Six months ago I wrote a short piece in The Centre for Policy Development suggesting that a major review of HealthConnect, the Commonwealth’s e-Health strategic plan and implementation program, was required. I was concerned that, among other things, there needed be a full and frank review of the whole program otherwise major failure and money wastage seemed inevitable.
It seems that I was right. A few weeks ago The Australian reported that the Director of e-Health Implementation had been moved to a new position (covering e-health, safety and quality) and that his staff were unsure who their new leader would be and what their future would hold.
More bad news followed a week later when the same paper reported that the lead implementation team had warned of the need for ‘the Federal Government to hose down consumer expectations about electronic health records in the wake of its ‘changed vision’ for HealthConnect‘.
This all appears to be the final step in killing off any concerted federal e-health initiative aimed at significant transformation of patient healthcare delivery and improvement of health outcomes. It now also appears that there is to be a complete passing of the baton to state jurisdictions and to their e-health co-ordinating and standards setting entity, the now corporatized National E-Health Transition Authority (NEHTA).
Sadly, as NEHTA is ‘owned’ by the stakeholder state jurisdictions and the commonwealth, and many state Health IT projects are delayed or problematic, there has been little public comment from the NEHTA board on the overall state of e-health. Furthermore, recently NEHTA disbanded its technical advisory board.
It is now obvious to all that the concept of a life-long shared electronic health record to assist in the care of the Australian population is simply not going to happen as it was envisaged in 1999. In my opinion, the whole project was overly-complex, poorly researched and piloted, politically and culturally naive, over-hyped as to its potential, built around unrealistic timeframes and costing and not designed to address the actual urgent needs of the health sector.
Following the failure of the trial and the implementation projects to deliver useful clinical outcomes, the goal posts and expectations of useful clinical outcomes have been changed and federal expenditure has been largely withdrawn, with costs shifted to the States as much as possible. This is made clear by the recent re-branding of HealthConnect as now being a ‘Health Market Change Management Strategy’ – whatever that means!
Why does this matter?
It matters for two major reasons. Firstly, there is a compelling business case for the successful implementation of information technology in the health sector. (Confirmation of this lies with the fact that Australia is now almost alone in its lack of a funded and coherent forward strategy – the US, UK, Canada and most of Western Europe are moving forward on this).
Secondly, if we do not successfully implement e-health, achievement of the other objectives of quality, efficiency, safety and consistency of care for our health system become impossible.
What is at stake?
Without national leadership on e-health, Australia runs the serious risk of its health system become even more uncoordinated and dysfunctional. Without coherent national leadership several problems may develop.
Firstly, if it is left to state jurisdictions, we will continue to have a ‘multiple railway gauge’ problem as occurs in other aspects of life. This is where information flows and interpretation between jurisdictions are profoundly problematic.
Secondly, we will see a worsening of information flows between the primary, secondary and tertiary sectors – as each is funded by a different tier of government. This will interfere with progress towards improvements in the quality, safety and efficiency of patient care.
Thirdly, we will continue to see waste and duplication as lessons are not learnt and mistakes are replicated across the nation.
What has also happened recently?
There are other worrying portents of the Commonwealth Government vacating the e-health space. Firstly, the formal role of the Australian Health Information Council to undertake national e-health planning was withdrawn after the AHMAC meeting in late 2005.
Secondly, the Health Minister failed even to attend the AMA e-health forum in December 2005. Thirdly, it is clear that all planned HealthConnect implementations have been drastically scaled back in both cost and likelihood to meet the goals of the original plan upon on which upwards of $100M has reportedly already been spent.
Current implementations are now simply e-mail notification to GPs schemes for patient hospital discharges and the like. What are now being implemented are trivial and un-standardised endeavours, far removed from the original HealthConnect concept of a life-long shared medical record.
What is likely to happen next?
The answer to this question lies with the various state jurisdictional Health IT initiatives. NSW is currently having substantial delays in making system selections for core systems. Victoria is now at least a year (or maybe two) behind in its HealthSmart Program.
Queensland is being sued by its clinical systems vendor. Initially Health IT was mentioned positively in a recent review of Health in Western Australia, but has somehow vanished from the relevant strategy papers, although some initial planning efforts are known to be underway.
Little progress in any of these states is likely any time soon and if progress is made it will be largely Hospital-centric, as that is what state health departments care about. Developing links to the community and GPs is not a priority while you are still trying to get the hospitals online.
What is to be done?
The worrying pattern described above must be reversed.
First, there needs to be a proper national business case developed to establish the costs and benefits of deployment of appropriate Health IT and the opportunity cost to the community of not doing so. This needs to be sponsored at Cabinet level, done by the most competent and credible advisors that can be found, and needs to convince the government of the need to invest. (The same exercise has happened in the US, the UK and Canada and in each case major investment has followed.)
This is predicated on finding a suitable sponsor in government who understands both the benefits and the opportunity costs. In the US and UK this role has been played by the President and the UK Prime Minister respectively – the same leadership is needed here.
Second, if this business case reflects similar studies elsewhere and is supportive of action, a national e-health plan which is properly funded and properly resourced needs to be jointly developed with the states. It should cover what needs to be addressed in all sectors (acute, chronic and aged care) and for all participants (consumers, health professionals, etc). Australia is too small to have each jurisdiction do its own planning – the states will simply not deliver the nationally co-ordinated plan that is required.
This plan needs to be genuinely national in scope, standards driven, and above all, practical and able to be implemented in small co-ordinated steps that deliver progressive benefit for the costs incurred. There also needs to be the recognition that a paradigm shift employing newer technologies and approaches may very well be required. The ‘same old, same old’ will not work.
It also needs to be recognised that there has been some excellent work (especially in the areas of information management and standards produced by NEHTA) done as part of the HealthConnect program (along with some disappointing work) and the baby should not be thrown out with the bathwater.
Any plan will need to recognise that those who incur the costs are often not those who reap the benefits. Mechanisms to address imbalances and the somewhat perverse set of incentives and barriers will be critical to develop. These exist elsewhere and can be adapted to our situation.
Careful and ongoing consultation of all stakeholders will also be vital for success.
Lastly, it seems clear that the bottom-up, standardised, connectivity-driven approach which avoids major privacy and security concerns (as is being deployed in the US) needs careful consideration as a potential approach for Australia. It seems likely that the centralised options currently planned for are unlikely to be either affordable or successful.
Doing nothing is not a real option. We need to bury the past, but not before we learn the lessons of what was done well, and then start afresh.