E-Health: turning plans into action
The method of the enterprising is to plan with audacity and execute with vigour
Christian Nevell Bovee (1820-1904)
Electronic communications and data management systems are widely adopted in almost all sectors of business and society except healthcare. While most baby boomers are happy to relate to friends and live in the real world with mobile phones, the Internet and email, Gen X and Y are hooking up in ways that we can barely imagine. The real world of healthcare still involves paper records, heavy reliance on verbal communication, memory, and information which is locked away and unable to be used for improving patient care or health system management. E-health is meant to make a difference, yet is somewhat stuck at the starting gates.
Despite the cries that we need a national e-health plan, in reality we have been drowning in plans, reviews and consultancies. Previous plans suffered from the following problems:
- A tendency to be narrowly focused within one of the many health silos;
- Planning can become an alternative to implementation;
- Plans should spread from goals to execution. Often an interlocking series of plans is required, not just one plan or strategy;
- High turnover of staff in the Government sector impacts on corporate memory;
- E-health is infrastructure and difficult to justify when the waiting lists of sick to be treated are long and there is a track record of failure to deliver in Health IT projects.
In April 2008, Deloitte Touche Tohmatsu were engaged on behalf of state and federal health departments to deliver a comprehensive e-health strategy in some 16 weeks. This work is in progress and readers may wish to contribute by making submissions when the opportunity arises.
This plan is the latest of a long string of planning efforts. Frustration at the lack of progress has lead several organisations such as the Health Informatics Society of Australia (HISA), the newly formed Coalition for E-health, and the Australian Healthcare and Hospitals Association (AHHA), to develop their own plans in the hope of influencing the policy agenda. Canada and Sweden have developed national e-health plans. With so much planning going on, how might a good plan be recognised?
Such a plan might:
- identify the core business objectives of the health system and its components and align these with e-health developments;
- focus on applications and function rather than technology;
- be truly inclusive of consumers, healthcare providers and the IT industry;
- address immediate problems, justifying the investment in infrastructure, with outcomes that have political appeal;
- be practical and lead to solutions which are implementable in stages with short time frames;
- cover the whole health sector; federal and states, hospital and community; public and private; individual and population health;
- start with current technology, yet have a development pathway;
- understand key consumer factors such as expectations of delivery, engagement and reasonable privacy and security standards, and the need to minimise change management challenges for users;
- support a viable market in solutions and applications;
- support verifiable interoperability between systems using Australian and international standards;
- learn from international and other industry experience.
The plan must provide a strategy that recognises and tackles the disconnected nature of our system, allowing e-health to link up different services for patients moving along their healthcare journey. This is nowhere seen better than in cancer care where patients are treated in many facilities, by many providers using the multidisciplinary care process, and where the nature of condition, the care and follow-up is complex.
The aphorism, if you cant measure it, you cant manage it prevails, yet the same thinking does not apply to the same extent in clinical care. What is measured are processes of care such as diagnoses made, bed days occupied, medications prescribed, and tests ordered most of this to support financial management and reporting. If we cant recognise and measure patient outcomes and good care processes, where is the incentive or business case to install e-health systems? It is a catch 22 situation.
At the risk of being considered a cynic, there is a certain level of comfort for all involved in healthcare (except the patient) in using the head in the sand approach. Practitioners can believe that they are doing their best and poor results are put down to external factors; the health service does not see aggregated reports which reflect on their inadequate systems of care; the political process is happy when a lack of such data keeps healthcare off the front pages. As a GP, I am reinforced in my belief that I know how to practice good medicine every time I remember to do a smear test or treat diabetes according to the best evidence. I am oblivious to the times I forget to do these things; without outcomes data and systems to prompt me in real time, how can the situation improve?
Plans must also be informed by a large dose of reality. Australia is not a country that accepts radical change or will adopt high risk strategies. Failure is not well tolerated and second chances are hard to come by. E-health systems will be rolled out gradually as the political will and resources permit, and do so at a different pace across the country and with different priorities. The market model will ensure that there are competing products, and in the long run, this is a good thing to spur improvement.
In this type of scenario, it is vital that a consistent architecture can link the various systems, both up, down, and across the traditional information silos. This goes further than just standards for messages (HL7), or terminology (SNOMED‑CT). Standards are necessary, but not sufficient in themselves to achieve interoperability. We are in a post-standards age that is starting to focus on the integration of the many standard components, privacy, business objectives and workflow to effectively join the different e-health applications into a workable clinical system. There is no reason why an Emergency Department system in a Victorian public hospital should query a patient identity server differently to one in a Queensland private hospital. Getting agreement about how to achieve this is critical, and once decided, the policy makers and users can move on to implementation.
Radiology led in interoperability a decade ago when it sponsored the development of a process called Integrating the Healthcare Enterprise (IHE). IHE has solved the integration of many systems within single services or departments, and is now tackling the problem of health record and document sharing and standards-based communication through an innovative approach known as Cross Enterprise Document Sharing (XDS). This is based on standard document centric technologies used to index and access information on the world wide web. As new issues emerge such as how to handle e-prescribing or e-referrals for radiology and pathology, the XDS model can be expanded to support this, providing one communication infrastructure rather than several.
IHE is both a governed process and creator of profiles to support implementation. It reduces the costs of interfaces, and supports patient care in a tangible way through the delivery of information from the many different health records at the time it is needed. IHE responds to, and solves industry problems, accepting user input into the problem definition and requirements phase. Vendor experts then define the interoperability profile using underlying standards. Systems are conformance checked and available for public demonstration in a little over a year from the start of the process. Over time, an impressive array of profiles and infrastructure have developed and been adopted in international standards and systems development.
At some, stage e-health has to move beyond planning and make decisions about a direction, even if we are not sure of the destination. Making decisions means accepting some uncertainty and taking some risks, which can be mitigated by working in collaboration with users, vendors and the international e-health community. Perhaps a more open, systems based, engaging, and international approach such as that offered by IHE could be that direction. It is vital that IHE is recognised as a way of supporting the implementation of systems based on existing standards and industry collaboration, and not an alternative. It is the next step and rather than asking, is IHE the one?, we could just make it happen.
Dr Peter MacIsaac
Posted in Australian eHealth