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Volume 2012 Number 1

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Health Informatics - The State of the Nation

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Pat Gallagher articles by this author...

Patrick Gallagher is well known in Information Technology circles. He has a vital interest in e-health, particularly in the area of shared records and e-prescriptions, also supply chain issues. He maintains a very clear vision of what ought to be, but he and many others in the IT field, are frustrated by government agencies full of experts who have never actually worked in a professional health setting. So we see ongoing wastage, astronomical spends and "top down" systems that are never going to work. Patrick needs to be listened to.

Editor's Note: Pat Gallagher departs from his usual format this month and has sent a recent paper provided to an industry group with links to Standards Australia.
Any health professional who has an interest in e.health will find the paper interesting, as well as disturbing, and you might ask why the issues seem to be so hard to resolve. 

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Health Informatics Sector - overview

1 Preamble: the most common description used today regarding any matter pertaining to change in the health sector is the word ‘complex’. While this is not strictly true, a constant chattering of the mantra takes on a life of its own encouraging a belief in relationship complexity that inhibits rational problem solving. There are three ‘P’ that reflect complexity – people, policy and practice. To take a very simplistic comparison let us consider that a hospital is a hotel in basic functionality. In a hospital the tribal attitudes and administrative processes are all disparate; in a hotel all systems work seamlessly to one set of goals. Helps explain a raft of otherwise bewildering claims of complexity that merely hides an unwillingness to face the fact that health costs will become unsustainable without efficiency evolutions that are widespread in all other sectors of the national economy.

2 Standards and E-scripts: prescriptions touch more Australians, more often, than other clinical application. Prescriptions represents, other than procurement and wages, the highest taxpayer funded component of the annual health spend. Yet the conversion from paper to pixels has been slow to implement

2.1 NeHTA - have carriage of the terms of reference and use specifications that were only made public in late 2009 in an ETP document;

2.2 Standards - IT-014-6-4 has the responsibility to publish the messaging standards (HL7 2.5) to replace an expired version of a standard. This work is well behind time and suffers from a lack of resources (standards work is carried out by time poor volunteers). Not before time IT-014-6-4 has opened up a formal and collaborative relationship with the NeHTA ETP cohort and is seeking access to funds to outsource much of the detailed work load. Timeframes – with funded expert assistance a messaging standard could be published by Q4 2010. With only volunteer effort it could blow out to late 2011 or even 2012. A scandalous situation

2.3 Hubs: fortunately, and I mean fortunately two industry players, tired of waiting for leadership from Canberra, launched ETP hubs in mid-2009. Messy as this is, at least now the policy level has stopped navel gazing and understand they have to ‘catch up’

2.4 Tree and branch: In e-health terms prescriptions can be seen as a standards making tree trunk that can foster branch links for other clinical services and applications. That is: a) messaging rules need to be common and interoperable (scripts and pathology reports); b) patient details and medical data content needs to be aligned for all clinical activities (scripts and any other medical procedure); and c) scripts need to end up in a IEHR archive as do all the other clinical events

3 Standards and Secure messaging: in the tree and branch analogy this could be expressed as the roots of the system. Rightly or wrongly this is seen as a high priority by the ‘governors’ to meet the concern, verging on hysteria, from consumer advocates regarding privacy and personal security issues

3.1 NeHTA - have held recent SMD workshops and have tried hard to get consensus on secure messaging rules

3.2 Vendors – even though, at last, they have been consulted and been given access to previously ‘secret’ thinking there is still a high level of anxiety that it is all still too rubbery for companies to invest in changing their software just yet

3.3 Handbraking - the inwards looking attitude of the ‘Canberra/Jurisdiction’ community over the past years has contributed to unnecessary confusion and mistrust that in turn created further delays due to a lack of belief, that is widespread in the community, that ‘this’ will happen anytime soon.

4 The health agenda - strategy versus reality: remembering that a decade ago, in 2000, the DoHA of the time held a three day “Health Online Summit”. Which spawned HealthConnect, MediConnect and a host of other then soon flawed and now failed models. This poor national leadership performance is still troublesome as while once there were many owners and defenders of ideas and projects; nowadays the odium of failure is all shovelled off to NeHTA.

On a brighter note we have:

4.1 Deloitte: National E-Health and Information Practical Committee-

National E-health Strategy: even though this was kept from public view for over a year, once it was released it was a breath of fresh air. If the right mix of stakeholders can use this guidance as a platform for focused and cooperative implementation, then something tangible occurring by a 20101/2011 timeframe is doable. Otherwise things will remain flaky and I believe more will happen from the industry side than from government, as they are not yet even in the tunnel, let alone ready to see if there is any light approaching

4.2 NHHRC Report - on the other hand, into this vacuum, we have this massive document with an unbelievable number of detailed recommendations that has little chance of traction until some form of a national body of stakeholder’s takes responsibility for setting priorities and ticking the actions off one-by-one. A tedious, laborious, unsexy task load that no group to date has exhibited the zeal required to attack the list of actions to completion. A lot of ink on a lot of paper is maybe all this will deliver in the mid term at least.

4.3 Blogs, promises and disappointments- as the e-health reform status and planned deliverables is still much of a mystery; it gives bloggers a field day, every day. Somehow a public information and awareness campaign needs to be undertaken to inform ‘us’ what will happen and why that will be better; and that’s just the taxpayer/voter, someone also needs to tell the doctors and nurses! There are today a myriad ways to get messages out and understood, including the phenomena of social media – Facebook, Twitter, iPhone – as well as more conventional information dissemination channels.

5 Major impediments: the single factor is a fear of failure. Many people will talk the talk but few are prepared or are even capable of actually doing something tangible at the coal face. We can blame the false cry of ‘complexity’, as well as a lack of leadership and notably a lack of accountability. The public ‘service’ culture is risk and invest adverse. This has to change. The broad church of the health community also refuses to learn from other industry sectors, under the nonsense of a ‘we are complex’ mindset, as to what works in an online setting. The banking, insurance, hospitality, retail and a host of others have moved into a new century – healthcare has not.

6 Industry ‘matters’: by this I mean industry does have a role to play as health is everybody’s business. Including access to a healthy workforce, raising national productivity, the overall cost to the economy of a dysfunctional business model and business links in supplying goods and services. I am encouraged by the BCA’s recent move to address this health sector malaise from a business leadership perspective. In 2009 they published a powerful paper – ‘Fit for the job’ – and wrote to the Prime Minister in October 2009 asking him to urgently raise e-health goals to a supreme kitchen-cabinet attention level. I would suggest that the AiG would be another very significant voice in this space

7 Clinically not much is broke: the silly thing is that while all this dysfunctionality merrily abounds, most Australians still receive world’s best clinical care. In spite of all the barriers, bureaucrats and naysayers our doctors and nurses deliver beyond any reasonable expectation, considering the administration and policy mess we are in. My contention is that perhaps we should go slow on the mad hatter intervention into the lives of clinicians and first concentrate on the fundamental business process gaps. By fixing basic ICT pipes and plumbing, controlling cash management visibility, with effective accounts payable and receivable systems, and make all hospitals function, like a good hotel, as a clean and pleasant place to work. The promise of an e-health world is undeniably powerful and desirable, but it will not be all that great if no one can electronically share basic data, while waste and money gushes into black holes and the working and service environments are dirty and unmaintained.

8 Summary : we need a jolt. Australia has a proud record of large national change management projects – think in particular of the Decimal Currency and Metric Conversion Boards. And using a long bow we could also include the Y2K Task Force model. Whereas these councils, boards and committees used and promoted proper and transparent guidelines in project management to achieve known deliverables. With a wide and comprehensive stakeholder involvement, adequate funding, effective secretariat support and executive leadership to foster a common commitment to succeed.

Australia needs an E-Health Conversion Board. Think NeHTA being re-engineered to work with industry associations and expert business leaders to meet mandatory milestones and to do all that on a fixed budget. As well as meeting a fixed sunset date - with the journey receiving the full backing of the Government of the day, treating the project as mission critical for the nation’s citizens. As opposed to merely being blind sided by complex elite self-interest; otherwise and usually called protectionism.

Please feel free to contact me with any comment or question - Pat Gallagher

Casprel P/L - Casprel@attglobal.net - 0418 976 069

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