Coming year a 'big complicated gig' for DoH's Paul Madden
Next month, the federal Department of Health is set to announce a special task force that will begin to get the ball rolling on a fundamental revamp of the PCEHR after more than 18 months of uncertainty.
This will involve designing the organisational structure for the proposed new Australian Commission for eHealth (ACeH), which will take on operational control of the PCEHR from the department as well as some of the functions of the National E-Health Transition Authority (NEHTA), which is set to close after a decade in existence.
Rules for the operation of and the governance structure for the new commission are due by the end of the year, and a board and management should be announced early in the new year, all set for a new start to eHealth in Australia from June 30, 2016.
In the meantime, discussions have begun with the states and territories to decide on trial sites for testing an opt-out model for the PCEHR, which are due to be announced in September, and what some would consider the dull work of rewriting a number of pieces of legislation – including the PCEHR Act, which will see the name of the system changed to My Health Record – is due by August, following a public consultation period currently underway.
Moves to increase the usability of the PCEHR are also planned, with a firm emphasis on the user interface and making the system more mobile-compatible, and a new set of incentives aimed at getting GPs to use the system meaningfully are also on the cards for some time next year.
All of this adds up to a “big complicated gig” for the department's special adviser for strategic health systems and information, Paul Madden, who has the responsibility of overseeing the revamp.
His team at the department was recently bolstered by the appointment of former departmental CIO Bettina Konti to the role of first assistant secretary for eHealth, formerly held by Linda Powell, with Ms Konti's previous position now filled by former Immigration Department CIO Matt Yannopolous.
Mr Madden is also acting as the public face for the department's eHealth policy, currently chairing a series of information briefings on the proposed changes to the legislative framework for the PCEHR and the Healthcare Identifiers (HI) Service.
He is also in charge of driving policy development for the short- and medium-term improvements to the system that might actually get clinicians using it, as well as overseeing changes to the incentives program that will take the next step towards meaningful use.
This flurry of activity is in stark contrast to the last 18 months or so, as the sector awaited the release of the Royle review into the PCEHR, commissioned and delivered to former health minister Peter Dutton at the end of 2013 and released publicly just after the May 2014 budget. That budget saw just one more year of funding for the operation of the system, adding to the sense of uncertainty about its future.
However, following the commitment of $485 million over three years to supporting the operation of the PCEHR, the establishment of the opt-out trials and to setting up the new eHealth commission, a line seems to have been drawn under that uncertainty.
Mr Madden agrees that ongoing uncertainty had software vendors and healthcare providers alike questioning how much they should invest in the system. The one-year extension in 2014 did allowNEHTA to begin its clinical usability program (CUP), which is making what seems like very small inroads into the deep problem of lack of usability, but for Mr Madden, the huge commitment in this year's budget is the key.
“The notion that we now have three years of operational funding and some intentions to bring about even greater levels of usability will start to push it along again,” he said.
According to Mr Madden, the new eHealth commission will be created under the rules laid out by the Public Governance, Public Accountability Act. The department expects the operational regulations for the agency to be ready in late December, with the process of filling roles on the board, the various committees and key positions in the organisation occurring sometime in early 2016.
“We’re creating an implementation task force, which we expect to have running from July, which will actually do the organisational design for the new statutory authority,” he said. “They will work out what its function should be, which will be the key functions that should move from the Department of Health, the functions that move from NEHTA and the functions that might move from Human Services, if there is anything that moves out of Human Services.
“[It will also] mastermind the organisational arrangements, all of the accountabilities and work through the process of a transition plan to move the functions and relevant staff where that is appropriate and the recruitment to fill additional jobs if that’s appropriate too.”
The commission will also be overseen by an independent assurer, which Mr Madden expects to be an organisation situated at arm's length from the commission that can report impartially to the Minister for Health. A key principle of large program management, the independent assurer will be used to provide advice on whether what people are being told about the relative success of the program is in fact real and true.
“It is someone who is not entrenched in the daily routine and activity of the program,” he said. “It is someone who is connected to the stakeholder groups, such that if the healthcare provider community is saying this really isn't working, [the assurer can tell us] we’ve still got some work to do, as opposed to glowing reports that say the project is on time.”
Along with governance surrounding the whole program, Mr Madden believes the key to its success over the next few years is getting usability right. By usability he not only means the actual user interface for both consumers and providers and the consolidated views of clinical information that are conspicuously lacking, but the system's compatibility with mobile devices and its ability to be re-architected to take in new interoperability developments such as the FHIR standard.
NEHTA has so far been in charge of the clinical usability program, which has seen a first round of minor changes implemented in general practice software systems, but many software vendors have been dismissive at the least or scathing at the most about this program in private conversations with Pulse+IT.
“The CUP program brings together a bunch of clinicians and software vendors and some people from government to work through what are the key issues from the usability perspective and this is largely through third-party products, so the GP desktop,” Mr Madden said.
“They have done plans for resolving usability issues and bringing about higher degrees of usability. They've had CUP release one, which was a set of specifications. Release one of CUP has been implemented by all of the GP desktop vendors, except for one, which is due in late June, or early July this year.
“NEHTA has been working with vendors on plans to progress release two and the specifications of that clinical usability group as well. I expect that by the end of the year we'll have some of those as well.”
While CUP moves slowly along, another potential change is to the view of the system that clinicians have when opening a patient's record. What many want and have long asked for are summary views of a patient's problem list, an up-to-date medications list and any recent pathology results without having to wade through lots of different documents.
This is definitely on the cards, Mr Madden said, although he did defend the system's capabilities considering its underlying infrastructure, which is based on the clinical document architecture (CDA) standard that was leading edge at the time the system was designed.
“We’ve had some feedback about the clinical content and the ability to provide summary views of some of the clinical information in there,” Mr Madden said. “For good reason it was created as a clinical document system ... but most of those clinical documents do in fact have some clinical content, some of which is based on standards at an atomic level.
“What we are looking to explore is how we can provide views of that clinical data as a summary of things that exist in the clinical documents as opposed to asking someone to open each one of them.”
Mr Madden said there are clinicians who are happy with a clinical document system and are using it quite effectively, but he accepts that the department and the new commission will need to work on some of these issues. The key one, which was highlighted in the Royle review, is the current medications view, he said.
“[Medications information] can exist in a discharge summary, shared health summary, as a prescription document... [but] there’s no reason we can’t display it in context as a summary of information to save them opening those documents. If they wish they can go deeper.
“I think getting this to the stage where getting usability and views of that clinical information in a way that clinicians will actually want it, will help to drive demand from the user perspective.
“The system is what it is. It was designed a long time ago and it’s based and built on that architecture, but we need to pick out what’s the strategy from here for the longer term, and based on that, what are the things we will do immediately.”
A big part of improving usability is making the system more mobile-friendly, and Mr Madden sees that as an imperative. While there is a bespoke child eHealth record app available, he wants to see the PCEHR become more open to innovation from third parties, and is confident that the system can be re-architected to take into account new and emerging web standards.
“One of the early things we will be doing is to make our services mobile compatible so that people who develop apps will be able to develop and connect their apps to the system with confidence that it will actually work, and to be able to share the authentication of the sign-on components from one system to the next,” he said.
“We want to get that out there pretty early because then people can start to build views of that information but also homogenise it with other apps that people find very useful. Some of the wearable technologies for example – they can pull information out of the PCEHR and use it … and similarly there might be things that individuals might want to have included in their eHealth record as well.
“We want to build that bridge and make sure that we’re not creating bespoke apps. We just want to have the services and the data there and the rules about how to play.”
Work has already begun on how to use the emerging FHIR standard for interoperability with the PCEHR, but the very process of making the platform more mobile compatible will probably see the system working with FHIR a whole lot sooner as part of that mobile strategy, he said.
Work also needs to be done on the web browsers and platforms that support it. A major criticism is that the provider portal, which some clinicians prefer to use over their locally installed system, is only supported on some web browsers, many of which are not the most up to date version available. The system is not very iPad-friendly either.
“I think if we can conquer the problem of getting ourselves an industry standard connection for mobile compatibility, then I think we’ll start to open the doors to what else is available to what we are doing,” he said.
“For example, the authentication tokens for healthcare providers who might want to access an iPad application – their tokens are on a USB stick and there isn't a USB port in my iPad. So we need to do some work on that. I put all of those things together under the heading of usability.”
While the emphasis is definitely on getting usability up to scratch, there is scope to get additional functionality added to the system. Mr Madden concedes that progress in having pathology and diagnostic imaging reports uploaded have stalled somewhat, but believes this can now be kickstarted as the three-year funding envelope reinforces the view that the government is committed to the system.
It is also possible to kickstart some of the other functions that certain sectors of the industry, in particular aged care, have been crying out for, such as uploading advance care directives and looking at the development of an aged care transfer document.
At the moment, there is space in the PCEHR for pathology and DI reports to be uploaded to, but no actual connection between the pathology and DI providers themselves to begin uploading. Mr Madden said discussions with providers did begin to wane at the end of last year as uncertainty over the outcomes of the budget began to predominate, but now that certainty is there for the foreseeable future, the pathology and DI sectors will need to be re-engaged.
“Other things which we looked at in the past, things like advance care plans, we probably need to look at that again, because we have got the early designs for that. But the rest of it is going to be concentrated on getting the usability of what’s there and providing a better view of the clinical content.
“[For] things like an aged care transfer form for when you move a person from a residence to the hospital and back, we’ll explore some of those again just to see whether that is something we can do in the short term. If not, we need to get started on the design to make it a medium-term thing, but I guess our work is kind of cut out getting usability, plus the opt-out trials under way and transitioning all of this to a new organisation all at the same time.”
It has been the argument of many in the industry that had financial incentives gone straight to the software vendors and the end users themselves rather than middlemen like Medicare Locals, the system may have very well seen much higher rates of adoption.
Mr Madden does not necessarily agree that paying GPs $20 or $30 per shared health summary created would have been a good idea – “we probably may have got a larger number but I’d question the quality”, he said – but there is definite scope for a re-arrangement of the incentives program, particularly for GPs.
Submissions by medical groups such as the AMA and the RACGP that clinicians will use the system if it is useful to them and they get something out of it will also increase adoption if the vast majority of patients have a record.
On direct incentives, Mr Madden said it is probable that there will be a change from paying incentives to healthcare providers to connect to the system to the next level of actual use. This could take the form of requiring GPs, for example, to create a shared health summary for specific cohorts of patients. Many GPs also say they will contribute to the system when everyone else does.
“Three per cent of every GP’s patients are in the top end of the user category of health systems - they are the ones who deserve to have a shared health summary,” he said. “There’s the GPs, that's one issue, and I think getting the hospitals connected in a meaningful way, not only to provide discharge summaries but actually use it as information source, [is another]. And also to tap out to the private hospitals, the specialists and the allied [health practitioners] as well, because that's where the GPs have the traffic: between themselves and the other practitioners, not other GPs generally.
“There’s a whole set of things around the incentives, the training, the education, the notion that we’ll have a greater proportion of individuals who are registered in the system and a broader spectrum in what I call the need for a connected healthcare service, which is not just GP to GP; it’s GP to hospital, GP to specialist, GP to private hospital.”
Wider eHealth initiatives
One of the biggest criticisms from the eHealth community over the last few years has been that the intense concentration on and investment in the PCEHR has sucked all the life out of any wider eHealth innovations, in particular secure messaging between healthcare providers.
Mr Madden said the new eHealth commission would be responsible for both PCEHR and non-PCEHR initiatives, but that the department won't be waiting around for the agency to be established before focusing on improvements to things like secure messaging.
While NEHTA has been working on secure messaging, more emphasis is now being placed on it by the National Health CIOs Forum, which involves the CIOs from each state and territory health department. According to Mr Madden, the forum has been focusing on secure messaging in particular over the last few months.
“We, NEHTA and the department, actually met with all of the secure messaging vendors to discuss what’s the difference between what we have, which is not interoperable, and a workable solution which is actually being used,” he said.
“It’s true to say that most of the healthcare providers, if anything in the world they would love to be able to do, is to actually share electronic messages securely.”
Secure messaging is an area where the industry has insisted on developing the rules themselves, but while a secure message delivery (SMD) standard was developed five years ago, not much has happened since then, to the detriment of better health information sharing between providers.
The secure messaging vendors have tested the interoperability of their systems in the wild, but while there remains no financial or business case for commercial rivals to interoperate, little real progress has been noticed by the end users.
Mr Madden hopes this will soon begin to change. A technical conformance process is moving ahead, led by NEHTA, and the department has been working with NEHTA and the states and territories to get approaches for secure messaging interoperability that will hopefully satisfy the vendors and secure the wider uptake that everyone agrees is necessary.
Posted in Australian eHealth