An Australian e-Health Strategy - The Outline

As the sole reader (nod to Crikey.com) of this blog is aware I have been saying for a while now that Australia is being badly short changed by the lack of a coherent national e-health strategy and implementation plan to frame and put in context both NEHTA and the various State and Commonwealth initiatives.

While developing relatively more comprehensive documentation for publication initially in a different forum, it has occurred to me that what I feel is required can be very simply summarised. In summary what is needed is a two prong approach :

1. The NEHTA work plan to be supported and advanced and where possible and useful increased investment made. In saying this I am recognising that NEHTA will not deliver much of practical use until 2008/9 by its own estimation and that NEHTA will need to operate for a good deal longer (in perpetuity actually) and that reaching its apparent goals may take a good deal longer than a “transition” timeframe.

2. There should be a separate national initiative to get in place nationwide proven health information systems that are known, already to be both practical and to make a real difference to the quality and safety of health care delivery.

I see there are five areas such an initiative should cover.

a. General Practice and relevant office based Specialists should be encouraged and provided with incentives to obtain and use advanced ambulatory EHR systems with sophisticated Clinical Decision Support.

b. Secure Clinical Messaging should be established between Laboratories, Radiology Practices, Hospitals and GPs with documents to be exchanged to include discharge summaries, specialist letters and pathology and radiology reports (and maybe images)

c. Public and Private Hospitals should all implement appropriate clinical and patient management systems including Clinical Physician Order Entry, Nursing Documentation and Medication Management using “closed loop” drug administration control.

d. Health Insurers and Medicare should offer their clients Personal Electronic Health Records where individual can record important health information for use, by those they authorise, in their care.

e. There should be a concerted push by the Commonwealth to establish appropriate disease pattern incidence and monitoring systems for monitoring epidemic disease outbreaks and bioterrorism.

All this is totally feasible today using commercially available and in some cases ‘open source’ software. The only block to major progress in the short term and a better long term future is a strategic vision and the appropriate funds. The paralytic inactivity of the Commonwealth in not setting such an proven and doable agenda is a public scandal I believe.

This is all so obvious I am alarmed some one did not think of it ages ago!

David.

The Road to e-Health Success – What’s Missing?

This article suggests that the National E-Health Transition Authority (NEHTA) has lost its rationale and reason for being, if, indeed, it ever had it. I accept that this is a fairly large call, so how do I justify it?

The premise on which NEHTA is based is that the provision of relevant, timely and accurate information needed by those who deliver and manage patient care will improve patient safety and reduce clinical accidents, thereby allowing us all to live happier, longer and more productive lives.

NEHTA is the offspring of a Boston Consulting Group Report which was delivered to the Australian Health Information Council (AHIC) and Health Ministers in April 2004. This report recommended, among other things, that an entity (that subsequently became NEHTA) be established and that its focus be on development of e-health connectivity and standards at a National level. It also recommended work to advance Electronic Health Records and Clinical Information Systems but this suggestion was not followed up if the funding allocations from COAG are to be believed (see below).

Later in 2004 NEHTA was established with Dr Ian Reinecke as its CEO. As at June 2006 the organisation has more than thirty staff scattered across offices in a number of States befitting its role as a cross-jurisdictional entity. A little under twelve months ago NEHTA was incorporated as NEHTA Ltd with its board being made up of each of the jurisdictional Health Department CEOs and some Commonwealth representation.

About three months ago the Council of Australian Governments (COAG) provided NEHTA with $131 Million in funding over three years for initiatives in the areas of clinical terminology and patient and provider identification. The timetable for these initiatives to be operational extends to 2009. In the meantime, in terms of meeting the implicit goals of the premise identified above not much seems to be happening, and indeed it could be claimed, with some justification, that a wet blanket of indecision and uncertainty has been cast over the Australian e-Health Space. The fact that NEHTA says it is determining the National Standards to be used in e-Health in Australia, but has yet to decide what they should be, is not helpful to most participants in the sector.

This has been made worse by the approach NEHTA has adopted to its communications with stakeholders. These stakeholders include medical practitioners, pharmacists, nurses, patients, the medical software industry, health system managers and others. It would be fair to say that outside the e-health cogniscenti NEHTA is virtually unknown and that the public in general are totally unaware of its existence. Worse still, is that despite being publicly funded and having accumulated a great deal of valuable intellectual capital over the last two years, essentially none of this material has been shared with the specialists working in the e-health space or the community in general.

Parties impacted by this authoritarian vacuum have essentially responded by moving forward as best they can, not asking permission but recognising at some point they may have to seek forgiveness. Consequently, we have seen emerging the use of an increasing variety of clinical communication systems and tools from multiple providers, be they pathology or radiology service providers or local hospitals, wanting to communicate with local GPs. Each has tried to service the needs of their customers within the known Standards.

Further we see a patchwork of potentially non-harmonised hospital systems being purchased and implemented by the different States as well as a progressively fragmented market in the private hospital sector.

It seems that over the last few decades there has been a significant trend towards acceptance of the idea that it is managers and experts, rather than clinicians, who know what is best in the running of hospitals and the delivery of patient care. The consequences of this ‘managerialist’ approach has been amply demonstrated in the outcomes seen recently in Queensland Health, where ultimately a Health Minister had to apologise to a physician who was wrongly disciplined by departmental bureaucrats.

NEHTA appears to have only one practicing clinician among its publicly acknowledged 30+ staff and no clinicians on its Board. This is a recipe leading to a profound clinical ‘disconnect’ and loss of a proper appreciation of NEHTA’s raison d’etre.

What is needed, is for NEHTA to get back to servicing its stakeholders – the clinicians and their patients. To achieve this it needs to continue with the work already initiated and at the same time start developing and making public a road-map; one that is focussed on meeting the objective of getting systems that make a difference into the hands of clinicians as soon as possible. What is needed by clinicians is well known. Indeed, a full description has been publicly available in detailed reports for over a decade!

If this is not done very soon we will find ourselves with a health system that is not properly wired, that will be more unsafe than it should be, and which will be inefficient and unnecessarily costly. The six year HealthConnect experiment was finally put out of its misery in the 2006 Budget papers (disappearing without trace!). The NEHTA experiment has now been running for two years and as best anyone can tell not a single patient has benefited from its work. It is time NEHTA explained to the public and to the caring professions how NEHTA is going to address the information needs of the Health System and when we can expect to see some substantive change. Lives are being lost as NEHTA cogitates in secret.

David.

Identity Management - What's Happening?

I must say this is all getting pretty confusing. In the late 1980’s an initial attempt to introduce an identity card for the Australian population was rolled by the Privacy Lobby. This experience of public revolt scarred many politicians and bureaucrats and the “Australia” card remained off the agenda for a good 20 years.

After 9/11 there was a recognition that a review of the management of citizen’s identity could be valuable and this led to a number of proposals beginning to circulate within Government. At around the same time the HealthConnect program was recognising the need for patient identification as one of the key infrastructure pieces for the then proposed National Shared Electronic Health Record. When HealthConnect programs were transferred to NEHTA the work on patient (and provider) identification were key initial elements.

Consulting reports addressing this area were commissioned after COAG Meeting in July 2004 recommended the development of a National Patient Identifier System and the report was delivered in early February 2005. The report has not been made public but it seems likely some of that work has informed the Individual Health Identifier (IHI) which is being developed with funding from the March 2006 COAG Meeting. This identifier is planned to be voluntary, i.e. all health services will be available without its use, and the individual will have easy access to the information held under the identifier (e.g Name, Address etc). Registered Health Providers will also have access.

So far so good. However in the recent Federal Budget it was announced that there was to be a National Services Access Card developed – at a cost of $1.1Billion Dollars. This card is to be a Smartcard which will have to be produced to access any Commonwealth (and possibly State Based) payments for Health and Social Services. For most citizens this will make this card “about as voluntary as breathing” as it has been put by more than one commentator.

We also have in the mix the Document Verification Service (operated by the Attorney General’s Department) and up until a few days we had the Medicare SmartCard that was announced by Minister Abbott in 2004. We discovered a day or so ago – as the Senate Estimates Hearings that this project had been cancelled after $4.4M had been spent – and presumably wasted. The adoption of the card in the Pilot Area of Tasmania over the two years had been of the order of 1% of the population. Clearly a remarkable success with the Tasmanian Community.

Lastly, of course we have the identity management systems currently used by Medicare and Centre Link as well, of course, as the database used by the Passport Office running out of the Department of Foreign Affairs and Trade (DFAT).

It seems to this humble observer we have a large number of right and left hands ignorant of each other’s activities, objectives and requirements. Expect this mess to cost us all dearly both in financial failed system terms and in lack of progress with the e-health agenda.

David.

Who Pays the Piper

In the last few weeks I have been reflecting on the rather sad series of outcomes we have seen in the e-health space in Australia and wondering just what can be done to change the present situation for the better.

The first thing that is obvious is that there is no quick and easy fix. Standing back from the day to day fray a little I think most would accept that what the desired end state is clinicians (covering doctors, nurses and others providing patient care) being able to access the information and decision support they need to do their job well and safely.

It is clear that without this end-state being reached clinical error of both commission and omission will continue and patients will be injured or die as a result. It is thus clear that what is needed is a national infrastructure that provides these services to the clinicians. (Note: this analysis leaves aside for now the thorny issue of how to achieve use of the technology once it is available at the point of care delivery for use).

There are thus two issues – the first is who pays, and the second is how to obtain adoption and use of the technology once there is no longer the “elephant in the room” that blocks adoption – viz. that the clinician user is expected to pay personally for benefits to be harvested by others.

The Australian Health Care System has a powerful, built-in, disincentive to the use of technology in the delivery of clinical care – that is that not only do you have to spend your money to obtain the technology but that, because your financial rewards are linked to patient throughput, once you have the technology in place you will see your income drop as you use the technology to do a better but unrewarded better job (at the very least for the first few months of use).

For reasons that totally escape me the Department of Health and Aging are of the view that clinicians (who are essentially small businesses) will adopt technology and pay for it on the basis of warm feelings in their nether regions that they are doing the “right thing”. This is clearly rubbish.

Automation of clinical practice provides the bulk of its benefits to the payers (i.e. the Medicare system) and the patients through less quality poor care and reduced cost of care. It is these sector that need to pay. The policy question for Government is how best to deliver the funding – not to place it’s head firmly in the sand and hope something will happen as if by magic.

Once the issue of the “financial friction” is addressed we can then start to use the appropriate change management approaches to foster uptake. Without the first step we might as well just forget it and look for other windmills at which to tilt.

David.

Oh Wonder of Wonders – NEHTA Recognises We Need an e-Health Vision.

Dr Zoran Milosevic is obviously a smart man. With the job of managing the NEHTA Interoperability Framework you would need to be!

Further evidence of his talent is revealed in a recent e-mail which was published in the Australian College of Health Informatics (ACHI) e-mail list. Among a range of comments came the following:

“5. Regarding your comment on the lack of national vision, I believe that this is now prime time for us all (NEHTA, jurisdictions, clinical experts, clinical informatics people, and many other stakeholders) to work on such a national vision while leveraging the past efforts, including HealthConnect.”

Implicit in this comment is the acknowledgement that such a vision, and associated plans does not exist at present. One must wonder if Dr Milosevic had cleared this comment with his CEO or is it just possible that Dr Reinecke agrees?

I certainly hope so, as while there were many aspects of the Interoperability Framework I was not happy with (See the Blog entry of April 4 for details) the key deficiency that concerned me was that the document did not provide details of the strategic context and environment for which it was intended.

Clearly I wish all power to Dr Milosevic’s arm! If he can persuade NEHTA to undertake the consultative and open process he seems to foresee to develop a National e-health Vision (and subsequent Strategy and Implementation Plan) he will be the friend of many.

While he is at it he might also like to suggest the other components of NEHTA’s work are also opened up to similar discussion and review. Were that to be achieved we would all be encouraged progress was really possible.

David.

Progress in e-Health – Blocked by Government Secrecy?

The Australian College Health Informatics (ACHI) is to have the CEO of NEHTA (Dr Ian Reinecke) as the Guest Speaker at its AGM in August 2006. As part of preparing for this speech ACHI members have been asked to consider what would be useful questions to put to our guest.

In reflecting on this, and wishing not to be too repetitive in addressing issues that have already been raised in an ACHI e-Health Strategy paper from late last year (which is available here from the ACHI web site www.achi.org.au), I wondered what else could be usefully explored.

The comments of another ACHI member provoked me to think about what else was needed to have the e-Health Agenda move forward. It struck me that there have been all sorts of e-Health initiatives over the last few years – both under the HealthConnect or NEHTA banners of initiated by the different States but that we know very little about the outcomes and contributions of much of this work.

HealthConnect is an interesting case study in point. While this project produced a range of strategy and research documents – some of which are still very worthwhile and useful – it also conducted a number of trials. These included Mediconnect and the following:

“HealthConnect trials have been operating in Tasmania and the Northern Territory since 2002. In 2003 another trial commenced in North Queensland, and in 2005 more trials will begin in New South Wales and South Brisbane.

The Tasmanian HealthConnect Trial took place in southern Tasmania and focussed on adults with diabetes. The Trial ended on 30 November 2004.

The Northern Territory HealthConnect Trial is taking place in the Katherine region and focuses on Indigenous health issues associated with a mobile population in a rural and remote area.

The North Queensland HealthConnect Trial is based in the Townsville region and focuses on people undergoing elective surgery at The Townsville Hospital, many of whom travel long distances to attend the hospital for surgery.

The Brisbane Southside HealthConnect Trial will test particular design architecture for HealthConnect and will focus on adults with diabetes.

The New South Wales HealthConnect Trial involves two separate pilot projects. One pilot will involve children in Greater Western Sydney, the other focuses on adults with chronic disease in the Hunter Valley region on the NSW Central Coast.”

Given all these were publicly funded, and indeed there were many publicly funded evaluations undertaken, one wonders what has been delivered in terms of learning and feedback to the Health Informatics Community.

The answer is not much we have been told about! And, as a colleague has pointed out, we all learn more from our failures than our successes (Thanks Terry).

MediConnect is the only initiative which appears to have had a substantial evaluation report published. This report, indeed, found so many problems and issues with the so called Field Trial that the initiative was cancelled and rather than moving to national implementation was folded into HealthConnect.

As for HealthConnect itself a single evaluation report has been produced. This covers the following”

“The two years of field testing MediConnect and trialling HealthConnect have provided many lessons to inform and guide the national implementation of HealthConnect. These lessons are derived from the extensive evaluation activity, the experience of trial management committees and teams in each of the trials and the Field Test and related research activity. As part of the formative approach to informing trial management, around 30 independent evaluation reports (many unpublished interim or specific issue reports) have been produced. The lessons learned documented in these reports are brought together in this overarching ‘Lessons Learned Report.”

None of these 30 individual reports on HealthConnect have been made public despite the very substantial investment of public money that has gone into them. One really wonders why? One can only assume that there is so much that was done badly, wrongly or technically poorly or that so little was achieved that these are too embarrassing to release. If not, what’s the secret? The downside is, of course that as no one know what went badly – the same mistakes are liable to be repeated.

One thing is for sure, no clinical outcome benefits were identified from any of the reported trials – such a heading did not even get a mention in the Report - and the most significant outcome of virtually all the trials is that they have either been cancelled or dramatically scaled back in utility and complexity.

Move forward to the present and we seem to have the same secrecy and media management instincts operating. NEHTA has commissioned a large range of valuable – and expensive – consulting reports on a wide range of topics including Standards Priorities, Identifiers, Clinical Terminology and Shared Electronic Health Record. Sadly virtually none of these have seen the light of day either.

Even the current Eastern Goldfields Trial looking at the Broadband for Health initiatives has been the subject of detailed evaluation but, yet again, none of the evaluation reports has been made public. For what possible reason could a project providing internet connectivity and services to some scattered health sites be controversial or need to be evaluated in secret. Such projects have happened all over the world.

It is really getting to be a joke. This is work paid for by the public to assist public decision making and the public can’t see, review or critique any of it. Frankly I think it is a scandal.

David.

HealthConnect's New Website – And a New HealthConnect!

Last week (May 10, 2006 to be exact) I had occasion to visit the old HealthConnect web site at www.healthconnect.com.au. I needed to find a copy of a study into the benefits of Health IT that I knew was there. All was as expected, I found the report and was able to send it to the colleague who wanted to read it.

On Monday (May 15, 2006) I was alerted to the fact that a major change had occurred and that the old and familiar site had disappeared. As a regular commentator on the Government’s HealthConnect saga I felt it my duty to investigate the new site. What is there to report?

First it has a uniquely unmemorable URL so it will now be necessary to bookmark the site in the hope of ever being able to find it again – did someone not pay to maintain the URL one wonders.

Second, oddly, the new site seems to have been largely developed well over three months ago but it only appeared a week ago. Enquiring minds wonder about the delay.

To more serious matters – what can one learn about the status of the HealthConnect change management strategy? The following are some random observations:

1. An all new sense of time seems to have developed for the site. We are told:

“ The expectation is that by 2008, Australia will be well advanced in achieving the goal of electronic connectivity between all major health institutions and health care providers.”

It would be difficult to imagine something more vague and non-specific. My guess is that it means someone will assemble a directory of e-mail addresses and make sure “all major health institutions and providers” can swap an e-mail. I thought they could largely do that now! Maybe I was misled?

2. We are offered on the same “What’s Happening page” the following as well:

“Looking to the future
There are a number of developments currently underway in various stages that could be nationally implemented within the next 12 to 18 months:

• e-prescriptions is about a prescription for medication in the form of an electronic message being sent from a health care provider to a community pharmacy
• e-referral could replace the current paper based referral or request sent from one health care provider to another (for example, from a doctor to a radiologist)
• hospital discharge summaries, which is a summary of the treatment provided and the proposed future care plan could be sent electronically from a hospital to a doctor, a specialist or an aged care facility.”

The operative words here clearly are “could be nationally implemented”. Not will just "could". Given the lack of HealthConnect funding in the present, just announced, budget the subtext is clearly if we can work out who will pay for it.

3. It is great to see we now know who is responsible for implementing HealthConnect. On the Governance page we find the following useful information:

“Governance arrangements
HealthConnect is managed under the national e-health governance arrangements established by the Australian Health Ministers’ Advisory Council as a joint Australian, State and Territory Governments’ project.

The Australian Health Ministers Advisory Council (AHMAC) whose members are the chief executives of Australian, State and Territory Government departments of health, has responsibility for HealthConnect.

The national implementation of HealthConnect is the responsibility of the National Health Information Group (NHIG) which is an AHMAC sub-committee. NHIG obtains stakeholder advice in consultation with the Australian Health Information Council (AHIC).”

So the NHIG is to be accountable!. Now who are they?

“The National Health Information Group (NHIG) has been established by Australian Health Ministers to provide advice on national health information requirements and related technology planning and management requirements. NHIG manages and allocates resources to health information projects and working groups where joint Commonwealth/State and Territory resources are involved.”

They are clearly a policy committee with no obvious implementation capability and no significant budget other than that they can agree on between all the jurisdictions. The committee does not even have its own secretariat to manage its internal affairs as best it can be identified.

4. The actual implementation of the HealthConnect vision it to be driven as follows:

“National coordination
The e-Health Branch within the Department of Health and Ageing has a national coordinating role in managing the implementation of the HealthConnect change management strategy. It carries out its role by leveraging existing Australian, State and Territory Government and private sector initiatives to achieve the goal of a shared electronic health record network.

The Branch, in partnership with the State and Territory Governments, is fostering strong relationships between key peak stakeholder groups representing healthcare providers, consumers and industry to engage them in the implementation of the strategy.”

Here we have a lot of fostering, leveraging, consultation and partnering but sadly not much actual spending and implementation!

5. The last really interesting point – and there are all sort of goodies to be found comes from the FAQ page.

“Where will the information be held?
Event summary information that is exchanged between providers will be held at the point of care. At the point of care, the health provider will be able to draw together, with the consumer’s permission, relevant information from other providers involved in a person’s care.”

Translation – No actual Shared Electronic Health Record is planned and no repositories are to be built or paid for – we will hold information at each point of care and exchange on demand. Much cheaper that way, assuming you can make it work.

All I can say is “Welcome to the world of New HealthConnect!” The old one has gone!

David.

Service Improvements

This tiny corner of Cyberspace has now been operational for going on for three months. In that time we have added about thirty articles commenting on the various issues as they emerge in the e-health space in Australia.

While a .atom feed and I believe and RSS feed are available - I have now managed mastery of enough html to provide e-mail updates as well. You can subscribe on the site and it does its best to make sure your e-mail is secure and that you can opt-out again as required. Feel free to tell friends and enemies that they can now know quickly about the views I am putting.

While I have your attention let me make a few points about the experience of writing the blog. First it has been useful in clarifying my thoughts and positions and has acted an interesting exercise in exploration of a range of issues - prompting extra research etc which is all to the good.

I have to say that there are ominous portents for e-health in Australia brewing. First is the awareness that Medical Observer magazine has taken the e-health section it used to have off its website. Seems no one is interested.

Second we note that HealthConnect has been removed in all its guises from the recently announced Australian Budget.

Thirdly there seems to be a pervasive feeling of despondency regarding what is possible in Australia given the politics and Governments (of all shades) views. I see this most in the nihilism and frustration expressed in private e-mail and in correspondence in the GP_Talk forum, HL7-Info and OpenHealth.

The really annoying thing is that it is now clear Health IT, done right, works! It improves care, saves lives and in the hands of competent organisations saves money!

See below for the best facts currently available.

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Chaudhry B, Wang J, Wu S, et al.

Impact of health information technology on quality of medical care
Annals of Internal Medicine 16 May 2006; Volume 144 Issue 10 (early on-line publication)

http://www.annals.org/cgi/content/full/0000605-200605160-00125v1

Background: Experts consider health information technology key to improving efficiency and quality of health care.

Purpose: To systematically review evidence on the effect of health information technology on quality, efficiency, and costs of health care.

Data Sources: The authors systematically searched the English-language literature indexed in MEDLINE (1995 to January 2004), the Cochrane Central Register of Controlled Trials, the Cochrane Database of Abstracts of Reviews of Effects, and the Periodical Abstracts Database. We also added studies identified by experts up to April 2005.

Study Selection: Descriptive and comparative studies and systematic reviews of health information technology.

Data Extraction: Two reviewers independently extracted information on system capabilities, design, effects on quality, system acquisition, implementation context, and costs.

Data Synthesis: 257 studies met the inclusion criteria. Most studies addressed decision support systems or electronic health records. Approximately 25% of the studies were from 4 academic institutions that implemented internally developed systems; only 9 studies evaluated multifunctional, commercially developed systems. Three major benefits on quality were demonstrated: increased adherence to guideline-based care, enhanced surveillance and monitoring, and decreased medication errors. The primary domain of improvement was preventive health. The major efficiency benefit shown was decreased utilization of care. Data on another efficiency measure, time utilization, were mixed. Empirical cost data were limited.

Limitations: Available quantitative research was limited and was done by a small number of institutions. Systems were heterogeneous and sometimes incompletely described. Available financial and contextual data were limited.

Conclusions: Four benchmark institutions have demonstrated the efficacy of health information technologies in improving quality and efficiency. Whether and how other institutions can achieve similar benefits, and at what costs, are unclear.
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Just what has to be done to get NEHTA to develop and articulate a comprehensive e-health plan and to persuade Government to adopt it, is feeling as though it is beyond your simple scribe.

I will, however, press on!

David.