MSIA: From eHealth blue sky to eHealth grass roots - will the twain ever meet?
This article first appeared in the 20 February 2012 edition of Pulse+IT Magazine.
Since the Federal Government’s announcement that all Australians will be able to sign up for a Personally Controlled Electronic Health Record (PCEHR) by 1st July 2012, you would think there would be frenetic activity going on at every level of the sector towards that common goal. But with blue-sky-thinking outpacing grass-roots-doing at a ratio of around four hundred and sixty seven million to one, the world of eHealth is in danger of spinning off its axis into the blue beyond.
If you think it is only doctors and other health professionals who are feeling bemused by all of this, think again. I have had eSomething in my job title literally or metaphorically for nearly fifteen years and I am more bemused today than ever by the passion the term can engender, the bureaucracies it can support, the debates it can foster, the conferences it can spawn, the acronym‑wielding academics it can breed and the consultants’ nests it can feather.
And let’s not forget the Committees it can spawn. Listing them all would chew up the word length of this article quick smart. The MSIA — because we are told we are the ones who have to make all of this eHealth stuff automagically happen — is participating at just about all of them. Though industry is at the forefront of the passion and the debate and the acronym creation, we all collectively seem to be more bemused than ever.
A melding of grass roots doing and blue sky thinking is urgently called for. Let me illustrate the extent of the disconnect with an example.
The manager of a busy day surgery had a presentation from a software vendor on the benefits of eClaims. An annual figure was mentioned which sounded pretty reasonable to me, but then, I was looking at this from a software industry perspective, with some knowledge of what kind of effort probably went into the product R&D, what salaries solution architects and healthcare integration specialists are commanding, let alone the hoops this company had to jump through to get the various Notices of Integration with Medicare to offer this particular product as an add-on to their main system. ‘Cheap’ was the word that sprang to my mind.
It’s a bit like catching a taxi. On first blush, $75 seems an outrageous amount to pay to cross a few suburbs. But when you consider fuel and car running costs and the cost of taxi licensing and the 45 minutes it took to get there and the likelihood that the driver will have to head back into town empty to pick up their next fare, you start to worry that the modest tip you gave him was woefully inadequate.
The day surgery manager’s perspective was very different — ‘expensive’ was the word that sprang to her mind. And that was in no way an unreasonable point of view. Like most taxi passengers, she was looking at the price at its face value relative to all her other costs.
When it came to it, we didn’t even get beyond adding up the postage before the vendor’s solution had paid for itself; and that was before any of the potential savings in staff time were included.
If grass roots providers have that amount of difficulty placing a value on software when the value is readily quantifiable, placing a value upon clinical computing, upon maintenance of clinical data quality and data transfer is even more challenging.
In the case of clinical information exchange, there is a quantifiable cost of what can go wrong when a referral slips through the cracks, when critical results get faxed to the wrong doctor, when current conditions are not known because of inadequate handover and a contraindicated medication is prescribed, when clinical content is transcribed incorrectly, when clarity is needed and a plethora of phone-calls ensue. So why is it not patently clear to most healthcare businesses that they are paying a high price for inefficiency in their clinical processes? Because it’s buried in day to day activity, because it’s made up of many small ticket items, because the staff have to be there anyway, that’s why. People become so adept at managing entrenched inefficiency as efficiently as possible, the issues become invisible.
Much more important than inefficiency, though less quantifiable, is the human cost. When the process of handover goes disastrously wrong, the ultimate price can be paid by the patient. Which is why the common view of “why fix a system that works most of the time?” does not come close to a ‘best practice’ approach — it’s not even in the ‘best endeavours’ neighbourhood.
The purchase of an IT system by a healthcare business with their eye on the bottom line (which is all of them in my experience) starts with a business case, a real one that means something to the business. A real one that stands up to the scrutiny of a business manager or a Board weighing up investment in eAnything against all the other investment priorities for their business.
Instead of some useful proformas for calculating a return on investment for eHealth solutions at the grass roots, we get the expected returns for the whole nation: impressive enough for a headline but not remotely meaningful to someone at the front line of care. And when some of the most quoted figures are also known to be downright rubbery, there is a widespread upgrade from bemusement to scepticism among the folk at the grass roots.
Assuming that healthcare businesses, large and small, will continue to invest in eHealth at their usual pace — which is to say no more quickly than you’d expect to see anyway in a gradually maturing market — getting them to align their eHealth priorities with the national agenda is the next challenging objective. Without this alignment, it is quite probable that Australian taxpayers will be signing up to a Personally Controlled Largely Empty Shell (PC-LES) in 2012. That is fine, so long as taxpayers know what to expect. It will certainly simplify the current debates about privacy and confidentiality and medicolegal risk. Still, we are all confident the content will follow at some stage … aren’t we? At the current rate of pace of investment by grass roots care providers, when exactly do we imagine that the content will come?
Not soon enough for some eHealth mafia. I recently heard that some GPs were demanding specialists adopt a certain secure messaging agent or they would cease to refer to them. Can this sort of market lever really be considered a force for good? Some blue sky people would just count up all the new electronic referrals and think that healthcare had improved but don’t consumers have a right to expect that the professional they are relying upon to act in their interests will give more weight to the specialist’s reputation as a specialist and less weight to what widget they have on their computer?
The next goal in alignment of grass roots and blue sky is tackling the renegade software industry. One way to get as many of us as possible on the same page is to make sure the page says what it ought — no more, no less. A spot poll at our recent MSIA forum tells us that more than half of the senior people in the medical software industry have been working in Health IT for more than ten years. These seasoned practitioners of Health IT are often the first port of call for reviewing any eHealth specifications that a company is considering implementing. These are the people with the domain knowledge of clinical practice and/or healthcare business practice who won’t hand something to their developer colleagues until they’ve got some handle on what is required themselves. Many of these people are still practising clinicians or former practising clinicians; many are hands on software developers themselves.
So the majority audience for eHealth implementation guides are time‑poor who have to manage a very finite set of resources carefully and who only want to be told what they don’t know already, not what they’ve known most of their working lives and certainly not reams of stuff they don’t need to know at all. Like our customers, we are looking for practical and succinct guidance that is tailored to the needs of experienced practitioners who have no interest in the theorising.
Another interesting result from our spot poll was that over half of the industry is made up of businesses of less than ten people. Some blue sky folks think that the grass roots Health IT industry is too fragmented, that as many of these small businesses as possible should get steamrollered when we move to the next notch of marketplace maturity. There is nothing more irritating to a small businessperson than to hear a tenured well superannuated person think that. You can only hope they can’t hear what you are thinking. This isn’t the fast moving consumer goods industry. Healthcare providers are not necessarily guaranteed lower price, higher quality IT product and greater choice from increased marketplace consolidation. There is one lesson we should have learned from the global financial crisis — business maturity has nothing to do with organisational size.
So this fragmented industry is being asked to adopt an increasing number of specifications rolling off the NEHTA presses. Interoperability with other systems is a cost of doing business for most of us, not the main event. This means you want to get through the process as efficiently and painlessly as possible and get back to your own product R&D. Furthermore, it is complex, time‑consuming and costly relative to most other development because at least two parties need to be co-ordinated and often more than two, so once an interface is operational, you don’t want to mess with it unless there is a genuine need. Exchanging one message format for another is not a genuine need. A genuine need is a new requirement not met by the current method or a general groundswell of adoption across the sector such that staying on the current path will result in having a less interoperable system. Even when there is a need, you also want to be sure that there is no loss of functionality in moving from something older and proven to something newer and less proven, that there has been governance over the safety and reusability of the specification, that the version in question will stay the flavour of the month for a lot longer than a month and that there is a map to migrate from whatever is operational at the moment.
A health informatics practitioner only has to read a couple of specifications tailored to beginners or worse, to academic informaticians, to cause them to disengage from the national eHealth agenda completely and let the PCHER ‘Wave sites’ sort it out. Unfortunately for the ‘Wave sites’, they are being engulfed by a veritable tsunami of not quite complete specifications. One wave site colleague told me recently that his team needed to read no less than 93 documents to implement what they needed for their project, most of them published in the fourth quarter of 2011. Another Wave site colleague told me that if he hadn’t had the hand-holding to navigate the specifications he had to implement by the people who wrote them, he couldn’t have implemented them — and this coming from one of the most experienced health informaticians in the country. Which begs the question: how is the rest of industry supposed to do this without hand-holding?
There is no shortage of experience among MSIA members in developing sustainable businesses around eHealth, but there is a shortage in understanding how currently sustainable solutions and businesses will fit in with the national agenda. And there is an absolute dearth of members who can justify adding a further 200% to a project budget to trawl through such an enormous number of specifications and pages to find out how closely their own domain knowledge and customer requirements aligns with the national approach.
The grass roots people in clinical care and clinical software provision are in dire need of practical assistance and clarity: clarity on exactly why they should invest in eHealth at all, much less the national eHealth agenda. And assuming the why is solved, how they can invest in the most efficient way, given finite resources, competing pressures and the need to run their own grass roots continuous improvement agendas.
You cannot allocate $467M to eHealth over a two year period, move nearly all of it between government agencies or to large consulting firms and start up companies and expect to answer the question in the minds of most healthcare businesses and eHealth businesses at the grass roots: why fix a system that works most of the time? The answer to that question is the key to building a sustainable ecosystem of interconnected independently sustainable solutions long after the political ribbon is cut in mid 2012 on the PC-LES.
I don’t suppose the majority of consumers will be too troubled by the slow start. When you don’t have time to go to the doctor, let’s face it — you’re not going to be generating too many clinical event summaries. The trouble is that the line between wellness and illness is as thin as the edge of a coin. It is when you cross that line or you have a loved one cross that line that you start to appreciate what the eHealth lost opportunity feels like. It feels like attempting a jigsaw puzzle containing large amounts of blue sky, but not enough colour and variety to gain the clear perspectives required to solve it.
About the author
Jenny O’Neill has been a member of the management committee of the MSIA since 2008 and has been on the national executive as Hon Secretary since 2009. During this time she has represented the MSIA on numerous working groups in addition to undertaking her duties as Director of eHealth company EpiSoft.
Posted in Australian eHealth