No silver bullet for secure messaging
As we alluded to last week, the Australian Digital Health Agency has come back to the table this week with a bit of cash for clinical software vendors that weren't involved in the two secure messaging proof-of-concept trials it sponsored in Victoria to update their systems to incorporate new standards for interoperability.
While the money on offer was the headline, no one is under any illusion that this is the end of the road for what has been an intractable problem for well over a decade. In fact, pretty much everyone agrees it's just the start. Pulse+IT has written numerous screeds about the many challenges – technical, financial, cultural and practical – that face the healthcare industry in achieving a secure system of electronic communication so we won't repeat them again, but we will point you to an opinion piece we published yesterday by by Peter MacIsaac, who does a great job outlining some of the many challenges that remain, particularly around aspects such as message content and vocabulary adoption.
Over at his blog, Grahame Grieve mentions a few of them too, while lamenting some missed opportunities in the past. And in the comments on Dr MacIsaac's opinion piece, we hear of new obstacles for GPs from Oliver Frank, who has been resolute in insisting on electronic means from those he communicates with but is finding new and interesting barriers that pop up despite his best efforts.
While accepting there are numerous challenges, a question does need to be asked about whether these challenges are insurmountable. The technical ones are difficult enough, although the advent of FHIR is helping. Best Practice, for instance, now has a FHIR API in the wild that will let its GP users check not just their own provider directory for endpoints but the secure messaging vendor's and other vendors' as well. While seemingly a small step, this is actually a pretty big breakthrough.
There are the commercial pressures that secure messaging interoperability entails not just for competitor vendors but for clinical software users as well, particularly in allied health and specialist practice. The question then turns to whether there is a role for governments in mandating the use of secure messaging. Where secure messaging is successfully used on a service-wide scale, such as in the greater Auckland region in New Zealand, it is because the three DHBs there insist upon all incoming referrals only be sent electronically.
We asked the RACGP's Nathan Pinskier about the idea of mandating use this week, and he reminded us that it had already been recommended, way back in the National Health and Hospitals Reform Commission's final report in 2009. That report, which Stephen Duckett and Mukesh Haikerwal had a hand in writing, recommended that by 2012/13, if you as a healthcare provider are receiving public benefits you have to be able to send patient data using a secure communication system. (It also recommended that by 2012, every Australian should have an electronic health record that is controlled and owned by them, but let's not go there.)
Dr Pinskier says it could be the case that if public money is involved for a service, and there is a requirement that to receive that money you have to demonstrate you can communicate using a secure messaging capability, that would massively drive adoption.
But can you mandate that private pathology providers, for instance, change their systems, or can you only ask very nicely? In his opinion piece, Dr MacIsaac makes some excellent points about the difficulties in getting pathology providers to use standard formats and vocabularies for their messages. “No authority has been prepared to mandate or regulate that standard messages are used,” he says.
SDS Pathology and Sonic have come on board with the My Health Record initiative so it is possible, but it will be tough. That is why ADHA COO Bettina McMahon emphasises that there is still a long way to go towards national-scale interoperability. Ms McMahon told us this week that she doesn't want anyone to see the proof-of-concepts or the money on offer as a silver bullet. “One thing I've learnt through this whole process is that there aren't any silver bullets and that is why the progress has been at the pace it has,” she said.
“I don't want anyone to underestimate that yes we've got the standards there, yes we've demonstrated they do work and yes we'll be funding vendors to implement those, but we've still got a long way to go. We are hoping that over the next year we can get to national scale. We understand the sense of urgency on this but there's a lot that needs to happen.”
Dr Pinskier was of a similar mind. “The two big challenges that remain are the commercial case for both the vendors and for consumers of the product, and a second one is support for change and adoption,” he said. “It is where the effort now needs to be focused over the next couple of years.”
He is positive, however. “We will probably see within 12 to 24 months they will break the back of it,” he said. “There is still a commercial challenge for the vendors but we are on the journey.”
That brings us to our poll question for the week: Do you think the use of secure messaging services should be mandatory?
Last week, we asked: Will secure messaging interoperability be a reality in practice this year? Not a huge amount of optimism out there: 22.5 said yes, but 77.5 per cent said no.