MSIA: There and back again: an eHealth journey
With apologies to the Bard, this has been a summer of malcontent. In Sydney it feels that we have missed out on summer altogether due to the constant wet weather. No one can remember having a sunny day at all and yet you can feel the eHealth debate getting hotter and hotter as we get closer to the infamous July 1, 2012 deadline.
Let’s recap what we are actually going to get delivered — the ability to register for a personally controlled electronic health record (PCEHR). We will be reminded of that with greater frequency as we close in on that date, and as ambition is tempered by reality. There is a palpable sense that there is a push to deliver a working system so that the ambition and opportunity is not lost before political attention and interest is diverted elsewhere.
Rolling out a national system for the sharing of patient information with the necessary provisions from a technical, legal and social perspective is not something that happens quickly. It is also something that has never been done before anywhere in the world within the timeframe on offer here.
We have also been told it is possible to align 12 different projects with different vendors, stakeholders and ambitions into a common single thread of interoperability. In the likely event of there not being a nationally available PCEHR, there will be plenty of people saying ‘I told you so’, but what can we expect to see on the eHealth journey as we get to the finish line?
Browsing the Web, it is now possible to get an opinion or answer on anything. I have always been bemused by the bloggers and anonymous posters who have rampaged through the eHealth debate in Australia. Reputations are sullied, innuendo is everywhere and Dr Spin is not as qualified with the same rigour as the medical fraternity.
There is clearly emotion in eHealth. At one end of the spectrum we hear calls of an impending train wreck and at the other end we hear “trust us, we know what we are doing”. I always think what I am actually hearing is “trust us, we’re from the government — we’re here to help”. (Not to be confused of course with “trust me, I’m a doctor”.)
Let’s look at the train wreck analogy that is being used to describe the eHealth agenda in this country. If you have heard any speaker on eHealth, the train gauge analogy is trotted out time and time again. That is, if you allow the states to work independently they will come up with different systems that won’t allow you to move things across borders. There won’t be a common gauge and the track work won’t meet up.
This occurs because different specifications and standards would be employed, or more likely different interpretations of specifications and standards would result. Unfortunately, this is already part and parcel of healthcare, with variations in its delivery across geographies because of different interpretations of what is best practice, the best funding models and what is the art of clinical practice.
When you think about a train wreck, this will occur when a train on one rail gauge encounters rail that is of a different gauge or alignment. The train will jump off the track and it is likely carnage follows, or at the very least nothing else can move down that track until a clean-up operation has been undertaken. We have already seen the Wave 1 sites delayed when it was discovered that different groups were working on different specifications.
While there is considerable work being undertaken to get things back on track, it is fair to say in the current eHealth environment, we have specifications and use of standards out of sync.
Have we averted a train wreck by finding out that some standards are out of alignment and getting them lined up again? Or have we just delayed the wreck as there are other things that can cause it? Most failures in transport are due to wider system failures or issues that when lined up cause things to go horribly wrong. In eHealth, the evidence from the Senate review would suggest that there are other things out of alignment as well.
Based on the many submissions to the Senate committee, we seem to have:
- Interest groups out of alignment
- Funding models out of alignment
- Project plans out of alignment
- Foundation pieces out of alignment
- Governance out of alignment
That sure is a lot of things gone a bit wonky. And these are reasons for serious concern for anything wanting to travel down the eHealth track to a PCEHR any time soon. Whenever there is pressure to deliver on ambitious promises in eHealth, there is a risk of short cuts with standards that could end up causing longer term problems or take us to dead ends with no discernible improvement. We seem to have forgotten the lessons from the earlier Health Connect trials a decade ago. It appears that we have also lost the original intentions behind the Wave 1 and Wave 2 sites.
We are yet to learn the lessons from early initiatives and yet there are already cycles of redevelopment being asked of vendors taking part in the Wave 1 activities because of specifications changes. What happens when it goes live to field? Will there be more iterations of software coding?
It would be naïve to suggest no. Remember, an iteration of software code comes with extra burdens of quality assurance and testing. There will also be pressure on project teams and vendors to take short cuts or cut back on functionality to meet a deadline. We have already experienced a misalignment because of the pressure to deliver. We will be doing that again unless we reduce the task at hand to a manageable level, recalibrate the timelines and reset the expectations.
The functionality we leave on the side of the tracks may be important ones that give us the early wins for a longer term success and push us to the tipping point.
It is easy to predict that terminologies will most likely fall by the wayside and be left behind on the PCEHR track. Terminologies are a significant part of the eHealth rail gauge — a critical foundation piece for all exchanges of health-related data whether they have anything to do with a PCEHR or not. It would mean a lost opportunity to actually get terminologies working, to get these delivered into clinical systems.
Granted, it is not an easy thing to do and has been a work in progress for over a decade. In recent time considerable efforts have been made to get it back on track to a usable system, but the crucial step of actual deployment may be lost due to expediency.
It is easy to predict that data quality issues will not be addressed. There are the camps that say that GPs are required by RACGP Standards of Care to ensure that patients have an accurate and up to date health summary. This would mean that it is not an additional workload to provide such summaries. However, don’t think that consenting and change processes will not place a burden and additional workloads on GPs and other healthcare workers. We also have to be mindful that health summaries for a GP’s practice are not always the same health summary you would want to have for a PCEHR.
It is also possible that final legislation supporting the PCEHR may not be passed on time. While the initial bill has passed through the lower house, the opposition has reserved its right to amend it following the Senate committee review. Will we trust that the final legislation will deliver the necessary amendments from the submission and review processes? Will it be too late to test the models that the new legislation will support and the rules and regulations around the legislation?
What will be the new models for eHealth if the models proposed fail? It is most likely to be a regression to the pre-PCEHR-ambition status quo. The enthusiasm may be lost for improvements unless there are sustainable benefits that are demonstrated from the Wave 1 and Wave 2 sites for the foundation pieces.
The positioning of the PCEHR as equivalent to landing a man on the moon is a nice ideal but what we saw out of that ambition was significant improvements in technologies and approaches to computers, engineering and science that are now used whether you want to go to the moon or not. These have sustainable uses beyond the moon landing program and stimulated innovation.
In contrast, the current approach to the PCEHR has no alignment with the business cases that will attract all vendor participation and there are no sustainable business models for the ongoing participation of vendors to operate in an innovative and competitive environment. It seems also that the tipping point argument we were told would diffuse the new technology across the landscape seems to have fallen by the wayside. Now nothing happens unless the public chequebook is pulled out.
We have to be passionate that the foundation pieces of Healthcare Identifiers for patients, providers and healthcare organisations, along with secure message delivery (secure message delivery (SMD)), authentication (National Authentication Service for Health (NASH)) and terminologies (Australian Medicines Terminology (AMT)s and SNOMED CT) are not lost due to any failure or pause for consideration of the PCEHR. They have to be the real focus of the remaining time.
Money will be found to help get political will over the line so it can be seen to have delivered the promise of “registration”, but let’s make sure that we are using that money to leave a lasting legacy through the foundation pieces, so that no matter what happens, there are pieces to pick up if a train wreck occurs. Otherwise we are back where we started when we first went on this eHealth journey.
About the author
Dr Geoffrey Sayer
BSc(Psychol), MCH, PhD
Immediate past president, MSIA
As well as being immediate past president of the MSIA, Geoffrey is head of operations, HealthLink. He has spent the past 20 years working as an epidemiologist. For the past 10 years Geoffrey has occupied senior management positions in medical software companies.
Posted in Australian eHealth