Argonaut in Australia, and the MyHR
This is a big deal for Australian EHR vendors that compete with the US vendors – they better start offering the same capabilities based on the same standards, or one of their key market advantages will be consigned to the dust of history. They’ll also find themselves competing with established SMART on FHIR Application vendors too. So I look forward to good engagement with Australian companies as we flesh this out (I know at least one will be deeply involved).
This also offers us an opportunity to consider what to do with the MyHR. The government has spent a great deal of money on this, and results have been disappointing. (Yes, the government publishes regular usage stats which show continuous increase, but these are not the important usage metrics, and they’re not the kind of stats that were hoped for back when we were designing the system). And it’s hardly popular amongst the typical candidate users (see, for example, AMA comments, or for more color, this or even David More’s blog).
But I’m not surprised at this. Back when it was the pcEHR, the intentions were solid, and though the original timeline was impossibly tight, it came together in an amazingly quick time (kudos to the implementers). But as it came together, I knew it was doomed. This is inevitable given it’s architecture:
- The providers push CDA documents to the central document repository
- Patients can view documents about them
- Patient’s can write their own documents, but providers won’t see them
- Patient’s can exert their control only by ‘hiding’ documents – e.g. they can only break the flow of information (reminder, the internet age treats censorship as damage and routes around it)
- Clinicians can find and read documents
- Each document is it’s own little snap shot. There’s no continuity between them, no way to reconcile information between them
- There are no notifications associated with the system
Well, 10 years later, and we’re still trying to load ever more use into the same broken design, and the government sponsors are still wondering why it’s not ‘working’. (at least we stopped calling it the ‘personally controlled’ EHR, since it’s the government controlled EHR). And as long as it exists and is the focus of all government efforts to make digital health happen, it will continue to hold up innovation in this country – a fact which is terribly evident as I travel and see what’s happening elsewhere.
But it doesn’t have to be like this.
The MyHR is built on a bunch of useful infrastructure. There is good ideas in here, and it can do good things. It’s just that everything is locked up into a single broken solution. But we can break it up, and reuse the infrastructure. And the easiest way I can see to do this is to flip the push over. That is, instead of the source information providers pushing CDA documents to a single repository, we should get them to put up an Argonaut interface that provides a read/write API to the patient’s data. Then, you change the MyHR so that it takes that information and generates CDA documents to go into the MyHR – so no change needed to the core MyHR.
What this does is open up the system so all sorts of innovation, the most important of which is that the patient can authorise their care providers to exchange information directly, and build working clinically functional systems (e.g. GP/local hospital, or coordinated care planning), all without the government bureaucrats having to decide in advance that they can’t be liable for anything like that. That is, an actually personally controlled health record system not a government controlled one. And there’s still a MyHR for all the purposes it does exist for
This alternative looks like this:
The salient features of this architecture:
- The providers make healthcare information services available using an Argonaut interface (including write services)
- Patients can control the flow at the source – or authorise flows globally through myGov (needs new work on myGov)
- Systems can read and write data between them without central control
- The MyHR can pull data (as authorised) from the sources and populate the MyHR as it does now
- Vendors and providers can leverage the same infrastructure to provide additional services (notifications, say)
These features lead to some important and different outcomes:
- Clinical Trials and companies can innovate to build distributed care models that provide a good balance between risk and reward for different populations (instead of the one-size suits bureaucrats that we have now)
- Patient’s can control the system by enabling the care flows that they want
- Clinicians can engage in better care processes and improve their process and outcomes (though the US process shows clearly that things get worse before they get better, and you have to plan for that)
Note: Adapted from my presentation yesterday at the HL7 Australia Meeting
Here is the link to the original blog:
To me this is spot on but it is my view there are additionally some other issues that add to the 'fatally flawed' case. Among these I would highlight that you can't build a system for both patients AND docs and that any secondary system is intrinsically dangerous because of synchronisation and currency issues. I hope the ADHA is listening!
Enough said - this is Grahame's blog!