The Medical Software Industry Association (MSIA) is convening a MSIA Round Table Conference on Tuesday – 22nd May, 2007 in Sydney at the Stamford Plaza Sydney Airport Hotel. Tomorrow, if you are reading this on the day it is being posted!
According to the Pre-Meeting Publicity:
“This is a key opportunity for Federal and State Health agencies, clinicians, academics, standards bodies, and health information professionals to exchange views with the nation’s leading providers of clinical software and health communications systems solutions.
With the increase in government Health Information Management initiatives such as Health On-line, The Medical Software Industry Association (MSIA) has become increasingly active in representing the interests of all healthcare software providers and has negotiated a range of important changes.
This MSIA led Round Table Conference will reflect the MSIA's current standing on these relationships and develop strategies to move towards formalising these relationships with industry organisations and government groups. This is a major opportunity for various bodies to express their concerns and aspirations to a wide audience to create a better understanding of major issues affecting the health sector and the impact upon the industry.
Presentation and discussion forums will include:
1. Communicating with the Software Industry – what has worked?
- Commonwealth e-health Agencies and Initiative,
- PBS on-line,
- Pharmbiz,
- DoHA,
- MBF
- nehta Communication Strategies
2. Interoperability and Messaging – Why is it so Hard?
- What Standards should be used?
- Accreditation
- Making e-Communication more like the Telephone Network
3. nehta – what has been achieved?
- SNOMED CT – Update & Licensing
- Medications Terminology
- Building Blocks and Communication
4. E-Claiming
- HIC on-line – What next?
- Is x400 dead?
- Who is making money?
- The banks and e-Claiming
5. The Health IT ‘Action Agenda’
- What is it and what is the potential?
- What I need to know about it?
- How will it help me and my business?
- Current state of play and progress – DoHA presentation
6. The Way Forward and Conclusion”
This sounds like a very useful meeting and it seemed a good opportunity to prepare some thoughts on the question of NEHTA – what has been achieved and to try and form a view as to whether we are headed in the right direction. It is a pity that NEHTA – for their own reasons as I am informed – has chosen not to attend.
I think the answer to the question of what NEHTA has achieved is that "It is too early to tell yet” as the probably apocryphal story suggests was said by the great Chinese revolutionary Chou En-lai when asked for his for his evaluation of the French Revolution.
This said there are two things that can also be said. First , what NEHTA is attempting is no doubt a major complex challenge and second that so far, from the point of view of an external observer, they seem to be going about their brief very incompetently. From where I sit the risk of overall failure looks worryingly high.
What have they and are they doing wrong?
The key things I see as mistakes are:
1. The failure to develop an operational Strategic Plan, Business Case and Implementation Plan to facilitated the delivery of the outcomes sought by Health Ministers in August 2004 when NEHTA was authorized (Based on the Boston Consulting Group work of the same year).
2. The decision to corporatise the NEHTA entity which has removed NEHTA from effective public scrutiny and review and has disengaged the body from many of its public sector clients.
3. The ongoing lack of quality in many of the NEHTA documentary deliverables. Other than the document relating to the adoption of HL7 there have – in the last year – been a series of either useless or incomplete or excessively impractical documents produced with have added minimum value to the Australian E-Health domain. ( A secondary problem is the ‘ex cathedra’ approach to document release).
4. The continuing lack of transparency regarding NEHTA internal decision making with commercial-in-confidence and secrecy being made an art form quite unnecessarily. Given the public policy and standards role NEHTA is meant to play there should be totally open policy development processes and all strategic advice received by NEHTA should be made public for comment and feedback. Equally the NEHTA Board should publish relevant and adequately detailed minutes of the policy aspects of their meetings.
5. The failure to seek proper engagement with the Medical Software Industry.
6. The failure to ensure the boundaries between the roles of DoHA, the Australian Health Information Council, the States and Standards Australia’s IT-14 Committee were well defined and able to be understood so roles and responsibilities were clear.
7. The tokenistic way much of the stakeholder consultation has been undertaken and the almost Joh like “don’t you worry about that” style of management. The privacy consultations undertaken so far are examples of listening at its worst.
8. The obvious “tail wagging the dog” mode of operation seen in the way the NEHTA Executive and the NEHTA Board interact. Given the public sector backgrounds of the Board members if they actually understood what was at stake and enough of what was happening internally within NEHTA to manage it actively I am sure it would be a different, more open, more consultative and much more useful organisation.
9. The failure of the NEHTA Board and Management to recognise there are urgent issues which need to be addressed at both State and Commonwealth levels. The time frames NEHTA is working to are excessively relaxed – especially given the level of resourcing and staff available.
10. The sectional focus – on Public State Hospital Issues and Commonwealth Issues with minimal focus on either the private hospital or private practitioner needs. The lack of a holistic Health System Wide vision and approach is a key failing.
11. The delays that are now becoming obvious in a range of the work program components. The worst apparent examples are in the Benefits Realization , Shared EHR and Medicine Terminology areas.
To date the only successes I can see are the acquisition of the national license for SNOMED CT and the decision to adopt HL7 as a messaging and possibly EHR content Standard. Not much really for the $20+ million NEHTA has cost to date – excluding the money being spent on the UHI projects. Progress on the needed extensions to SNOMED CT before it is useful has been slow and seemingly badly managed if the delays in delivery are anything to go by.
The bottom line is that what NEHTA is trying to do is very badly needed, but the way they are going about it is deeply flawed in my view and the direction needs serious modification.
One can only hope the planned review will get them back on a sensible path.
David.
5 comments:
David - FWIW this was published in the trade magazine 'Hospital & Healthcare" Sep 2003.
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Katherine McGrath's hopes for the Electronic Health Record are very optimistic. She apparently said that Hunter Health is aiming to have it in place in five years.
One of the absolute requirements for a nation-wide EHR is a system for uniquely identifying individuals. It would probably take three years of constant debate, and a referendum, to get permission to examination the pros and cons of a centralised electronic database. Eventually, a substantial Bill will be needed to revive an equivalent of the Australia Card. Yet, dialogue between Canberra and the States has fallen on hard, ideological times of late, so there is little hope of rational discussion about the issue, between Ministers.
In the meantime, my GP continues to be frustrated by the inability, or unwillingness, of his local hospital to tell him in good time when one of his patients has had an emergency attendance at the A&E. This pathetic situation is emblematic of the widening divide between Federal and State "responsibilities". The constant tick-tacking between the Ministers may have some political point, but who is going to break the cycle and bring on some collaboration?
Can I suggest the Medical Software Industry approaches Department of Health & Ageing, to co-sponsor a major conference to discuss a national identification scheme? Then, with agreement on the basic issues, perhaps the Australian Law Reform Commission could be briefed to review the legislative requirements. The ALRC has done a superb job for genetic privacy, and many of the findings from that inquiry are relevant.
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Professor Katherine McGrath is now the deputy director-general of health system performance at NSW Health.
Sep 2003 is BN - Before NEHTA.
Therefore Professor Katherine McGrath's suggestion advocating - MSIA and DOHA co-sponsor a conference on a national identification scheme is no longer relevant.
‘IDENTIFIERS’ has been clearly designated as a NEHTA task and her jurisdiction (NSW Health) must toe that line.
I think Katherine McGrath's article is almost as fresh and relevant as the day it was written.
We need to have a broad ranging public debate about the risks and benefits of having a unique identifier for healthcare. The debate could also cover the benefits of alternative approaches.
The only thing I would change about the approach recommended in the article is to include discussion of the content of the national database in the debate.
I think it is time to stop thinking about centralised clinical data storage and instead to look at alternatives designed to support the organisational and administrative aspects of clinical healthcare.
I contend (admittedly with limited evidence) that it would be of significant benefit to clinicians to be able to quickly and conveniently answer the question "Who else has been or is involved in the care of this person and how do I contact them?"
The privacy issues relating to this kind of data store, while not insignificant, have proven in my experience to be easier to debate than those surrounding a fully centralised health data store.
Using a trusted organisation such as the ALRC to draft legislation seems like a good approach to me. Only then can various levels of government, healthcare providers (public and private) and vendors really commit to implementation. It is a shame that absolutely no progress has been made on this issue.
I believe the focus on clinical data is premature in the current circumstances and should be abandoned until we get some of the fundamentals right.
Maybe we should put some effort into evaluating some of the less glamorous efforts that are taking place around the country despite the lack of resources allocated to them?
Jon, I agree with much of what you say which is why it is so troubling to see the lack of understanding around the basics of the problem, and the continual emphasis on the big bang, big bucks, big projects, big egos approach.
Unique identifiers for healthcare are essential. NEHTA and the jurisdictions have also recognised the importance of this. We would both agree that recognising the need is the easy part. Architecting, developing and implementing a system of unique identifiers are somewhat harder. The money, it seems, has been made available to NEHTA. But NEHTA seems to be struggling with the politics and making heavy weather of the market's perceptions of its capabilities.
I, for one, am fairly sceptical of the need to employ more people in NEHTA to do the job. I may be wrong, maybe more people are needed. Maybe the task should be put out to tender. Maybe there are people working at the coalface today who have wrestled with this problem for a long time - but who have not been listened to so-far to-date. I recall seeing some comments from you along those lines in a blog not so long ago.
You, quite correctly have highlighted probably the most important step that needs to be taken before the architecture is tackled - “a broad ranging public debate about the risks and benefits of having a unique identifier for healthcare”, and most importantly a careful analysis of “alternative approaches”.
The concept of a national centralised electronic health record is very hard to justify from virtually every direction. As you infer a case can be made for approaching the problem in a way which is designed “to support the organisational and administrative aspects of clinical healthcare”. I would go further and suggest an approach encompassing geographic boundaries would not be inappropriate; be it State-based or even smaller involving Divisions of General Practice or somewhere in between.
The clinicians are important and I have no doubt they would welcome a facility which enabled them to quickly and conveniently answer some basic questions regarding their patients. However, I contend that the focus on clinicians, whilst valid, is missing the nub of the issue - the focus should be on the patient as the consumer of health services.
This means, that whatever thinking we choose to apply in addressing the multitude of problems at hand, the focus must always be pivoted around the patient. If this holds true we should be asking “What does the consumer want”?, “What will help the patient?”, “How will it help the patient?”. As one extends this thinking we arrive at the point of asking “How will this benefit the clinician?”, “How will it benefit Government?”, “How will it benefit the community?”.
Ian, I agree with most of what you say also, especially the bit about consumer focus. My only excuse is that, having been through a very lengthy consumer focused change management process in Victoria (the PCP Service Coordination process), and designed an IT system to support it (the Eastern Region Service Coordination System), I have convinced myself that there is no doubt that giving practitioners easy access to the information I suggested helps consumers because it stops practitioners asking them the same questions over and over. I understand that there is much more to it than that.
One point of difference is that I think local initiatives can only go so far. My experience with them is that you eventually run into boundary issues that cause big problems with coordination of care, especially if you focus on geographic boundaries. The one I have been involved with (Eastern Region Service Coordination System) now covers an entire DHS Region, involving four Divisions and three Health Services. Most of the problems arise for the two health services at the boundary of the region - they are having trouble using the system effectively because they need to use different systems (IT or otherwise) for the other regions that they are also engaged with. The same thing happens with GPs, but of course they are used to these problems and stopped complaining years ago.
What I *would* like to do though is greatly reduce the scope of the problem by narrowing our initial focus (as was done in the case of the Eastern Region Referral System.) I think we need the right combination of big and local. Big for some things (identity management for consumers, practitioners and services, and a list of encounters between them) and local for other things, such as records repositories. If we had the basics right at a State or National level, then geography would become less relevant, and information could follow the consumer around using Internet technology, and an EHR appropriate for the needs of each consumer would emerge naturally over time as more and more communication between providers, or between providers and consumers is managed electronically.
I would also suggest that we need to consider increasing the scope of the identity management for providers so that it encompasses all providers of health related services - not just registered medical or allied health practitioners.
Finally, I am frustrated at the lack of a comprehensive evaluation of the Eastern Region Service Coordination System that is not focussed on ensuring continuing funding (as all other evaluations of the system have been, and the evaluation currently underway is) but rather on how the idea has worked in practice, how the approach could be improved and what lessons can be learned that will assist us with the task at hand.
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