MSIA: Taking shortcuts will get you lost
I spend a lot of time in Auckland. Auckland is a wonderful and beautiful city. I like to think Auckland is well known to me. I know Auckland CBD better than the locals. I know how to get to where I want to go. But because I know Auckland, it doesn’t mean I know the surrounding suburbs of Auckland, the surrounding regions of Auckland, nor the rest of New Zealand.
For all the city’s charm, I wanted to explore the Northland region to the north of Auckland on the North Island. I clearly had my heart set on going as far ‘north’ as possible. The first objective was to get out of Auckland.
Having set out from the southern suburbs, I wanted to avoid the traffic that I knew would be banked up to cross the Auckland Harbour Bridge. I wasn’t the only one wanting to go ‘north’ — it was a long weekend. I had looked at a less than detailed map that only covered the main roads in Auckland as I climbed into my rented Subaru Outback. I decided to take a road that skipped around the city’s western rim. It would ultimately end in the general direction of ‘north’. My destination was ‘north’ so as long as I was going ‘north’ I would eventually arrive at my destination, despite the ‘non-north’ pathways I would travel. It would be quicker to travel the ‘unknown’ route compared to the ‘known’ route. That is what a short cut is all about — avoiding a longer but ‘known’ way.
There are many pathways to a destination. It wouldn’t matter which one I took. I believed the pathway would just open up before me and there would be signs reassuring me that I was going the right way. I could reassess my direction as I was going along — as long as I was moving ‘north’ it would be all good. My intention was well meaning and my desire was there. These qualities would cover any shortfalls I may have done in preparation, homework or consideration of the details that it actually takes to go from a ‘known’ place to an ‘unknown’ place.
Not surprisingly, 50 minutes later I found myself at a dead end with a front row view of Auckland Harbour, bridges off in the distance...and still in Auckland.
In the e-health world, we want to move away from where we are to what we believe will be a better place, and indeed a place that we haven’t been to before: the Personally Controlled Electronic Health Record (PCEHR). While slightly longer than a long weekend, there is limited time (July 1, 2012) to connect a considerable number of pieces together to achieve the deadline. We of course have to be careful that we don’t break the pieces in doing so, or we won’t be able to make them fit.
Careful planning and detailed maps will give you the best chance of getting you where you want to go. The beauty of careful planning and detailed maps is you can share these resources with others. Planning and objective setting can also temper overzealous ambition, while still delivering tangible benefits from the journey. Remember the journey itself can bring delights and benefits.”
Unforeseen things will always happen, even on a well-mapped journey. During my weekend in the Northland region, the effects of a cyclone flooded many areas and landslides were common, resulting in changed road conditions or total closures. It was necessary to back track, take stock and change the immediate plan but not the long term goal of reaching the Bay of Islands.
There are considerable pressures on many people to deliver the promise of a PCEHR. The work being undertaken by the Wave 1 sites (GP Access, GPpartners and Melbourne East General Practice Network) and the Wave 2 of the PCEHR project, as the names imply, are building up momentum. It is important that these waves don’t come crashing down on the unsuspecting clinicians and healthcare users if not carefully managed. The pressure to deliver on ambitious promises will result in short cuts around the implementation of standards that could end up causing longer term problems or take us to dead ends.
The point of technical standards is to ensure quality, consistency and interoperability. It is important that we look at the standards work that has been done previously. At times the market moves faster than the standards setting process. There are also lessons to be learnt from why the previous standards haven’t been implemented consistently. We need to make sure we don’t just develop new standards in an attempt to overcome the perceived implementation problems of previous ones. Many problems have occurred in the past from the lack of harmonisation and testing of compliance with the standards, not because of the standards themselves.
If I have a criticism of New Zealand it’s that they don’t have as many road signs as Australia in rural and remote areas. What is considered a major road on a map is not a major road in my Australian experience. You therefore need to make sure you speak to the people who know the roads and pathways — those who have travelled the area before. It is rewarding talking to the locals as you learn things you haven’t even considered or you can discover things that are not on the map. You find real short cuts from the people who know.
There has been an ever increasing recognition for the role for software vendors in delivering the building blocks that will underpin the PCEHR. Vendors are an experienced and valuable asset to provide guidance in what is possible and how long things actually take. However, software vendors are unfairly cast as putting money before patient safety and as road blocks to progress. It is fair to say the software vendor community has given more than they have actually received from the funding directed to e-health in the last five years. Recently a vendor emailed the MSIA with a simple analysis they had undertaken that showed that the vendor community had possibly spent more money on assisting in the development of the building blocks and engaging in the bidding process for Wave 1 than what has been reported will be available to those vendors who are in negotiations to be on the GP Vendor Panel.
Bidding takes time and money. For Wave 2 ($55 million) there have been reports of over 90 applications from consortia of like minded software vendors and healthcare organisations. This shows the considerable interest in the PCEHR program but we need to be mindful that there is only limited funding relative to what is being attempted. It is speculated that there will be 10-15 successful bids which, if correct, will leave 80+ bids unfulfilled. Now while we all want value for money and are keen to show that the PCEHR can deliver tangible benefits, how do we harness the enthusiasm that is on display? Were the bids that will ultimately miss out unable to demonstrate an ability to deliver tangible benefits? Were the pathways they were mapping out taking us to places where we don’t want to go?
As we learn from the lessons of these early initiatives there will be cycles of redevelopment. While there is a belief that it provides an advantage to those software vendors participating early, any iteration of software code comes with extra burdens of quality assurance and testing. Testing processes under the Conformance, Compliance and Accreditation (CCA) program are also evolving. Companies who get involved earlier will most likely be required to repeat cycles of CCA.
There will be pressure on software vendors participating in the PCEHR program to take short cuts, while many non-participating companies will wait until the dust has settled. Furthermore, unless there is alignment of the business cases that will attract all vendor participation and sustainable business models, then the participation by vendors will be further reduced over time.
Many of us have taken short cuts because we know where we want go, but haven’t bothered to consider the steps it actually takes to get us there. A high level view is not enough. A desire is not enough. It is a form of risk taking when we take short cuts — we are not sure it will work but we feel it is better than the longer way. The problem we create for ourselves is that we are trying to achieve too much at once in too short a time. A long journey is best broken up into smaller journeys. Each one brings their own benefits — IHIs, SMD, terminologies and patient summaries. With the addition of other journeys we will have the ability to have PCEHRs for those who want one to assist in their journey through the healthcare system.
For my own road trip the benefits were new friendships formed; drinking with the locals at the Boar and Marlin in Oponini; counting stars and satellites as they appeared on a clear night on Cable Beach; and the view across the Bay of Islands from a hilltop vantage point on horseback.
Dr Geoffrey Sayer
BSc(Psychol), MCH, PhD
Posted in Australian eHealth