Where to next for NEHTA?
Very late December, 2007 the National E-Health Transition Authority (NEHTA) released a report developed by the Boston Consulting Group (BCG) reviewing NEHTAs performance since establishment. A response to the BCG report, prepared by NEHTA, was released on the same day.
The BCG NEHTA Review had been finalised in October 2007 and the NEHTA response on December 6, 2007. If it was not for reasons of media management in immediate proximity to the Christmas holiday period, the reason for the delayed release of the two documents remains unclear. That there was a long congratulatory piece published in association with the documents release would lend some support to that view.
Delayed release aside, it is the purpose of this article to critically review each document in turn.
The BCG NEHTA Review
The review document is the outcome of a consultative process (with a call for public submissions) that ran from July to late October 2007. The review involved interviews with over sixty stakeholders and consideration of some nineteen written submissions.
The major findings of the review were:
- NEHTA has raised the profile of e-Health in Australia.
- NEHTA has largely focused its efforts in the right areas to facilitate the emergence of an appropriate e-Health infrastructure in Australia.
- NEHTAs initial work plan was overly ambitious why NEHTA lacked the insight to recognise that is not explained but a revised, less ambitious plan is now only a few months behind its reframed target dates.
- NEHTA has put in place recommendations for terminology and secure messaging standards, but is yet to have reference implementations available. Additionally there is no certification process in place to assess interoperability.
- NEHTA has been unable to recruit an adequately skilled workforce to deliver on many of its plans. While a lot of documentation has been developed, the implementation of much of this documentation is yet to be achieved meaning it is unclear how well some of the major projects will be delivered.
- The delay in staff recruitment has meant many initiatives are very substantially underspent.
- NEHTA has dealt with virtually all stakeholders, other than its jurisdictional masters, with a lack of transparency and virtually no effective communication leading to very considerable annoyance and frustration on the part of many stakeholders.
- While NEHTA has delivered much documentation, actual proof on concept implementations are yet to happen.
- As far as Shared Electronic Health Records (EHR) are concerned, NEHTA wont be delivering in the 2009 timeframe and so should focus on building support for the concept and ensuring issues such as privacy are properly addressed. The BCG report says NEHTA has done a lot of high-quality work in this area but has not let anyone external to the organisation assess it so there is really no agreed status of all this.
It should be noted that the BCG report suggests that by mid 2009 there is a good chance terminology, secure messaging, supply chain improvements and identifiers will be in place but that the Shared EHR is unlikely to make much progress.
The essential recommendations of the review were:
- Start communicating sensibly and openly with stakeholders. Move from the theoretical to more practically focused proof of concept implementations and re-organise around project delivery.
- Fix staff shortages possibly by recruiting overseas or outsourcing.
- Put in place accreditation and implementation / interoperation functions.
- Create a much more representative Board to guide the organisation and build stakeholder trust.
In summary what the report says is that NEHTA has not recognised Lesson 101 of working in the health sector i.e. you must communicate, listen and engage and have thus essentially fallen at the first hurdle. Unless this is rapidly changed it is likely success will elude them in the long term is the very clear subtext of the BCG Report.
In response to the BCG report, NEHTA developed a 10 page document titled Action Plan for Adoption Success. In this document, NEHTA responded to each of the formal recommendations and agreed to each of them however I am still wondering what the title of the document actually means it is hardly an action plan and there is much more at stake than adoption.
Recommendation 1: Create a more outwardly-focused culture.
NEHTA says it recognises the need for this and has developed a plan to achieve it.
Recommendation 2: Reorient the workplan to deliver tried and tested outputs through practical domains.
In an important shift, NEHTA now says it will work with partner organisations to make deliverables that actually meet a need e.g. pathology messaging, referrals and e-prescription while continuing to deliver identification, authentication and terminologies.
Recommendation 3: Raise the level of proactive engagement through clinical and technical leads.
NEHTA plans to recognise the importance of the various clinical groups. Unfortunately it did not list nurses, allied health or specialists as targets but we can wait and hope.
In a worrying example of non-openness, NEHTA reveals it has finalised a submission for the Council of Australian Governments for a Personal e-Health Record (PHR) and the first the public will really know anything about it is when it is approved. To quote:
NEHTA will increase its engagement with healthcare consumer audiences. The focus of this program is on raising awareness of the proposed personal e-health record, and will establish a basis for a significant increase in engagement once the business case for the personal e-health record is approved.
I must note it is by no means clear if the proposed Personal e-Health Record is the same thing as the Shared EHR of the recent past. If ever there was a candidate for full and open stakeholder review and discussion, this is it!
Recommendation 4: Accelerate resourcing through outsourcing, offshore recruiting and more creative contractual arrangements.
NEHTA admits there is a problem but seems hesitant to go overseas. It does however seem keen to outsource some key operations.
Recommendation 5: Reshape the organisation structure to address revised priorities.
This response actually reveals some interesting elements. First there are now three (not two) National Infrastructure Programs:
- Unique Healthcare Identifiers Services
- The National Authentication Service for Health
- Clinical Terminologies
As far as I am aware, this was the first mention of an authentication service. It was apparently approved in October 2007 by the NEHTA board and it seems to be intended to replace in a year or three HESA, Medicare and other private authenticators.
Second, we discover there is to be a NEHTA Conformance, Compliance and Accreditation program whose scope is yet to be fully revealed.
Third, we discover very belatedly that NEHTA will also examine requirements for clinical registries, GP desktop systems, e-consulting, and decision support techniques and tools to determine the scope of any future involvement by NEHTA. Frankly, if NEHTA is not involved deeply in each of these domains, the organisation is a waste of time in my view!
Recommendation 6: Add a number of independent directors to the NEHTA board to be broader advocates of e-health, and to counter stakeholder perceptions of conflict of interest.
While it is great the recommendation has been accepted (if not yet actioned at the time of writing), it would have been good to see some admission that the present board structure was unsatisfactory and worked very poorly. NEHTA have clearly ignored primary care and the private sector, and it is excellent the BCG has pointed this out.
The Need For A Plan
The main question is what is missing here. Given all the apparent agreement between the reviewer and reviewed, a number of major things concern me about all this.
My first major issue is that the last paragraph of the executive summary, identifying the need for a national Health IT Strategy, has simply been ignored by the NEHTA Board.
In parallel, planning for the next phase of eHealth coordination and implementation needs to commence now or momentum could be lost. An eHealth strategy and eHealth policies need to be developed. Further analysis and debate by NEHTA and its members on the future vision for eHealth and the role of a central agency (as described above) is needed now to generate a plan by mid 2008. Regardless of the funding scenario and any future role of NEHTA II, we believe that the transition NEHTA is tasked to support has at least another five to ten years to run.
I welcome all the recommendations, cited above, as far as they go - but feel they do not point to where the real work is needed - i.e. a National e-Health Strategy.
This analysis needs to be in-depth and fundamentally assess where e-Health is up to now, what has worked and what has not and then design a practical and pragmatic route to an e-Health enabled future for the Health Sector.
My second major concern is that while it is clear there have been a very large number of issues with the way NEHTA has operated - there is no apparent accountability for the mis-steps being accepted by the Board and Staff of NEHTA.
That said, the BCG reports findings seem to me to accurately reflect the view of external stakeholders (Health IT experts, Health Providers and IT experts) but the impact is diluted by continual use throughout the report of the views of the NEHTA staff on the quality of the job they are doing. The staff and Board are hardly likely to be objective regarding their own performance!
It is clear from the BCG report that NEHTA has received a fail from its customers, while the staff are so disconnected from reality they cannot even grasp why they are seen as having done such an indifferent job.
My third major concern is that we now seem to have NEHTA recommending a business case for a National Shared EHR (or Personal e-Health Record or whatever) to the Council of Australian Government and the public has had no apparent input other than via a discredited NEHTA Board and a few bureaucrats. This is hardly the new open, engaging and consultative NEHTA! This is frankly unacceptable in my view.
My fourth concern is that with this review completed, it is not clear that there will be any assessment of NEHTAs success in getting back on the rails. I, for one, think a reassessment in 12 to 18 months is vital.
My fifth major concern is that to date, there is no evidence that NEHTA (or the BCG) really understands that its client is the entire Health Sector and that its efforts need to be shaped in a way that addresses the needs of all the sectors components and treats the health sector as an integrated whole.
In summary, the BCG report addresses some of the operational, cultural and engagement failures of NEHTA, while failing to firmly recommend the development of a national e-Health plan to achieve value from NEHTAs work. Without this, NEHTA will remain an unguided missile operating without strategic context and at risk of continuing to underperform.
For the BCG to let NEHTA escape from this review without a clear articulation of the need for a National E-Health Plan and a strong recommendation for the work to be done is really very poor indeed.
Hewett J. Healing Australia via broadband. Available at http://www.australianit.news.com.au/story/0,24897,22935859-24169,00.html [Accessed on 7/2/2008].
Posted in Australian eHealth