The following was released by HL7 today.
==================
22 March 2007
MEDIA RELEASE
NEHTA confirms Health Level 7 as the national standards for the electronic messaging of health information across Australia.
Across the Australian healthcare sector there are many different types of computer software and systems that are involved in the exchange of information. Currently, these systems use various exchange formats to send and receive information. To ensure that all systems across Australia have the ability to reliably and safely communicate with each other, a standard exchange format is required. The National E-Health Transition Authority (NEHTA) has determined that this standard will be based on the HL7 family of standards.
"This decision provides a clear national direction. Those who develop these systems now have certainty about what the Australian customers of their systems will require," said Dr Ian Reinecke, Chief Executive of NEHTA. "Without all systems in the healthcare sector using common standards such as this, the promise of electronic health communication can't be fulfilled on a national scale."
"The endorsement of the HL7 standards by NEHTA is good news for the Australian e-health community and an acknowledgement of the value and maturity of HL7 standards in a global context. We look forward to working with NEHTA to develop the support required for industry to implement this national direction," said the Chairman of HL7 Australia and Board Member of HL7 globally, Mr Klaus Veil.
To assist the health IT sector to migrate to this standard, NEHTA has identified the following approach:
1. Where HL7 version 2.x standards are already extensively used and yielding benefits, for example pathology and patient administration, these standards should continue to be supported. Where HL7 standards are not in use, they should be factored into system upgrades where practicable.
2. NEHTA will now focus on developing Web services specifications based on work undertaken by the HL7 Services Specification Project (HSSP), and content specifications based on the HL7 Clinical Document Architecture – Release 2 (CDA R2) for areas such as referral, discharge, prescribing, dispensing and pathology.
3. This work will then form the basis by which industry will migrate to HL7 version 3 .
This approach ensures that migration occurs in a consistent manner, and in conformance with NEHTA's requirements.
"NEHTA will work closely with HL7 Australia and Standards Australia in this development work," said Dr Reinecke. "In addition, NEHTA is closely liaising with its international counterparts - such as the UK's National Health Service and Canada's Health Infoway - to ensure that the specifications developed in Australia are consistent with international efforts."
This direction is consistent with the endorsement of HL7 standards for use in Australia by the National Health Information Group in 2004. In the international community, the largest adopter of HL7 v3 standards is the Connecting for Health program run by the UK's National Health Service; the UK, US and Canada have also adopted HL7 CDA specifications.
A report providing further details on this decision will be released shortly by NEHTA. Further information about HL7 standards can be found at www.hl7.org.au.
====================
It must be said it has taken rather too long to get some basic clarity and to permit further e-health development to be undertaken with some confidence.
The decision is, however, most welcome. Whether it is the right one only time will tell.
David.
Thursday, March 22, 2007
Wednesday, March 21, 2007
What a Difference a Presentation Makes!
Seems the Health E-Nation Conference that was organised by CHIK Services on 21 March, 2007 has had an interesting outcome.
It seems NEHTA has recognised, in its presentation, that there are Standards in place and in use that can’t be ignored and that the approach of the ‘jackboot’ as opposed to real consultation can lead to embarrassment! All of us in the health sector could have told them that three years ago!
At last – after three years – maybe we will see some sanity emerge. The steps announced to continue with use of HL7 V2.x are a useful first step.
Much, much more pragmatism, commonsense and flexibility is required – as is a real understanding of the Health Sector’s needs – but this step offers a minute glimmer of hope.
Well done – and how about some serious next steps!
I wonder will it be followed up with a range of other sensible moves - most especially the development of a National e-Health Development approach?
This blog is not short on suggestions on areas that could be fruitfully reviewed.
David.
It seems NEHTA has recognised, in its presentation, that there are Standards in place and in use that can’t be ignored and that the approach of the ‘jackboot’ as opposed to real consultation can lead to embarrassment! All of us in the health sector could have told them that three years ago!
At last – after three years – maybe we will see some sanity emerge. The steps announced to continue with use of HL7 V2.x are a useful first step.
Much, much more pragmatism, commonsense and flexibility is required – as is a real understanding of the Health Sector’s needs – but this step offers a minute glimmer of hope.
Well done – and how about some serious next steps!
I wonder will it be followed up with a range of other sensible moves - most especially the development of a National e-Health Development approach?
This blog is not short on suggestions on areas that could be fruitfully reviewed.
David.
Tuesday, March 20, 2007
Software Quality Assurance – What do we Need and must Demand?
A number of elements have come together over the last few weeks to have me thinking about the expectations we should have of the software and systems we deploy to aid the delivery of clinical care.
First there was a very lively discussion that emerged on the GP_TALK e-mail list which discussed the various issues that surround the handing of clinical results arriving into Patient Management Systems. The discussion was triggered by a question on just what the legal responsibilities were to monitor the incoming areas for arriving results from pathologists, radiologists etc and who was legally liable if an important result went astray and just what the dividing line, if any, was between the test orderer, the result provider and the result receiver / reviewer.
The interest in this topic is considerable because of previous legal liability decisions which make it clear it is the court's view that when a clinician orders an investigation which has the possibility to reveal 'clinically significant' information the practitioner has a considerable legal onus upon them to ensure they have systems in place to ensure that they will, within a reasonable period of time, note and act on the results as they are received.
Second there have been a number of concerns expressed by a range of authorities considering what expectations should be held for the functionality, reliability, usability and clinical safety of software designed to be used by clinicians. This is seen as encompassing areas such as scope, currency, accuracy and reliability of clinical decision support, the aspects of the system design that facilitate safe and consistent use of the software as well as the overall functionality offered.
Third the CEO of HealthLink (Mr Tom Bowden) recently wrote a discussion paper highlighting the problems that can arise if there is not 'end to end' accountability for the entire investigation ordering cycle – covering ordering, processing, resulting and review. This paper clearly recognises the need for substantive co-operation between clinical messaging providers and developers of clinician systems to ensure highly effective integration and the practical removal of any risk of important information 'falling between the cracks'.
This paper – in its current version – can be found at the following URL
http://www.healthlink.net/healthlink_documents/brochure/Electronic%20messaging%20safety%20Issues%20-%20HealthLink%20viewpoint.pdf
Fourth, as best I can tell, NEHTA has articulated no policies or plans in the area of clinical software quality and safety to date, and has not been sponsoring any publicly announced programs in the area.
Fifth, if discussions in GP e-mail forums are to believed, there are some real issues regarding to responsiveness of providers of GP software to both functional gaps and ‘bugs’.
Lastly, to date, while there has been medical software industry contribution work to support the health information Standards development process, there have been limited real outcomes in terms of data portability and interoperation between GP applications. We lack any Australian Standards for patient data portability, for medical software quality and for the quality of functionality and decision support provided.
None of these issues are exactly new, but their emergence does serve to highlight that there are considerable risks associated with having an e-health environment which is fragmented in terms of how quality and safety issues are addressed.
What is needed is really quite clear – a clear division of labour as to who is responsible for which part of the information chain and accountability on the part of all to deliver as fail-safe and reliable solutions as is humanly possible.
It seems to me there needs to be some form of national round table convened which brings together the patient management system developers, the messaging providers, result providers, expert clinicians and health informaticians to develop a framework under which responsibility for each part of the chain can be identified and those involved can then work to develop approaches and solutions which will solve the problem and obviate the risk of computerisation of General Practice being seen as a cause of patient harm.
Ideally all this could be handled in the form of a range of Industry Codes of Practice perhaps combined with appropriate Standards in the relevant areas. There is also a place for entities like the Australian Health Messaging Laboratory (AHML) to provide certification of conformance to agreed Standards to ensure safe inter-operation can be essentially guaranteed. Additionally the round table could consider the role of standardised approaches to interoperation between the various systems involved. Certification of GP systems may also need to be considered if progress in this area does not follow reasonably soon.
It is important for all involved to be very clear that we are only one Coroner's Case or Supreme Court decision away from compulsory application of solutions that may be neither ideal or in-expensive, so delay would be unwise. Recognition of the problem on the part of Medical Defence organisations is also likely to result in pressure to ensure safe and reliable systems are available and used.
It is also clear that well designed practice management systems can greatly assist in ensuring all important results are received (or followed up if not) and actioned appropriately once received. The issue is not if GP computing is needed or not – it clearly is. The issue is to be sure what is functional, safe and reliable and fully meets the needs of its users. I am not yet convinced the ‘market’ has sorted these issues out adequately and the patience of the GP community of users should not be too elastic.
Hopefully the area of the quality and safety of GP computing will be one that will be incorporated in the National E-Health Strategy, which I believe the new Australian Health Information Council should be developing. They should not see taking their time on this issue as an option!
David.
First there was a very lively discussion that emerged on the GP_TALK e-mail list which discussed the various issues that surround the handing of clinical results arriving into Patient Management Systems. The discussion was triggered by a question on just what the legal responsibilities were to monitor the incoming areas for arriving results from pathologists, radiologists etc and who was legally liable if an important result went astray and just what the dividing line, if any, was between the test orderer, the result provider and the result receiver / reviewer.
The interest in this topic is considerable because of previous legal liability decisions which make it clear it is the court's view that when a clinician orders an investigation which has the possibility to reveal 'clinically significant' information the practitioner has a considerable legal onus upon them to ensure they have systems in place to ensure that they will, within a reasonable period of time, note and act on the results as they are received.
Second there have been a number of concerns expressed by a range of authorities considering what expectations should be held for the functionality, reliability, usability and clinical safety of software designed to be used by clinicians. This is seen as encompassing areas such as scope, currency, accuracy and reliability of clinical decision support, the aspects of the system design that facilitate safe and consistent use of the software as well as the overall functionality offered.
Third the CEO of HealthLink (Mr Tom Bowden) recently wrote a discussion paper highlighting the problems that can arise if there is not 'end to end' accountability for the entire investigation ordering cycle – covering ordering, processing, resulting and review. This paper clearly recognises the need for substantive co-operation between clinical messaging providers and developers of clinician systems to ensure highly effective integration and the practical removal of any risk of important information 'falling between the cracks'.
This paper – in its current version – can be found at the following URL
http://www.healthlink.net/healthlink_documents/brochure/Electronic%20messaging%20safety%20Issues%20-%20HealthLink%20viewpoint.pdf
Fourth, as best I can tell, NEHTA has articulated no policies or plans in the area of clinical software quality and safety to date, and has not been sponsoring any publicly announced programs in the area.
Fifth, if discussions in GP e-mail forums are to believed, there are some real issues regarding to responsiveness of providers of GP software to both functional gaps and ‘bugs’.
Lastly, to date, while there has been medical software industry contribution work to support the health information Standards development process, there have been limited real outcomes in terms of data portability and interoperation between GP applications. We lack any Australian Standards for patient data portability, for medical software quality and for the quality of functionality and decision support provided.
None of these issues are exactly new, but their emergence does serve to highlight that there are considerable risks associated with having an e-health environment which is fragmented in terms of how quality and safety issues are addressed.
What is needed is really quite clear – a clear division of labour as to who is responsible for which part of the information chain and accountability on the part of all to deliver as fail-safe and reliable solutions as is humanly possible.
It seems to me there needs to be some form of national round table convened which brings together the patient management system developers, the messaging providers, result providers, expert clinicians and health informaticians to develop a framework under which responsibility for each part of the chain can be identified and those involved can then work to develop approaches and solutions which will solve the problem and obviate the risk of computerisation of General Practice being seen as a cause of patient harm.
Ideally all this could be handled in the form of a range of Industry Codes of Practice perhaps combined with appropriate Standards in the relevant areas. There is also a place for entities like the Australian Health Messaging Laboratory (AHML) to provide certification of conformance to agreed Standards to ensure safe inter-operation can be essentially guaranteed. Additionally the round table could consider the role of standardised approaches to interoperation between the various systems involved. Certification of GP systems may also need to be considered if progress in this area does not follow reasonably soon.
It is important for all involved to be very clear that we are only one Coroner's Case or Supreme Court decision away from compulsory application of solutions that may be neither ideal or in-expensive, so delay would be unwise. Recognition of the problem on the part of Medical Defence organisations is also likely to result in pressure to ensure safe and reliable systems are available and used.
It is also clear that well designed practice management systems can greatly assist in ensuring all important results are received (or followed up if not) and actioned appropriately once received. The issue is not if GP computing is needed or not – it clearly is. The issue is to be sure what is functional, safe and reliable and fully meets the needs of its users. I am not yet convinced the ‘market’ has sorted these issues out adequately and the patience of the GP community of users should not be too elastic.
Hopefully the area of the quality and safety of GP computing will be one that will be incorporated in the National E-Health Strategy, which I believe the new Australian Health Information Council should be developing. They should not see taking their time on this issue as an option!
David.
Sunday, March 18, 2007
An Open Letter to Minister Tony Abbott.
The following is a letter I e-mailed to Minister Tony Abbott a little over a week ago. In the covering note I pointed out I would like a response and that I planned to publish the letter on this site after a week or two.
-----------
An Open Letter to Minister Tony Abbott.
11th March 2007
The Hon Tony Abbott MP
Leader of the House; Minister for Health and Ageing.
PO Box 6022
House of Representatives
Parliament House
Canberra ACT 2600
Dear Mr Abbott,
The Australian health system is not as safe, as efficient or as cost effective as it could and should be.
A major, but not the only reason for this is that the health sector is not using proven Information and Communication Technology effectively in order to get the benefits which have been received by virtually all other sectors of the Australian economy.
I believe this is a major policy failure of the present Government and will have electoral consequences unless addressed promptly with a coherent, inclusive and properly funded National Health IT Strategy in conjunction with an appropriate Business Plan and Implementation Strategy. Neither NEHTA nor the newly re-formed Australian Health Information Council appear to be cognisant of and focussed upon the excess costs and suffering inaction is causing. Action is required promptly.
There will be electoral consequences due to the public perceptions of wastage of many dollars on the current strategy, the lack of transparency in the evaluation and reporting of what has been achieved to date, the recognition we are slipping well behind other countries (e.g. the UK, Canada and the Netherlands) and the unacceptable number of otherwise avoidable deaths and injuries due to unsafe and inadequate systems.
The net benefits of successful implementation of such a plan would conservatively be at least five percent of national health expenditure ($4 Billion per annum), if overseas research from the US, the UK and Canada are any guide.
I have developed an internet web-log containing over 140 articles on this topic over the last 12 months and I have exposed my thinking to public criticism and review. I have found that the 200 plus expert readers are typically very supportive of my suggestions in the Health IT domain.
I would be pleased to have your officials browse my web-log for a well considered and developed set of ideas and approaches on what is needed to recruit the benefits and to move Australia forward in this very important area.
The web-log can be viewed at http://www.aushealthit.blogspot.com/ .
Yours truly,
- Signed -
(Dr) David More MB, PhD, FACHI.
----------
As of the time of posting no response has been received from the minister
David.
-----------
An Open Letter to Minister Tony Abbott.
11th March 2007
The Hon Tony Abbott MP
Leader of the House; Minister for Health and Ageing.
PO Box 6022
House of Representatives
Parliament House
Canberra ACT 2600
Dear Mr Abbott,
The Australian health system is not as safe, as efficient or as cost effective as it could and should be.
A major, but not the only reason for this is that the health sector is not using proven Information and Communication Technology effectively in order to get the benefits which have been received by virtually all other sectors of the Australian economy.
I believe this is a major policy failure of the present Government and will have electoral consequences unless addressed promptly with a coherent, inclusive and properly funded National Health IT Strategy in conjunction with an appropriate Business Plan and Implementation Strategy. Neither NEHTA nor the newly re-formed Australian Health Information Council appear to be cognisant of and focussed upon the excess costs and suffering inaction is causing. Action is required promptly.
There will be electoral consequences due to the public perceptions of wastage of many dollars on the current strategy, the lack of transparency in the evaluation and reporting of what has been achieved to date, the recognition we are slipping well behind other countries (e.g. the UK, Canada and the Netherlands) and the unacceptable number of otherwise avoidable deaths and injuries due to unsafe and inadequate systems.
The net benefits of successful implementation of such a plan would conservatively be at least five percent of national health expenditure ($4 Billion per annum), if overseas research from the US, the UK and Canada are any guide.
I have developed an internet web-log containing over 140 articles on this topic over the last 12 months and I have exposed my thinking to public criticism and review. I have found that the 200 plus expert readers are typically very supportive of my suggestions in the Health IT domain.
I would be pleased to have your officials browse my web-log for a well considered and developed set of ideas and approaches on what is needed to recruit the benefits and to move Australia forward in this very important area.
The web-log can be viewed at http://www.aushealthit.blogspot.com/ .
Yours truly,
- Signed -
(Dr) David More MB, PhD, FACHI.
----------
As of the time of posting no response has been received from the minister
David.
Thursday, March 15, 2007
The Shared EHR – Can it Be Done Simply and Make a Difference?
In this short article I want to raise, and attempt to solve at a high level, some of the problems associated with the currently proposed Shared Electronic Health Record (SEHR).
The reason to document this is that in its latest presentations NEHTA is still saying it wants to put a business case for implementation of a National SEHR to the Council of Australian Government by the end of 2008.
What I mean by a SEHR is an arrangement (in its most simple form) where by a variety of feeder systems found in general practice, specialist offices, hospitals and services such as labs, pharmacies and radiology create summary records as they process patients which are then uploaded to a central repository. These summaries are envisaged to accumulate over the life of the patient to form a valuable longitudinal electronic patient record.
The central repository is then accessible to authorised users to assist with the care of the individual patient at some time later.
With minor tweaking around the edges the NEHTA proposal seems to be a re-run of the late 2004 HealthConnect project which was a month or two after that date placed into development limbo. The most evolved public version of the HealthConnect proposal was the Version 1.9 of its proposed Business Architecture (BA).
There do exist some slightly later NEHTA documents providing a “Concept of Operations” for a NEHTA SEHR but these are not publicly available.
It must be reasonably obvious to all that creation of a nation SEHR is not a uncomplicated exercise – indeed, since proposed in late 2001 – very considerable work has been done, pilots of components have been undertaken but any really extensible or expandable success simply has not been demonstrated. Those with a historical bent can follow all this is excruciating detail at the following URL:
http://www.health.gov.au/internet/hconnect/publishing.nsf/Content/home
This site was last updated 17 Feb, 2006.
I will state a prejudice here and state I think the SEHR of the BA Version 1.9 and NEHTA’s present plans are probably too complex, when fully analysed, to be made reality. That said I believe there is the possibility of doing something very clinically useful if those responsible stand back and work out clearly where information should be stored and processed within the health system.
What I suggest is that a practical approach to the SEHR should be a very simple base record – held voluntarily in a central repository - that contains the information that may change the way an individual is treated in the first day or so of an encounter with an emergency facility, hospital or new doctor. If that can be made to work, then, and only then, should consideration be given to doing more in a shared EHR sense.
There are a number of templates available for what to me should be a single form which is stored centrally and updated by the patient and their attending doctor at each appropriate encounter. All that would be stored would be essentially patient demographics, major current illnesses and problems, allergies and current medications, with maybe some free text for special items of warning or alert.
The standard of information I would suggest is appropriate is the amount of information a thorough GP would provide about a patient who as going for an overseas trip where they may need care from a doctor who had never seen them before.
If more detail is required, it is at that point reference is made to the owners of the patient’s detailed information – e.g. laboratory providers, specialists, local GP etc.
Any design that attempts more than this simple approach (of voluntary sharing of a basic information set agreed between the patient and their usual clinical adviser) will get tangled up with a range of issues.
These include:
• Concerns for privacy and lack of control of their personal information on the part of the consumer / patient
• Difficulties and delays in delivery of a workable system due to complexity if a more adventurous approach is attempted.
• Excessive cost in infrastructure requirements.
It seems to me such a basic standardised record would typically be able to be relatively easily read and created by quality GP and other relevant systems – and a secure messaging solution to and from a central repository would not be too difficult to devise within current standards.
Either the Access Card Identifier or the NEHTA Health IHI could be used to safely identify patients if either is available, or an alternative devised if required. Only one would be needed.
Under my approach all the heavy computational lifting – that promotes quality and safety in clinical care – would be done within client systems in the General Practice, Specialist’s Office or Hospital where clinicians engage with the details of care and where decision support is most valuable.
Such a model of a simple shared record and quality computing for the clinical workface (i.e. Local EHR) I find intrinsically appealing and doable today. I hope something practical, quickly implementable and workable emerges from NEHTA’s deliberations in this area.
I am firmly of the ‘walk before you run’ school in Health IT. Round the world we see simplification working and complexity confounding the most energetic. Let’s grasp that lesson and move forward.
David.
The reason to document this is that in its latest presentations NEHTA is still saying it wants to put a business case for implementation of a National SEHR to the Council of Australian Government by the end of 2008.
What I mean by a SEHR is an arrangement (in its most simple form) where by a variety of feeder systems found in general practice, specialist offices, hospitals and services such as labs, pharmacies and radiology create summary records as they process patients which are then uploaded to a central repository. These summaries are envisaged to accumulate over the life of the patient to form a valuable longitudinal electronic patient record.
The central repository is then accessible to authorised users to assist with the care of the individual patient at some time later.
With minor tweaking around the edges the NEHTA proposal seems to be a re-run of the late 2004 HealthConnect project which was a month or two after that date placed into development limbo. The most evolved public version of the HealthConnect proposal was the Version 1.9 of its proposed Business Architecture (BA).
There do exist some slightly later NEHTA documents providing a “Concept of Operations” for a NEHTA SEHR but these are not publicly available.
It must be reasonably obvious to all that creation of a nation SEHR is not a uncomplicated exercise – indeed, since proposed in late 2001 – very considerable work has been done, pilots of components have been undertaken but any really extensible or expandable success simply has not been demonstrated. Those with a historical bent can follow all this is excruciating detail at the following URL:
http://www.health.gov.au/internet/hconnect/publishing.nsf/Content/home
This site was last updated 17 Feb, 2006.
I will state a prejudice here and state I think the SEHR of the BA Version 1.9 and NEHTA’s present plans are probably too complex, when fully analysed, to be made reality. That said I believe there is the possibility of doing something very clinically useful if those responsible stand back and work out clearly where information should be stored and processed within the health system.
What I suggest is that a practical approach to the SEHR should be a very simple base record – held voluntarily in a central repository - that contains the information that may change the way an individual is treated in the first day or so of an encounter with an emergency facility, hospital or new doctor. If that can be made to work, then, and only then, should consideration be given to doing more in a shared EHR sense.
There are a number of templates available for what to me should be a single form which is stored centrally and updated by the patient and their attending doctor at each appropriate encounter. All that would be stored would be essentially patient demographics, major current illnesses and problems, allergies and current medications, with maybe some free text for special items of warning or alert.
The standard of information I would suggest is appropriate is the amount of information a thorough GP would provide about a patient who as going for an overseas trip where they may need care from a doctor who had never seen them before.
If more detail is required, it is at that point reference is made to the owners of the patient’s detailed information – e.g. laboratory providers, specialists, local GP etc.
Any design that attempts more than this simple approach (of voluntary sharing of a basic information set agreed between the patient and their usual clinical adviser) will get tangled up with a range of issues.
These include:
• Concerns for privacy and lack of control of their personal information on the part of the consumer / patient
• Difficulties and delays in delivery of a workable system due to complexity if a more adventurous approach is attempted.
• Excessive cost in infrastructure requirements.
It seems to me such a basic standardised record would typically be able to be relatively easily read and created by quality GP and other relevant systems – and a secure messaging solution to and from a central repository would not be too difficult to devise within current standards.
Either the Access Card Identifier or the NEHTA Health IHI could be used to safely identify patients if either is available, or an alternative devised if required. Only one would be needed.
Under my approach all the heavy computational lifting – that promotes quality and safety in clinical care – would be done within client systems in the General Practice, Specialist’s Office or Hospital where clinicians engage with the details of care and where decision support is most valuable.
Such a model of a simple shared record and quality computing for the clinical workface (i.e. Local EHR) I find intrinsically appealing and doable today. I hope something practical, quickly implementable and workable emerges from NEHTA’s deliberations in this area.
I am firmly of the ‘walk before you run’ school in Health IT. Round the world we see simplification working and complexity confounding the most energetic. Let’s grasp that lesson and move forward.
David.
Sunday, March 11, 2007
Three Years Too Late – NEHTA Asks What’s Next?
A few days ago I heard about an 80 minute Panel Session that NEHTA is planning to conduct on 20 March 2007. (The date is one day before the Health E-Nation Conference being organised by CHIK Services on 21 March)
The information I received is as follows:
_________________________________
“Planned Panel Session
Title
Joining the Dots… What’s Next
Aims
To identify the priority areas for action to enable e-reforms to progress to national implementation.
To identify the most significant outstanding obstacles to progress and what must be done in the next 12 months to address these priority issues.
To enjoy a lively discussion with questions and comments from the audience.
Interview questions
What do you believe are the 1 or 2 key areas for action over the next 2 to 3 years? Please give brief, specific examples to illustrate your points.
What do you believe is the single most important thing we need to do to accelerate e-health in the next 12 months from the point of view of health consumers or patients? And also from the point of view of health professionals?
What is your organisation currently doing to accelerate e-health reforms? Example?
Is there any other significant issue you would like to raise?”
_______________________
I was also told it is planned there will be panellists from six to eight different relevant organisations.
What is to be made of this?
My first reaction was to ask – Why was this work, which is essentially aimed at setting strategic and short term directions, not undertaken three years ago?
Then it occurred to me ponder – hang on – isn’t NEHTA meant to be managing the delivery and implementation of e-Health in Australia? How is it they don’t know the answers to all these questions as part of their strategic plan? If the aim of this Planned Panel Session is to confirm current directions I would be re-assured – but for NEHTA to now be asking what the priorities and barriers are at this point – three years into the mission – seems just quite absurd.
As readers of this blog will know I have been banging on about the need for an action orientated National E-Health Strategy, Business Case and Implementation Plan for a good while now! My answer to NEHTA’s request therefore is quite straightforward. Put simply what NEHTA has to do is as follows:
1. Recognise that their customer is not the NEHTA Board but the Australian Health Sector, and the 20 million people who use the services provided by it.
2. Swiftly enrol competent expertise and find the resources and funds to develop a consultative, inclusive, National E-Health Strategy, Business Case and Implementation Plan.
3. Use the Business Case to secure the appropriate level of funding required to move forward
4. Implement the agreed and recommended plan nationally.
I have had a feeling in the last few months that I have been missing something, else we would be seeing more constructive activity than seems to be the case. I have formed the view that the lack of an agreed national strategy is fundamentally a major obstacle to progress. Broadly speaking what I think we are now seeing is the following:-
1. State Governments working to use Health IT to try to get their hospitals working better (albeit with different levels of success and urgency) and starting to try and communicate with the relevant GPs and Specialists.
2. Most GPs and Specialists lacking the motivation (or the right incentives and support) to move beyond basic practice computing and prescription printing until future directions become clearer. (Note: there are all sorts of good things happening at many Divisions but somehow the task of co-ordinating information and skill sharing seems less than ideal).
3. The medical software industry is responding where it can but it lacks confidence in the stability of the direction being taken and the preparedness by Government(s) and practitioners to invest.
4. Service providers (labs, radiology etc) are optimising internal operations and providing external messaging of results etc largely only when asked. Electronic ordering is still at a low level.
5. A significant and consistent lack of support for implementation of already developed standards as well as some caution around standards which exist on paper but are not yet demonstrably implemented.
6. An evolving but still non-interoperable secure electronic messaging environment which lacks certainty in the forward directions that will be successful resulting in slow investment and complexity of use for end users.
7. A clear sense that the HealthConnect proposal(s) is/are going no-where in the next 3-4 years at best and that in reality HealthConnect has been canned.
8. Scepticism regarding announcements in areas such as e-prescribing, supply chain and medicine terminology among others.
Development of a comprehensive National E-Health Plan can, if funded and sponsored at the right level, provide the confidence, financial security and direction to get over the log-jam.
There are a few critical requirements for national E-Health Plans to be successful. These include at least the following:
1. That the plan be designed for the way the Health Sector in a country works in terms of funding, service delivery and so on. The implication is that what is done in the US, UK, Canada or Europe will only offer ideas – not a comprehensive solution.
2. That the plan, once developed, be sponsored, funded and committed to on a bi-partisan national interest motivated mode. Implementation of a plan of the type required is a major long term project and as far as possible politicisation needs to be avoided.
3. The plan be conceived to address the health system as a whole – and not fall into all the traps of Commonwealth / State rivalry, friction etc.
4. Inclusiveness of all the relevant stakeholders (Consumers, Providers, Government, Health Funds etc)
5. Focussed on delivery of clinical benefits for patients along with facilitation of health sector safety, efficiency and effectiveness.
6. Recognition that the benefits from the use of Health IT are often not captured by those whose work practices are changed and who may also bear additional costs.
7. Recognition that significant incentives for change will be required.
8. Recognition that Health IT is an enabler of Health Sector Reform and Improvement and that leadership of and commitment to Health System redesign is also needed.
There are a number of major strategic choices that also need to be made. Among these are (in no particular order – they are all crucial):
1. The level of standardisation that is to be imposed and at what level(s) this is to happen – as there is a trade off between user choice and the degree of inter-operation and information sharing that can be achieved without undue complexity.
2. Whether the approach to development and implementation will be ‘top down’ (as broadly it is in the UK) or ‘bottom up’ (as broadly it is in the US). This will ultimately drive a strategic E-Health Architecture for the county and the route by which that architecture will be evolved in practice.
3. The respective place and role(s) of the Government(s), the health service providers, the private sector software industry and so on the overall mix of how things are achieved.
4. Whether a Shared EHR or a messaging paradigm will be adopted and whether a distributed or centralised model will be adopted. There are a huge range of shades of choice that may be made in this area.
5. The suite of standards that will be utilised and how compliance with those standards will be obtained, certified and maintained.
6. The level of local and regional autonomy that will be available and the areas of the strategy where this will operate.
7. The amount of system development, service provision etc that will be undertaken centrally by Government(s) versus the use of commercially provided software and services.
8. The approach to risk management and to issues such as the verification of solution suitability and piloting of proposed solutions.
9. The funding model to be adopted and the approach to be adopted to benefits identification, management, realisation and distribution.
10. What is preferred and the optimal method of software provider and user / public / consumer involvement in the selection, deployment and use of Health IT and what consultative approach should be used in development of the strategy.
11. The strategies to be used in gaining public confidence regarding the privacy and security of their personal health information.
12. How best to take most advantage of the useful work undertaken to date in the field, while not constraining an optimal long term outcome for Australia.
13. The optimal governance framework and management structure for delivery of such a large and complex national initiative.
The benefits of providing clarity to all stakeholders on the shape of the future and the part they can play in advancing towards that future are obvious in terms of the levels of investment and benefits that will flow.
The best thing that could happen would be that the new AHIC and NEHTA jointly approach COAG / AHMAC to get such a planning process initiated as soon as possible.
I wonder whether those bodies have the ‘intestinal fortitude’ needed to step back, accept we are not getting anywhere fast, and initiate a new planning process.
I am reminded of the following quote:
There is a tide in the affairs of men,
Which, taken at the flood, leads on to fortune;
Omitted, all the voyage of their life
Is bound in shallows and in miseries.
William Shakespeare, Julius Caesar
Greatest English dramatist & poet (1564 - 1616)
The tide is rising right now!
David.
The information I received is as follows:
_________________________________
“Planned Panel Session
Title
Joining the Dots… What’s Next
Aims
To identify the priority areas for action to enable e-reforms to progress to national implementation.
To identify the most significant outstanding obstacles to progress and what must be done in the next 12 months to address these priority issues.
To enjoy a lively discussion with questions and comments from the audience.
Interview questions
What do you believe are the 1 or 2 key areas for action over the next 2 to 3 years? Please give brief, specific examples to illustrate your points.
What do you believe is the single most important thing we need to do to accelerate e-health in the next 12 months from the point of view of health consumers or patients? And also from the point of view of health professionals?
What is your organisation currently doing to accelerate e-health reforms? Example?
Is there any other significant issue you would like to raise?”
_______________________
I was also told it is planned there will be panellists from six to eight different relevant organisations.
What is to be made of this?
My first reaction was to ask – Why was this work, which is essentially aimed at setting strategic and short term directions, not undertaken three years ago?
Then it occurred to me ponder – hang on – isn’t NEHTA meant to be managing the delivery and implementation of e-Health in Australia? How is it they don’t know the answers to all these questions as part of their strategic plan? If the aim of this Planned Panel Session is to confirm current directions I would be re-assured – but for NEHTA to now be asking what the priorities and barriers are at this point – three years into the mission – seems just quite absurd.
As readers of this blog will know I have been banging on about the need for an action orientated National E-Health Strategy, Business Case and Implementation Plan for a good while now! My answer to NEHTA’s request therefore is quite straightforward. Put simply what NEHTA has to do is as follows:
1. Recognise that their customer is not the NEHTA Board but the Australian Health Sector, and the 20 million people who use the services provided by it.
2. Swiftly enrol competent expertise and find the resources and funds to develop a consultative, inclusive, National E-Health Strategy, Business Case and Implementation Plan.
3. Use the Business Case to secure the appropriate level of funding required to move forward
4. Implement the agreed and recommended plan nationally.
I have had a feeling in the last few months that I have been missing something, else we would be seeing more constructive activity than seems to be the case. I have formed the view that the lack of an agreed national strategy is fundamentally a major obstacle to progress. Broadly speaking what I think we are now seeing is the following:-
1. State Governments working to use Health IT to try to get their hospitals working better (albeit with different levels of success and urgency) and starting to try and communicate with the relevant GPs and Specialists.
2. Most GPs and Specialists lacking the motivation (or the right incentives and support) to move beyond basic practice computing and prescription printing until future directions become clearer. (Note: there are all sorts of good things happening at many Divisions but somehow the task of co-ordinating information and skill sharing seems less than ideal).
3. The medical software industry is responding where it can but it lacks confidence in the stability of the direction being taken and the preparedness by Government(s) and practitioners to invest.
4. Service providers (labs, radiology etc) are optimising internal operations and providing external messaging of results etc largely only when asked. Electronic ordering is still at a low level.
5. A significant and consistent lack of support for implementation of already developed standards as well as some caution around standards which exist on paper but are not yet demonstrably implemented.
6. An evolving but still non-interoperable secure electronic messaging environment which lacks certainty in the forward directions that will be successful resulting in slow investment and complexity of use for end users.
7. A clear sense that the HealthConnect proposal(s) is/are going no-where in the next 3-4 years at best and that in reality HealthConnect has been canned.
8. Scepticism regarding announcements in areas such as e-prescribing, supply chain and medicine terminology among others.
Development of a comprehensive National E-Health Plan can, if funded and sponsored at the right level, provide the confidence, financial security and direction to get over the log-jam.
There are a few critical requirements for national E-Health Plans to be successful. These include at least the following:
1. That the plan be designed for the way the Health Sector in a country works in terms of funding, service delivery and so on. The implication is that what is done in the US, UK, Canada or Europe will only offer ideas – not a comprehensive solution.
2. That the plan, once developed, be sponsored, funded and committed to on a bi-partisan national interest motivated mode. Implementation of a plan of the type required is a major long term project and as far as possible politicisation needs to be avoided.
3. The plan be conceived to address the health system as a whole – and not fall into all the traps of Commonwealth / State rivalry, friction etc.
4. Inclusiveness of all the relevant stakeholders (Consumers, Providers, Government, Health Funds etc)
5. Focussed on delivery of clinical benefits for patients along with facilitation of health sector safety, efficiency and effectiveness.
6. Recognition that the benefits from the use of Health IT are often not captured by those whose work practices are changed and who may also bear additional costs.
7. Recognition that significant incentives for change will be required.
8. Recognition that Health IT is an enabler of Health Sector Reform and Improvement and that leadership of and commitment to Health System redesign is also needed.
There are a number of major strategic choices that also need to be made. Among these are (in no particular order – they are all crucial):
1. The level of standardisation that is to be imposed and at what level(s) this is to happen – as there is a trade off between user choice and the degree of inter-operation and information sharing that can be achieved without undue complexity.
2. Whether the approach to development and implementation will be ‘top down’ (as broadly it is in the UK) or ‘bottom up’ (as broadly it is in the US). This will ultimately drive a strategic E-Health Architecture for the county and the route by which that architecture will be evolved in practice.
3. The respective place and role(s) of the Government(s), the health service providers, the private sector software industry and so on the overall mix of how things are achieved.
4. Whether a Shared EHR or a messaging paradigm will be adopted and whether a distributed or centralised model will be adopted. There are a huge range of shades of choice that may be made in this area.
5. The suite of standards that will be utilised and how compliance with those standards will be obtained, certified and maintained.
6. The level of local and regional autonomy that will be available and the areas of the strategy where this will operate.
7. The amount of system development, service provision etc that will be undertaken centrally by Government(s) versus the use of commercially provided software and services.
8. The approach to risk management and to issues such as the verification of solution suitability and piloting of proposed solutions.
9. The funding model to be adopted and the approach to be adopted to benefits identification, management, realisation and distribution.
10. What is preferred and the optimal method of software provider and user / public / consumer involvement in the selection, deployment and use of Health IT and what consultative approach should be used in development of the strategy.
11. The strategies to be used in gaining public confidence regarding the privacy and security of their personal health information.
12. How best to take most advantage of the useful work undertaken to date in the field, while not constraining an optimal long term outcome for Australia.
13. The optimal governance framework and management structure for delivery of such a large and complex national initiative.
The benefits of providing clarity to all stakeholders on the shape of the future and the part they can play in advancing towards that future are obvious in terms of the levels of investment and benefits that will flow.
The best thing that could happen would be that the new AHIC and NEHTA jointly approach COAG / AHMAC to get such a planning process initiated as soon as possible.
I wonder whether those bodies have the ‘intestinal fortitude’ needed to step back, accept we are not getting anywhere fast, and initiate a new planning process.
I am reminded of the following quote:
There is a tide in the affairs of men,
Which, taken at the flood, leads on to fortune;
Omitted, all the voyage of their life
Is bound in shallows and in miseries.
William Shakespeare, Julius Caesar
Greatest English dramatist & poet (1564 - 1616)
The tide is rising right now!
David.
Yes, It Really Can be Done!
Just a short posting to provide a URL for a fascinating ten minute downloadable video that explains what the Dutch have been up to in e-Health over the last few years!
The video describes AORTA which is the Dutch national infrastructure for the exchange of data between healthcare providers. The infrastructure specifications include a description of technical, organizational as well as implementation aspects. The focus of this program is to facilitate the realization of a national "continuity of care" oriented EHR. AORTA uses HL7 version 3 messages and documents as its core mechanism for information exchange.
Depending on your media preference you have a choice of formats.
AORTA introductory video (in English, 10 minutes),
http://www.uzi-register.nl/media/EMD_WDH_EN_256K.wmv (Windows Media file)
or
http://www.uzi-register.nl/media/EMD_WDH_EN_H264%20.mov (Apple Quicktime).
Vastly more information and detail on the project can be found at:
http://www.ringholm.de/docs/00980_en.htm
The author is René Spronk - Sr.Consultant, Ringholm GmbH
The current document status: Draft, version 0.5 (2007-01-01).
I commend this article and indeed the Ringholm site for a careful browse and review.
There are all sorts of lessons for Australia I believe here. The approach to security and privacy I found was especially pragmatic and robust.
I find it fascinating that the Dutch have committed so robustly to making HL7 V3.0 and CDA R2 work – despite it not being totally finalised – and seem to be having considerable success. This is encouraging news.
David.
The video describes AORTA which is the Dutch national infrastructure for the exchange of data between healthcare providers. The infrastructure specifications include a description of technical, organizational as well as implementation aspects. The focus of this program is to facilitate the realization of a national "continuity of care" oriented EHR. AORTA uses HL7 version 3 messages and documents as its core mechanism for information exchange.
Depending on your media preference you have a choice of formats.
AORTA introductory video (in English, 10 minutes),
http://www.uzi-register.nl/media/EMD_WDH_EN_256K.wmv (Windows Media file)
or
http://www.uzi-register.nl/media/EMD_WDH_EN_H264%20.mov (Apple Quicktime).
Vastly more information and detail on the project can be found at:
http://www.ringholm.de/docs/00980_en.htm
The author is René Spronk - Sr.Consultant, Ringholm GmbH
The current document status: Draft, version 0.5 (2007-01-01).
I commend this article and indeed the Ringholm site for a careful browse and review.
There are all sorts of lessons for Australia I believe here. The approach to security and privacy I found was especially pragmatic and robust.
I find it fascinating that the Dutch have committed so robustly to making HL7 V3.0 and CDA R2 work – despite it not being totally finalised – and seem to be having considerable success. This is encouraging news.
David.
Wednesday, March 07, 2007
Why the NEHTA Clinical Data Specifications Will Go Nowhere.
In early 2002 an organisation called the National Infostructure Development (NID) was funded to develop the information infrastructure that would be required as part of an implementation of the then planned HealthConnect. A key component was the Clinical Information Project (CIP).
The CIP focus was the clinical information content of shared EHRs for HealthConnect and the broader EHR agenda. The clinical information content relates to information that needs to be captured, stored and viewed to support the HealthConnect objective of improved delivery of health care and better quality of care.
Because the developmental focus of HealthConnect as a whole was based on the concept of event summaries, which were to make up the Shared EHR, the focus of the CIP was on the development of forms together with information content and definitions suitable for discharge summaries, referrals, result information and so on (the so called 'high priority' forms).
Efforts in this area continued when NEHTA took over responsibility for the CIP – since renamed a couple of times and, now seen as part of the Clinical Communications component of NEHTA's work. Recently (in December, 2006 and in February) we witnessed the release of two 500 page documents outlining the information structure and content of discharge summaries and specialist referrals.
What are we to make of these documents and how are they to be used?
_________________________________
In their introductory document the authors say:-
“NEHTA has released specifications to standardise the content of electronic referrals across Australia. This work also makes possible the development of improved decision support systems, which will be able to make use of the information in electronic versions of clinical documents (such as referrals) to assist healthcare practitioners make better decisions; and is an important step towards realising shared electronic health records.”
And they also say:-
“A Comprehensive Specification
It is important to understand the philosophy behind specifying referral content as comprehensively as appears in this specification. The specification needs to be comprehensive to capture as much information as required for the recipient to understand the patient's condition as fully as possible. However, it is quite clear that any one referral sent by a healthcare practitioner is unlikely to require the full suite of details embodied in the specification. In developing the referral specification, NEHTA has considered:
• - how prescriptive the referral template should be, in terms of:
o structure;
o comprehensiveness; and
o the terminology used;
• - the burden imposed on clinicians creating and receiving referrals; and
•- the burden on clinical information systems to capture, send and/or receive and process structured information.
Therefore, while the specification is prescriptive with respect to structure, information richness, and terminology, it is not prescriptive about which information should be sent under what circumstances. It is important to note that the specification was also designed for use within clinical information systems to reduce the burden of data entry for the referring healthcare provider, and the subsequent data interpretation, storage and manipulation by the referred-to provider.
The specification and included samples therefore indicate the richness of information that can be expressed, sent and ultimately imported into clinical information systems and shared electronic health records. The specification should not be interpreted as the set of information that must be sent, irrespective of the condition of the patient and the purpose of the referral.
Implementation Considerations
The establishment of clinical information systems that can interoperate regarding the transmission and computer interpretation of referrals (and other documents) is an evolutionary process. NEHTA anticipates that, in the first instance, the health community will review the GP and Specialist/Critical Care Referral Content Specification to become familiar with the content and intention of the specification, and plan to implement elements of the specification where possible within planned system upgrades.
Once the additional elements required by interoperable systems become available, the systems that have incorporated the specification will be able to quickly transition to interoperability. The key additional elements are outlined below.”
____________________________________
The document then goes on to cite SNOMED CT, HL7 V2.x and provider and patient identification.
I must say it takes some special form of arrogance to publish a set of specifications such as this without any reference to, or suggestion of, even the simplest of trial implementations, or ‘proof of concept and viability’, or any of the tools that are obviously required to make any sense or use of the material.
I am sure any system provider offered this specification would say: “Where in the world is something of this structure and complexity working and how much are you going to pay me to be your trial horse?”
Comments such as “NEHTA anticipates that, in the first instance, the health community will review the GP and Specialist/Critical Care Referral Content Specification to become familiar with the content and intention of the specification, and plan to implement elements of the specification where possible within planned system upgrades.” provide no assurance any of this is going anywhere in the foreseeable future – and leads to the inevitable question “Why should I spend anything on all this until it is clear that others are?”.
The other obvious problem is that NEHTA says that one does not need to do a comprehensive implementation of this specification but provides no roadmap to guide development and implementation priorities. Unless this is provided this looks like it’s pretty much an 'all or none' in terms of what is needed to begin developing system specifications. And the “all” is a huge project I would suggest, especially as the specification seems to only exist as an untested MS Word document at present!
The last major issue is that nowhere in the documentation is there any mention of how interoperation, if ever attempted, will be certified and provide a robust guarantee of accuracy, reliability, future maintenance and safety. If you offer a specification of this nature for use you take on the obligation to maintain and certify compliance with the specifications that you produce in perpetuity. Plans in this area simply do not exist as far as I can tell.
Slipping back to reality for a moment, the facts are these:
1. A national HealthConnect project, as originally envisaged, seems to have a very low probability of actually ever being implemented, even though NEHTA says it is still being worked on. The most obvious reason for this is that the costs of such a project (almost certainly billions of dollars) are not likely to easily be provided by Government – despite a compelling business case to make major investments in the e-Health space.
2. The world has moved on to more pragmatic international standards with experts and implementers on both sides of the Atlantic seeking simpler and more practical implementable approaches for deployment of interoperable systems. In the US the Continuity of Care Document (CCD) is emerging (deploying features of HL7, CDA R2 and ASTM CCR) as a credible standard and in the UK work has been undertaken to reduce the information content on the NHS Spine down to the minimum possible.
3. Without a guarantee of major investment in these specifications no vendor will invest to develop compliance. Attempts at mandating such specifications are likewise doomed as large vendors will simply say 'you set up the certification mechanisms so compliance can be verified and you pay us all our costs at time and material rates and we will develop what you require!” Meanwhile, small vendors will probably be put out of business if they attempt to address the complexity inherent in the specifications.
4. Unless the specification is implemented as a whole how are partially compliant systems to ‘understand’ what they are being sent? There are also versioning and maintenance issues that will emerge over time that are not addressed as best I can see. What is likely to happen as new versions of this specification are developed or new terminology is implemented. All of a sudden interoperation between old and new versions will become much more problematic. OpenEHR and its predecessor designs have devoted vast effort to addressing such matters. It is not clear the same is true with this work.
It seems clear that as of now, NEHTA would be far better off working with HL7 to spend whatever limited resources are available to assist with and influence the CCD and make sure it is suitable for Australia rather than continuing with what is an ill-considered, go it alone, and now past its time, local initiative. That way, more local skills in support of a global standard and its implementation would be developed in Australia. This in turn would enable Australia to maintain a place at the 'top table' of standards developers, and ensure that it can draw upon various sources of implementation capabilities and resources internationally.
Unless NEHTA is prepared to fund a range of genuine ‘proof of concept’ implementations of its specifications (to confirm their functionality, utility, viability and technical correctness) this is all going to be a waste of time and money. Even if NEHTA does decide to take that path the likelihood of eventual adoption by the Australian Health IT community would have to be rated as unlikely at best.
David.
The CIP focus was the clinical information content of shared EHRs for HealthConnect and the broader EHR agenda. The clinical information content relates to information that needs to be captured, stored and viewed to support the HealthConnect objective of improved delivery of health care and better quality of care.
Because the developmental focus of HealthConnect as a whole was based on the concept of event summaries, which were to make up the Shared EHR, the focus of the CIP was on the development of forms together with information content and definitions suitable for discharge summaries, referrals, result information and so on (the so called 'high priority' forms).
Efforts in this area continued when NEHTA took over responsibility for the CIP – since renamed a couple of times and, now seen as part of the Clinical Communications component of NEHTA's work. Recently (in December, 2006 and in February) we witnessed the release of two 500 page documents outlining the information structure and content of discharge summaries and specialist referrals.
What are we to make of these documents and how are they to be used?
_________________________________
In their introductory document the authors say:-
“NEHTA has released specifications to standardise the content of electronic referrals across Australia. This work also makes possible the development of improved decision support systems, which will be able to make use of the information in electronic versions of clinical documents (such as referrals) to assist healthcare practitioners make better decisions; and is an important step towards realising shared electronic health records.”
And they also say:-
“A Comprehensive Specification
It is important to understand the philosophy behind specifying referral content as comprehensively as appears in this specification. The specification needs to be comprehensive to capture as much information as required for the recipient to understand the patient's condition as fully as possible. However, it is quite clear that any one referral sent by a healthcare practitioner is unlikely to require the full suite of details embodied in the specification. In developing the referral specification, NEHTA has considered:
• - how prescriptive the referral template should be, in terms of:
o structure;
o comprehensiveness; and
o the terminology used;
• - the burden imposed on clinicians creating and receiving referrals; and
•- the burden on clinical information systems to capture, send and/or receive and process structured information.
Therefore, while the specification is prescriptive with respect to structure, information richness, and terminology, it is not prescriptive about which information should be sent under what circumstances. It is important to note that the specification was also designed for use within clinical information systems to reduce the burden of data entry for the referring healthcare provider, and the subsequent data interpretation, storage and manipulation by the referred-to provider.
The specification and included samples therefore indicate the richness of information that can be expressed, sent and ultimately imported into clinical information systems and shared electronic health records. The specification should not be interpreted as the set of information that must be sent, irrespective of the condition of the patient and the purpose of the referral.
Implementation Considerations
The establishment of clinical information systems that can interoperate regarding the transmission and computer interpretation of referrals (and other documents) is an evolutionary process. NEHTA anticipates that, in the first instance, the health community will review the GP and Specialist/Critical Care Referral Content Specification to become familiar with the content and intention of the specification, and plan to implement elements of the specification where possible within planned system upgrades.
Once the additional elements required by interoperable systems become available, the systems that have incorporated the specification will be able to quickly transition to interoperability. The key additional elements are outlined below.”
____________________________________
The document then goes on to cite SNOMED CT, HL7 V2.x and provider and patient identification.
I must say it takes some special form of arrogance to publish a set of specifications such as this without any reference to, or suggestion of, even the simplest of trial implementations, or ‘proof of concept and viability’, or any of the tools that are obviously required to make any sense or use of the material.
I am sure any system provider offered this specification would say: “Where in the world is something of this structure and complexity working and how much are you going to pay me to be your trial horse?”
Comments such as “NEHTA anticipates that, in the first instance, the health community will review the GP and Specialist/Critical Care Referral Content Specification to become familiar with the content and intention of the specification, and plan to implement elements of the specification where possible within planned system upgrades.” provide no assurance any of this is going anywhere in the foreseeable future – and leads to the inevitable question “Why should I spend anything on all this until it is clear that others are?”.
The other obvious problem is that NEHTA says that one does not need to do a comprehensive implementation of this specification but provides no roadmap to guide development and implementation priorities. Unless this is provided this looks like it’s pretty much an 'all or none' in terms of what is needed to begin developing system specifications. And the “all” is a huge project I would suggest, especially as the specification seems to only exist as an untested MS Word document at present!
The last major issue is that nowhere in the documentation is there any mention of how interoperation, if ever attempted, will be certified and provide a robust guarantee of accuracy, reliability, future maintenance and safety. If you offer a specification of this nature for use you take on the obligation to maintain and certify compliance with the specifications that you produce in perpetuity. Plans in this area simply do not exist as far as I can tell.
Slipping back to reality for a moment, the facts are these:
1. A national HealthConnect project, as originally envisaged, seems to have a very low probability of actually ever being implemented, even though NEHTA says it is still being worked on. The most obvious reason for this is that the costs of such a project (almost certainly billions of dollars) are not likely to easily be provided by Government – despite a compelling business case to make major investments in the e-Health space.
2. The world has moved on to more pragmatic international standards with experts and implementers on both sides of the Atlantic seeking simpler and more practical implementable approaches for deployment of interoperable systems. In the US the Continuity of Care Document (CCD) is emerging (deploying features of HL7, CDA R2 and ASTM CCR) as a credible standard and in the UK work has been undertaken to reduce the information content on the NHS Spine down to the minimum possible.
3. Without a guarantee of major investment in these specifications no vendor will invest to develop compliance. Attempts at mandating such specifications are likewise doomed as large vendors will simply say 'you set up the certification mechanisms so compliance can be verified and you pay us all our costs at time and material rates and we will develop what you require!” Meanwhile, small vendors will probably be put out of business if they attempt to address the complexity inherent in the specifications.
4. Unless the specification is implemented as a whole how are partially compliant systems to ‘understand’ what they are being sent? There are also versioning and maintenance issues that will emerge over time that are not addressed as best I can see. What is likely to happen as new versions of this specification are developed or new terminology is implemented. All of a sudden interoperation between old and new versions will become much more problematic. OpenEHR and its predecessor designs have devoted vast effort to addressing such matters. It is not clear the same is true with this work.
It seems clear that as of now, NEHTA would be far better off working with HL7 to spend whatever limited resources are available to assist with and influence the CCD and make sure it is suitable for Australia rather than continuing with what is an ill-considered, go it alone, and now past its time, local initiative. That way, more local skills in support of a global standard and its implementation would be developed in Australia. This in turn would enable Australia to maintain a place at the 'top table' of standards developers, and ensure that it can draw upon various sources of implementation capabilities and resources internationally.
Unless NEHTA is prepared to fund a range of genuine ‘proof of concept’ implementations of its specifications (to confirm their functionality, utility, viability and technical correctness) this is all going to be a waste of time and money. Even if NEHTA does decide to take that path the likelihood of eventual adoption by the Australian Health IT community would have to be rated as unlikely at best.
David.
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