brands like clinical informatics and developer programs but they are devoid of leadership, strategic direction and technical capability. I am yet to engage with anyone I would regard as an Architect that is suited to a national level.

Hopefully something new will emerge and take us forward, I hate to say it but it sure won’t be ADHL7 Aus

Peter said...

There was an article recently in The Conversation about government plans for a centralised Driver's License database to be used for tracking and identification by law enforcement. The author's point was that same outcome could be reached with far better security and end-user experience with a federated architecture rather than a centralised one. The similarity to the MyHR situation should be obvious.
I said there as I have said here, a decentralised model based around local health records, held by hospitals or clinics, and a well defined interoperability standard (granted a difficult, but not insurmountable problem) would provide much better privacy and security while allowed each end-point (medical provider) to use an interface suited to their own way of working.

Anonymous said...

Peter, I agree in much of what you imply. What do you mean by an Interoperability standard? You won’t get interoperability with a standard alone. Also we have an Australian standard for eHealth interoperability, there are a number of technical standards that then require the combination of other standards, much like your home consists of hundrends of Standards or even the device you wrote your post on. Could you enlighten as to what a single standard might look like?

Anonymous said...

There is little point looking to the ADHA, there role is to operate the MyHR. Their view of interoperability and that of standards is posting PDF documents to a central repository. Being federal system it will be so lock down it can’t be used for anything fortunately the rest of the world has better options and technology is not reliant on such a system

Anonymous said...

10:10am out of interest why do you imply HL7 Aus is under the control of ADHA? Is the what you mean by ADHL7?

There is nothing to indicate HL7 Aus is even that active. The CEO of ADHA would not be naive enough to let ADHA staff take on anything more than a technical contributor and certainly not on any Governing body where it would quickly become apparent the ADHA was manipulating a SDO for their own purposes.

Anonymous said...

7:52 PM. I think you will find that is the case. I have no idea if it is part of a broader ADHA strategy.

Grahame Grieve said...

Several comments:
- I'm amazed that there's such complete endorsement of post; such consistency is unusual in this area
- I don't think there's any evidence that HL7 Australia is under the control of ADHA, though it's certainly not as active as it should be. But there's plenty of energy going into it
- Tim K's comments at HIC certainly suggest that he thinks that ADHA needs to play the role of standards authority, and there's been no acknowledgement yet from the government (AFAIK) of the widely held belief that the old standards process collapsed because the government become a party with a conflict of interest due to becoming a solution provider. So given those circumstances, what would make us expect a different outcome in any future go around the same question?

Anonymous said...

I have no idea who the current HL7 Australia office bearers are (Other than one and names of others), even though I am a member. Care to elaborate?

Peter said...

@October 29, 2017 12:51 PM.
I didn't mean to suggest that a single standard would be sufficient. A number of architectural patterns need to be defined and I would expect something like an API specification that all vendors should comply with. Also, I am talking interoperability rather than integration, a much more inclusive and nebulous concept and I think most players are using the term incorrectly. It is the difference between 'speaking the same language' and 'playing well together'.
As a disclaimer - I have no direct knowledge of what ADHA are doing and I know that there are major complications in many areas but...
From a purely technical point of view, a federated model would have each EHR system hold its own records - for use by the system owners and local practitioners. It would provide a standards compliant API (I imagine RESTful would work best but it needs to be synchronous) which can provide a summary or detailed health record.
If the query is local (as most will be) the record never leads the network. If it comes from further afield the routing would be provided by nodes owned by Government. I am imagining nodes at regional, state and national levels. The nodes do NOT hold any records themselves, but may contain a directory of which systems hold information based on an ID.
There are a lot of optimisations that could be made to this basic structure, but it relies only on proven technology and standard techniques. Fundamentally it is the way the internet is set up and contains the same sort of robust, secure operating framework - compared with the mainframe type architecture MyHR is based on.

BTW - As a side issue, from the information I have seen, I not sure that many true standards do actually exist. For instance the 'Architectural Standards' produced by NEHTA (yes, old ones) are nothing more than a re-statement of a few basic principles with no attempt to provide useful guidance.

Anonymous said...

The more I read of comments in this blog, many quite valid I might add, the more it reinforces to me that there is little evidence of any strategic thinking peeping through the chinks. There is also no evidence of any competent leadership at the upper levels of the ADHA. Lack of strategy and lack of leadership is a toxic mix. Sorry to be so blunt but the evidence and the facts speak for themselves - replaying the past is no way to move forward..

Andrew McIntyre said...

The "Ban the fax" movement is marching on as there was a promised outcome by March 2018 and despite identifying significant barriers in capability and having developed/documented HL7 standards to allow recipients to receive high quality atomic data ADHA is keen to just do a pdf only standard which will I guess align the rest of health with MyEHR. I am not sure pdf only transmission is anything more that a electronic fax.

The standards have been developed in a way that recipients can ignore the atomic data (and must do this reliably) while displaying a pdf at this stage. You can also just send a pdf if that is all you can do, but you must not fall over when you do receive atomic data, which provides a path forward to real decision support and the ability for senders to actually send high quality data without worrying that it will break end points.

This level of capability requires development to implement by vendors and will not fit in the time frame. Instead of accepting that we need to start doing things properly ADHA want to push a crippled single PDF message through to meet these deadlines and there is no "Stage 2" in the plan. If we do this we will lock in provider to provider communication to a very low level which will be very difficult to shift in the future.

The secure messaging projects involve only a minority of pms vendors and if we settle on an incredibly dumbed down spec (Basically at MyEHR level) we will cripple the benefits of eHealth for 10 years.

There is a complete lack of technical understanding in the ADHA and all they are after is short term wins, even if it is at the expense of real future functionality. Its not something that I can be a part of!

Grahame Grieve said...

Andrew, I don't think I understand your logic. It appears to me that the spec the agency is working up says that 'you must walk, and you must allow other people to run', but you're not going to walk because it doesn't force everyone to run. If you really want to run, then why not run while other people walk as they are able to?

As for being after short term wins: ok. Surely you get why that is. So why make it harder to get short term wins, and even harder to get long term wins? It sounds as though your real goals aren't your stated goals here

Anonymous said...

Sounds a lot like a scatter gun approach to me, hope something sticks and gravitate around that and claim a victory. What win is this? Perhaps you see the road that others do do? What is exactly going on? If it is simply a spec that is a dissapointment, where is the requested infrastructure? Testing platforms.

Going for the lowest denominator will perhaps entrench the outcome into an expensive hole to get out of. What would be the motivated once there is claim that a couple of vendors can eFax.

The ADHA should IMHO stick to the forced inclusion of citizens into the GovHR system. All efforts will divert that that soon enough and we will be back to where SMD was 5 years ago.

Maybe not exclude yourself Andrew, you might be better placed to educate from within.

Andrew McIntyre said...

I am a little shocked you would think that way. The problem with pathology has been that recipients do not support compliant messages so all the path labs customize the messages to a PMS system but we end up in a mess because no one is able to just produce one high quality message. Even so the vast majority of pathology has the atomic data as well as a human displayable version and can be used for decision support.

What is proposed is removing atomic data from clinical messages and restricting it to a single OBX with a pdf in it. Its removing any chance of atomic data and once thats done I doubt it will ever appear. Perhaps you think we should all move to FHIR and that is good, but I don't agree. The proposal that we have put up is tightly constrained atomic data that there is no requirement to create or consume, but there is a requirement to not fall over when present. Then people can just display the pdf, for now, and just send a pdf, for now, but at any time atomic clinical data, like allergies, medication lists and past history can be added to the message and its the recipients responsibility to not fall over when present. This provides a path forward, the pdf only solution, with no plans to do any more work will actually make it non compliant to send a patients allergies and medication list in a way that can be understood for decision support. I am happy to stand on the fact that this move is crazy, what are your goals?

Anonymous said...

I must lean towards Andrews position on this one. We fund a fair amount of money to the ADHA to undertake important research and development to advance eHealth. I am not sure as a tax payer I see any value being delivered here. I do not see the future as static documents, nothing else in my electronic life gravitates towards this and I am in my early sixties.

This is simply busy work and at a cost of setting up the future. Bonfire of the PDF.

Andrew McIntyre said...

Hi Grahame,

On rereading your comment I suspect you do not realize that the proposal is to replace the HL7 Australia spec with one that only allows for a pdf display segment. That means everyone has to crawl and is not even allowed to walk, let alone run. There is no requirement that PMS system produce atomic data, just that they consume messages that contain compliant atomic data which allows people to progress their own implementation over time, knowing that recipients will handle it.

Andrew

Grahame Grieve said...

I'll investigate. I may have misread what you wrote, but it was my understanding from other channels that atomic data would still be allowed, just not required. Note that there's a difference between 'not allowed' and 'not required'

Grahame Grieve said...

@Andrew so I investigated, and I'm not more illuminated. The spec we are talking about is https://confluence.hl7australia.com/display/OO/Appendix+8+Simplified+REF+profile - delegated from the ADHA to HL7 Australia (good indicator for the future in spite of my comments about ADHA and standards above)) and maintained by Jarrod, who works for you. yes?

The spec allows atomic data, but does not require it. yes?

If you have any evidence for "the proposal is to replace the HL7 Australia spec with one that only allows for a pdf display segment" (i guess you refer to the one I referenced as being 'replaced'), then either publish it here, or send it to me directly if you can't. thx

thanks.

Anonymous said...

Should we still be encouraging or even accepting such a low entry bar after ten years. Surely we had a chance here to raise the bar. I am pleased though to see ADHA giving away their IP. Strangely all but two involved are ADHA people so I don’t see the value add from HL7 Aus. Maybe an earlier post was correct to call it ADHl7. Not a swipe at those involved just an observation.

Grahame Grieve said...

So Andrew and I communicated directly about this. We'll have to see how it plays out..
but the core questions are (1) how to trade short term outcomes to demonstrate value in the process vs long term outcomes that create deeper value in the outcomes, and (2) whether to stay involved in a community process that isn't generating all the outcomes you want in the time frame you want, when walking away from the process doesn't offer any more prospect of meeting your desired outcomes.

Personally, I think that's a retrograde step, even if you cannot judge the motivations and goals of all the participants. But in the end this is a personal judgement: my belief and experience is that for all the weakness of community processes, we are rarely better off working alone.

Grahame Grieve said...

"Should we still be encouraging or even accepting such a low entry bar after ten years. Surely we had a chance here to raise the bar" - actually, wouldn't the fact that we've got so little over the last X years (irrespective of where) be a good argument for lowering the entry bar?

Andrew McIntyre said...

If we had been trying to make messages compliant for 10 years I might agree with you, but no, vendors have been implementing all sorts of useless things since healthconnect days, none of which have gone anywhere.

Having identified compliance issues in messages that are being sent in the here & now I don't think lowering the bar to meet a public relations deadline is appropriate. These are the issues that prevent messaging interoperability and now is the time to address them. Its not as if vendors are unwilling to address the issues, its just not possible for it to be done because of unrealistic time frames. If the core issues are not fixed then free messaging interoperability cannot work. A "ministerial" directive to make it happen by March won't cut it. These are computers and they are pretty fussy about the bits and bytes being in the correct place.

The problem has always been a failure to fix low level problems of quality and compliance, but those issues appear to be beyond the understanding of generic managers.

Anonymous said...

Let us not mistake a good bar for the path of least resistance. My challenge with the lowest bar denominator is it becomes the only bar. Without a trajectory agreed to and a funding model to reward positive actions and a mechanism to quash actions of restrictive value then I feel any model will quickly dissipate into thin air and we return to the problem state. As a generic manager once taught me, if you cannot remove the old ways of working, change has little chance of taking root.

I do agree though, walking away from the process is limiting in achieving the end goal.

john scott said...

There are three things which stand out starkly in my view.

First is the enormous and costly contribution that some people and organizations have made in the hope of contributing, via medical software, to a safer, higher quality and more efficient health system.

Second, is the glaring reality that whatever it is that the Commonwealth thinks it is doing it bears no relationship to a modern health system and has been at the heart of much wasted investment.

Third, is the reality that we need a complete overhaul of the way we think about the relationship between our health system and digital technology and the manner by which we establish appropriate collaboration.

Our present situation is worse than shuffling the deck chairs on the Titanic. We are damaging and degrading a key piece of our social infrastructure--with no prospect of accountability for the damage that has been inflicted. And, no present hope for a light at the end of the tunnel to mix my metaphors.

Dr Ian Colclough said...

Reviewing the comments by Grahame (11:19 AM, 11:20 AM), Andrew (1:34 PM) and John (4:27 PM):

Grahame asks “actually, wouldn't the fact that we've got so little over the last X years (irrespective of where) be a good argument for lowering the entry bar?”

I’m sorry Grahame but that is a fallacious argument. Underlying your ‘question’ is the assumption that whatever has been done and the way in which it has been done has been the right way and the best way. There is an abundance of evidence that indicates the problem solving approach adopted “over the last X years” by the many disparate parties involved (I dare not list them all here) has been deficient on many levels. New ways of thinking (Refer to John 4:27 PM) focussed on solving the many complex and wicked problems involved have been repeatedly rejected. The conclusion therefore is that there is no good argument that I can see for “lowering the entry bar”.

On your other point (11:19 AM), I agree with you that “we are rarely better off working alone” but that is not to infer that the way we have been working together to date has been the right way. In fact, if the leadership has not been competent then working together will most likely be to no avail. I respectfully submit that has much to do with the status quo.

Andrew nails it thus “vendors have been implementing all sorts of useless things since HealthConnect days, none of which have gone anywhere.” And “If the core issues are not fixed then free messaging interoperability cannot work”. I can’t argue with that.

Finally I cannot help but agree with John’s unarguable observation “that whatever it is that the Commonwealth thinks it is doing it bears no relationship to a modern health system and has been at the heart of much wasted investment.”

Anonymous said...

A great discussion, something greatly missing these days.

A simple question - is there a set of defined bars? And is the ADHA running proof of concept project amounts vendors at each bar?

The conversations seem to indicate that there are defined bars and there is more than one. I then assume there is agreement on how to measure which bar you are in and how to get to the next bar, or fall to a lower bar.

Dr Ian Colclough said...

@6:51 AM I would submit the answer is NO - there are no defined bars. There is a great deal more work to be done to reach that point. Firstly, is the problem clearly understood, has it been well defined, .....

Andrew McIntyre said...

Here is the draft Australian standard, which is under development by HL7 Australia. The pathology components of this have already been balloted but this draft has been expanded to include clinical messaging and it includes optional atomic clinical data for decision support. You can still just send a pdf, but you must be able to receive the atomic data and not fall over. There are 2 clinical levels (this is draft) to allow for very basic messages ie walking

https://confluence.hl7australia.com/display/OO/Australian+Pathology+Messaging+-+Localisation+of+HL7+Version+2.4

Grahame Grieve said...

@Ian:

I’m sorry Grahame but that is a fallacious argument. Underlying your ‘question’ is the assumption that whatever has been done and the way in which it has been done has been the right way and the best way.

hmm, no, I do not have the assumption - should be clear. I take the current situation to demonstrate that this is a hard problem, and that's why it argues that the bar should be low. And, btw, if all solutions have been wrong, over a 15-20 year period, that has it's own message.

"New ways of thinking focussed on solving the many complex and wicked problems involved have been repeatedly rejected"

yes. It was a post of mine about this that started this discussion

"There is no good argument that I can see for “lowering the entry bar”."

well, we can talk about where it should be, but making it too high just ensures that most people just go straight under it. (reminds me of this old post of mine: http://www.healthintersections.com.au/?p=158)

Grahame Grieve said...

@Andrew - getting back to this after some investigation: there's been no change in plans in the messaging work with regard to atomic data. It can still be sent, it must not be rejected. I think your concerns in this regard are unfounded. What has been decided is to prohibit display segments with formats other than PDF. So FT, RTF, and XHTML are now prohibited, and only PDF can be sent. The spec remains the one your reference, and I'm told Jared has made the relevant changes. Hopefully we can lay this to rest

Peter said...

There is a lot of comment about ADHA and MyHR are not solving any problems - indeed are creating some where they need not exist (e.g. using PDF instead of (as well as) atomic data. These is not a lot of discussion on what can be done instead.
Is there anyway that a suitable approach to interoperability can be devised *without* government control/involvement/interference? Most industries manage to create joint standards between the major business groups - starting at a corporate collaboration level rather than with government oversight.
I don't know what the competitive environment is like, but if a couple of medical software vendors can get together and agree on a way of sharing data between them. That first step could form the kernel of a full framework without the need to create the whole thing upfront (which is a very government way of operating). Indeed, I would expect some useful guidelines to come from working examples overseas.
Is there a suitable special interest group or consortium in HealthIT, other than ADHA, who could facilitate the discussion?

Grahame Grieve said...

@Peter yes there are several such groups - HL7 Australia and MSIA would be the most obvious. But the kind of thing you are talking about cannot exist in a vacuum in healthcare - the government is too influential (service provider as well as governor). And we have lots of bilateral agreements between software vendors - but it's hard to scale those into a real working standard. We've shown how to do that in the FHIR community, but we haven't managed to make that scale into something meaningful in Australia in spite of the fact that several of the thought leaders in FHIR come from Australia.

Andrew McIntyre said...

I have been reassured that ADHA will support the HL7 standard in a form that insists that a PDF display segment be present, and requires that systems can handle the atomic data, even if they can not process it at this stage, so that sounds like a good outcome for the community as a whole as it provides for the ability to start including atomic data without fear of breaking endpoints. There are a number of compliance issues that may require delaying the time frame, so will see what happens with that.

Anonymous said...

Mmmm - I'm a bit bewildered. Does this mean the My Health Record will receive all my pathology results? And will that make the MHR useful to me and my doctors?

Anonymous said...

I hope so Andrew, I do get the feeling you are being told what you want to hear. As my kiwi dad would say, if it looks and smells like mountain oysters then it’s more than likely B....ks

Anonymous said...

@Anonymous

It is planned that MyEHR will get all your pathology results (which will be an interesting test of its scale-ability) but this discussion is about transfer of information between providers and the need to transmit machine readable information (the aim anyway) rather than just human readable information in the form of pdf documents.

MyEHR is a separate system making the workflow somewhat difficult for doctors, particularly when/if it has thousands of pathology tests in it, all of which have to be read my a human.

Anonymous said...

12:00am, the discussion may well be tied to transferring of information between providers. However the ADHA priority is the MHR, all raids must lead to that and reporting of the volume of transactions. Agree it will be an interesting scalability test. I would like to know what the cost of all those Oracle licenses are and the infrastructure to support it.

There was also another report yesterday of government records being compromised (50,000). Is the Governments Health department and the ADHA fit to hold such a volume of identifiable information. I always found the trouble with the ISM and PSPF is the APS simply use it as a tick box and as a mitigation for accountability rather than resources for good.

Anonymous said...

Thank you 12:00 AM Very succinct. I will rely on my doctor and his system.

Dr David More MB PhD FACHI said...

Grahame Grieve wrote:

"We've shown how to do that in the FHIR community, but we haven't managed to make that scale into something meaningful in Australia in spite of the fact that several of the thought leaders in FHIR come from Australia."

That is very,very sad as far as I am concerned and makes one wonder about the quality of leadership we are seeing from the ADHA does it not?

David.

Anonymous said...

You would first need leadership before you could measure the quality of it. I would be happy if they were authentic. The CEO and COO are not exactly inspiring and both have a legacy of questionable value.
I guess we have to wait a little longer, shame it is at great cost

Anonymous said...

I do not want to put words in others mouths and correct me if I am wrong, but the need for another step in evolution and this the thinking that kindled FHIR must in some degree be based on the Australian eHealth landscape. Why then we are not embracing this more is beyond me. Home grown innovation set to influence globally seems like a no brainer for a minister.

I question the need for the ADHA to retain what must be several million a year maintaining CDA modelling, why not outsource to HL7 Aus for a half of that to have them (HL7aus or something else) have the community refresh specifications with the Jurisdictions and vendors, whilst allowing standards to be created at arms length, I know HL7 Aus is not the only SDO but ADHA cannot currently undertake such work and be perceived as anything but bias and manipulated towards a single solution.

Keeping a few people funded to help drive the Australian voice internationally is tax money I am happy to support.

Anonymous said...

Why not outsource cds and FHIR? That sounds like the start of a good conversation. Could free up the ADHA to concentrate on defining the problem spaces with stakeholders, gain agreement on new, changed and current clinical workflows, whilst still able to operate things like MyHR. They could work with Jurisdictions and develop the architecture the clinical models so desperately need to be within.

Added value to standards and at an arms length.

Anonymous said...

I am not aware ADHA are doing any significant work on cds or FHIR, FHIR is involved in provider lookup, but that is being done via HL7 mostly. I mean they only have 300 staff so you can't expect much actual output.

Anonymous said...

ADHA exists to run MyHR. MyHR exists so that the federal government can obtain australians health data which it can then use for whatever purpose it wants. MyHR has nothing whatsoever to do with healthcare, it's all about surveillance and big data. I'm surprised they haven't used the "we must fight terrorism and keep illegals out whatever the cost" excuse - yet.

Anonymous said...

@ 3:50 PM Leadership (lack thereof) is only part of the problem. The real problem is the problem itself. The problem has never been defined adequately. When the leadership doesn't understand the problem where can they lead?

Anonymous said...

I thought the problem was the fax machine?

Anonymous said...

Silly question, but if clinical systems are specified, procured and implemented by private industry and the states, technologies like FHIR and open ehr are making it easier to share data, and vendors are increasingly seeing the business sense in open APIs and standards, and no one wants the myEHR except the Feds and those they pay, what is the point of the ADHA?

Dr David More MB PhD FACHI said...

I am not sure that is such a silly question - especially an ADHA with 300 staff!

What do others think?

David.

Anonymous said...


What is the point of the ADHR?

Anonymous said...
ADHA exists to run MyHR. MyHR exists so that the federal government can obtain australians health data which it can then use for whatever purpose it wants. MyHR has nothing whatsoever to do with healthcare, it's all about surveillance and big data. I'm surprised they haven't used the "we must fight terrorism and keep illegals out whatever the cost" excuse - yet.
November 05, 2017 9:18 AM

Anonymous said...

1:46 PM I am sure you are right. In other words ADHA and NEHTA before it have been a smokescreen and a great waste of time and resources. This conclusion is not a new revelation, it has been reached on a number of occasions over the last decade, yet the gullible have been disinclined to accept that reality; sadly that includes peak bodies and software developers and so they keep getting sucked into the vortex of ineptitude created by highly paid bureaucrats.

Anonymous said...

the NEHTA model was created by the states and territories, maybe it was not perfect in every sense but it was perhaps that it reflected the community and the situation. DoHA destroyed it with the PCEHR. The ADHA is just the department with a new logo.