The blog was started in 2006 (March) with the intent of providing come clarity as to just was happening in e-Health, which has subsequently been renamed Digital Health, in Australia and to a less extent overseas.
To me the progress has been what people term a ‘curate’s egg’ or ‘good in parts’!
The good has clearly been the progress made in general practice and in the information providers (pathology and radiology etc.) as well as the progress made in some States with hospital IT (especially NSW and Vic – with the ACT, WA being major laggards and the others still struggling to some degree.)
As far as Commonwealth Initiatives are concerned again there as been very variable progress. It could be argued that some Digital Health infrastructure efforts have been worthwhile (The Health Identifier Service for example, maybe some terminology efforts and some of security certificate efforts – excluding the NASH, which has been a fiasco) but it is hard to argue that the Commonwealth efforts (from NEHTA and the ADHA) on patient records have been anything other than wasteful, misguided and abysmal.
On Standardisation of Digital Health it would be hard to suggest, despite valiant efforts from HL7 (Australia) and some local experts, that we have got things optimally organised with modern standards in all the areas required. (The hiatus lies largely at the feet of a set of misguided efforts from NEHTA and the ADHA really not getting why Standards Development was core work for them.)
Despite the noisy screeching of the ADHA the fax – and most especially eFax built into PMS clients – is still widely and for the most part safely used and indeed three quality providers are doing good work with electronic Secure Clinical Messaging – almost despite the ADHA. This will continue to be the case until real end-point location services are working properly and easily.
Politically we have seem both State and Commonwealth Governments drinking the Kool Aide and supporting overscaled projects which were either overly ambitious or misguided. The waste of money has been horrific as has been revealed by many later Audit Reports and the idea of coming in on time and on budget has not been often observed in the wild! (We all await the ANAO Audit of the #myHealthRecord which is due next month.) Let us be quite clear about this - useful and safe, for all involved, Digital Health is a great deal harder and more complex than most realise!
At a macro-level I see some major issues.
1. We do not yet have well designed systems that serve the needs of practitioners (and patients), that support and enhance the quality of care provided and do not add a lot of work for the clinician.
2. We do not yet have clear evidence as to what really works with digital health and we lack a focus on sticking to those things where the benefit case for positive impact on care is established.
3. We have not yet got clear paths to interoperability and appropriate data sharing that protects privacy and which is really secure.
4. We have yet to fully exploit the potential of intuitive point of care decision support for diagnosis and decision making.
5. We still are much too easily seduced into investing in Digital Health projects at scale without quality evidence of their value – rather that just thinking it is digital so it must be good.
6. We have no real plan for how Digital Health will cross the Digital Divide!
7. We do not yet have the proper frameworks to control and manage what is coming with Secondary Data Use, Data Mining and AI.
8. We need a public discussion on just how much of our private health information should be shared with Government and Researchers.
9. We have yet to really work out how best to engage the patients with Digital Health and how that may assist them in their care journey.
10. Others may disagree but I really think we have a huge gap between Academia, the Coalface and the policy setters which needs to be bridged and we need much more actual, rather than token, consultation – and this farce of co-design!
The bottom line is that there are many good souls working in the Digital Health domain but I really feel that they are lacking the sort of visionary leadership to be able to really address the points above. The ADHA vision for Digital Health is ‘fit for purpose’ circa 2000.
What do others think?
David.
20 comments:
Good questions David.
Unlike ADHA. Here is a mind numbingly stupid survey from ADHA. Whoever dreamed this up should be shown the door. It's open to to stupid responses and is full of invalid assumptions.
https://www.surveymonkey.com/r/securemessagingsurvey?_cldee=YWxldGguc2FrYWlAZGlnaXRhbGhlYWx0aC5nb3YuYXU%3D&
Dry good questions David. The mess made by some around standards and compliance to standards has left the government out in the cold and to some extent robbed the standards community. I do notice some excellent work internationally involving our own leaders and sadly you do not see them in leadership roles at ADHA.
10:48 PM that survey must be a mockup surely? If not I agree the ADHA has hit a new low.
That ADHA survey is about as useful as this:
My Health Record Consumer Experiences
https://chf.engageable.net/guest/modules/5865
The preamble is:
This survey is about consumer experiences with My Health Record, so to begin with we want to confirm that you didn't choose to opt-out and do currently have a personal My Health Record.
The first question is Did you opt out of My Health Record?
If you say yes, the survey goes on to ask about your usage. Of a system you opted out of.
They're about as (in)competent as ADHA.
David, here are a few comments on your macro-level issues.
1. Agree;
2. This requires a deeper understanding of where and how value is created and the proper contributions of technology;
3. There are two separate issues here as I see it. The first is 'interoperabiity' and the second 'privacy and security'. Interoperability is the technology expression for the deficit in information flows to support clinical action.
Privacy and security are about Trust and Governance with respect to the matter of Assurances.
4. It is not clear to me what you mean by "the potential of intuitive point of care";
5. Agree. Two separate issues with the latter reminding me of the phrase "no one ever got fired for buying IBM";
6. Agree to which I would add: If we had a solution framework would leadership actually embrace it?
7. Agree. I would distinguish AI because it raises important ethical and IP-related issues which will require overarching Frame and Framework for their resolution;
8. Agree. I suggest the principles of Trust and Virtuous Cycle as well as Rules of Engagement covering Disclosure and Deployment of sensitive knowledge are needed;
9. Agree. Asymmetries of knowledge and power need to be acknowledged and addressed;
10. Agree. This goes to the heart of why we need a Solution Framework and a revolution in the quality of collaboration.
Bottom Line. Agree. Strategically, my sense is, to borrow the sentiments of Shakespeare: we know who we are but not what we may become.
4. It is not clear to me what you mean by "the potential of intuitive point of care";
I left 2 key words out - makes rather more sense now!
Thanks
David.
@1:05 PM You left 2 key words out! It might "make more sense now" to you. Do you plan sharing those "2 key words" with us?
In item 4 I left out 'decision support' - put it back!
D.
This was circulated yesterday:
"Software Developer Community Announcement
Electronic Prescribing
The Australian Digital Health Agency has released preliminary information on how it will support the implementation of electronic prescribing.
This information includes the preliminary Solution Architecture, Conformance Assessment Scheme and Conformance Profile documents and is intended to give software vendors early access to the technical framework and what will be required to enable electronic prescribing.
Electronic prescribing will provide an option for prescribers and their patients to have a digital prescription as an alternative to a paper-based prescription. Electronic prescriptions and paper prescriptions will co-exist. Electronic prescribing will not be mandatory, and patients and prescribers will be able to choose an electronic prescription.
Learn more about participating in electronic prescribing
https://developer.digitalhealth.gov.au/resources/articles/electronic-prescribing
Regards,
Australian Digital Health Agency"
For those who don't wish to register for access to ADHA's documents, here's a link to the requirements and the solution architecture.
www.drbrd.com/docs/eP/ePrescribing.zip
Both are approved for external circulation.
IMHO, the most troubling aspect of these documents is the section on related documents in the Solution Architecture.
The solution is based upon a two page list of Requirements (the other document in the zip file)
When it comes to architecture best practice, the most fundamental document, which drives all other documents, is a description of the problem and how it is to be solved, the last part of which are the requirements for the solution.
In the case of ePrescribing, there is no problem document that explains what the requirements are trying to achieve and more importantly what the business processes are - in detail.
A sign that this has been developed by the usual bunch of amateurs is this gem:
"Availability
Electronic prescriptions will be able to be dispensed in any pharmacy or other authorised place, irrespective of which authorised prescriber issued the rescription and which state or territory it was issued in (subject to regulatory constraints)."
In the architecture world, availability usually includes "hours of operation" i.e is it 24/7? Business hours? or what?
What they have described is the scope of access, not availability.
As they say - If you don't know where you are going, anywhere will do, and you'll never know you've got there.
As they also say, the earliest decisions are the most important. In the case of the Department of Health's ePrescribing initiative, it's not the decisions that have been made that will come back and bite them, it's the decisions they haven't made.
The requirements document is dated September 2017.
According to this, dated 29/07/2019:
https://ajp.com.au/news/a-brand-new-script/
"All systems will be set to go on full-scale e-prescribing by the end of 2019, Minister announces"
As Sir Humphrey would say "That's very brave of you, minister. An extremely courageous decision,"
Bernard this are old specs slightly tweaked by hand. ADHA does not use tooling to ensure consistency and traceability. What tools and tooling efforts ADHA inherited that killed off.
The solution architecture is dated 23 September 2019 and the document history make no mention of anything earlier.
Because of a full analysis of the problem and the problems created by the solution people who created the solution architecture have had to do at least some of the analysis themselves.
There is a fundamental requirement in the system that a prescription can only exist in paper or electronic form.
Sections 7.1.1.2 Community Electronic Prescribing Process and 7.1.1.3 Community Electronic Prescribing Exception Conditions and their Treatment discuss technical issues nd problems that may occur when dispensing medication.
On first reading, a couple of things occur to me.
As it says in section 7.1.1.2 "The point of departure in current process will occur at the time in the consultation when the prescription is produced. At this point, there are a series of decisions required:"
The GP, instead of just clicking a button and signing the script has to go through a new process of decision making.
Similarly, when I take a script in to a pharmacist all teh information is there on the script. It takes about 10 seconds for the assistant to check it and give me a receipt.
The new ePrescribing system process requires the assistant to retrieve the script from the Prescription Delivery Service.
I'm wondering if these changes to GP and pharmacist business processes have been analysed, tested and approved by those who will be impacted (not representatives and lobby groups). Or are they just being imposed on health providers by system developers?
Minister Hunt, in his announcement that the system will go live across Australia by the end of 2019, would appear to have ruled out any sort of proof of concept, pilot, limited release, full release strategy. It would appear to be big bang and hope for the best.
The PES (Prescription Delivery Service) is intended to displace the two private sector script exchanges, Medisecure and eRx.
For some years the government has been subsidising the private script exchanges per script to incentivise doctors and pharmacists and encourage uptake of escripts via the exchanges.
Now that the private sector has demonstrated the efficacy of escripts government has deemed it appropriate to exercise control over this space with a government-controlled Prescription Exchange Service.
Tricky dickies they are indeed. They wait for the private sector to carry all the investment risk and prove the concept is valid, then they move in to undermine the viability of the private initiatives by introducing a 'competitive' solution which they camouflage under a slightly different name, ie. Prescription Delivery Service (PDS), so no-one can accuse them of trying to introduce another script exchange.
They might try to justify their actions as being a valid disruption of the space. To the Minister they will present the business case based on 140 million scripts pa. subsidised at 15 cents / script being saved by not having to keep paying incentives to doctors and pharmacists, equating to an annual saving of $21 million.
And then, of course, they will outsource the operations to an Accenture type organisation for $50 million a year.
This does however raise a number of serious questions.
The solution architecture is dated 23 September 2019 and the document history make no mention of anything earlier.
Just another example of what a sloppy outfit ADHA is. Bernard the previous commentator is correct. Just a rehash or previous work that is not acknowledged.
Like to see a privacy impact assessment undertaken.
Well it's been obvious for years they want control and from a bureaucrat's perspective that's perfectly valid. Supporting private initiatives is only ok will it is convenient to do so. Sup with devil and don't cry over spilt milk, MSIA included.
It’s karma. What goes around comes around. Think back more than a decade to when the government tried to build a national escript system called MediConnect.
MediConnect failed and morphed into HealthConnect, which failed before morphing into NEHTA, which in turn failed and morphed into ADHA, and the My Health Record which has now failed.
So, in a desperate attempt to give ADHA a new lease of life we now see the emergence of another form of MediConnect called a Prescription Dispense Service. In due course that will be re-branded to be called MediConnect once again, assuming the government still has control of the MediConnect trademark!
Here is a good 2013 review of the history of MediConnect, HealthConnect and the PCEHR
http://www.e-healthsys.org.au/ehealthContent/uploads/2013/07/Implementationof-EHRSystemsinAustralia_ITMR_3_2_92_104-1.pdf
The last part of section 4.5.Being Patient with the PECHR System makes interesting reading.
“The current PECHR system is additional to, but does not replace the existing clinical systems. In the early years of PECHR implementation, because of the incomplete system, uncertain information quality, and learning curve, medical professionals will still go through their routine examination and do not use the PCEHR system as a solid foundation for future treatment. As the PCEHR system obtains information from clinical systems, synchronizing the clinical systems with the PECHR system is a critical activity for doctors and patients, especially doctors, in a foreseeable future”
Note the comment “As the PCEHR system obtains information from clinical systems, synchronizing the clinical systems with the PECHR system is a critical activity for doctors and patients, especially doctors, in a foreseeable future”
My Health Record, as it now exists, cannot be synchronised with clinical systems. That’s because it was not implemented as specified in the ConOp – a system that connected existing data repositories. My Health Record is a dumb data dump totally dependent on the uploading of clinical documents and with no history. It has totally failed to achieve a critical activity.
Which is probably why they are looking to “replatform” it by the end of next year.
"replatform" it by the end of next year ..... employing the same mindsets and problem solving approaches that government bureaucrats and big C consultants and large vendors know so well!
I presume that what you mean by "know so well" encompasses transferring huge sums away from government, promising nirvana and delivering open-ended, long-term, projects of no real value.
@11:10 AM That's a reasonable presumption. Let the evidence speak for itself.
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