Given this could be the most important blog I write this year, I felt it needed to be started by a relevant quotation. My chosen quotation is 'Those who cannot remember the past are condemned to repeat it.' This is one of the notable quotations from George Santayana and can be found in the work entitled Life of Reason, Reason in Common Sense, Scribner's, 1905, page 284.
Why is this relevant? Let me explain.
On the day the NEHTA Review by the Boston Consulting Group (BCG) was released the Australian published an article – clearly prepared well in advance – informing an unsuspecting populace that they were about to all have a Shared Electronic Health Record (Shared EHR) made available to them within four years, if they wanted one! Clearly an attempt to distract from the bad news of incompetence in the BCG report and to obscure what they planned for the future.
From the press release associated with the release of the BCG Review of NEHTA we also learned that the Board has been busy. In their words:
“The Board of NEHTA also endorsed a business case for developing a national platform for personal electronic health records to be put to the Council of Australian Governments (COAG) early next year.”
The Australian article makes it pretty clear the information to be held on the Shared EHR will be (to quote):
“ Core elements of most profiles would include:
* Allergies, alerts and adverse reactions.
* Current and ceased medications.
* Problems and diagnosis, active or persistent disorders.
* Family and social history and immunisations.
* Implants such as pacing wires, joint prostheses and medication implants.
* Screening results such as the last date and outcome of Pap smears and mammograms.
* Key physiological measurements, height, weight, body mass index.
* Planned activities, care plans and history of recent and past procedures.”
What does all this mean. It means that NEHTA imagines (fantasises) that it is ready to approach the Council of Australian Government (COAG) with a business case to implement a quite advanced Shared EHR over the next four years!
Implied in all of this is that NEHTA has worked out
1. the details of how the Shared EHR will work.
2. how the planned record will interact and communicate with hospital, specialist and GP systems
3. how the data will be stored and secured
4. how privacy will be protected and
5. how much it will all cost and what the benefits are that will flow from the recommended spend.
Even more amazing is that the business case apparently suggests this can all happen within four years – i.e. by 2012.
If COAG buys this megalomaniacal hubris, and agrees to this, it will be a total disaster and set back E-Health in Australia for a decade in my view.
Why is this initiative doomed to fail (Here is where recent and more distant history comes in)?
First, as we learn from the recent BCG report, NEHTA does not seem to be able to manage even quite simple projects effectively (can’t get staff, can’t spend what is needed and lacks implementation expertise for starters). Doing a project of this scale is clearly way beyond them – even with partners such as IBM and Telstra which you can bet they are hoping will do the heavy lifting.
Second, again as we learn from the BCG report, NEHTA has virtually no capability to engage with the Health Sector and simply does not ‘get health’. A project of the scale contemplated by NEHTA is not doable in that circumstance.
Third, when similar ideas were trialled in the years 2002-2005 by the Commonwealth, under the HealthConnect banner, the pilots were such dismal failures that not a single one was continued with in its planned form and ultimately the whole program turned into a ‘change management strategy’ having wasted $100 million +.
Fourth, to have a Shared EHR it is vital that the data that is shared from operational systems is of high quality and integrity – i.e. is ‘data for sharing’. NEHTA does not even have a plan for GP and Specialist data quality enhancement (it has cost the UK hundreds of millions of pounds over many years to make progress) and so ‘garbage in, garbage out’ will be the order of the day.
Fifth, the UK, Canada and the US have has EHRs on the political agenda for 4-5 years to build public support for a Shared EHR project – we have had one article in the Australian two days ago after a hiatus of years.
Sixth, it seems that we have had a collection of NEHTA boffins who, according to the BCG are not seen by practicing Health IT experts as being of much use, invent this business case in secret away from the public eye as well as those who actually understand the risk and complexity of such undertakings. So much for the new open NEHTA and for any substantial chance of success!
Seventh, any maturity analysis of the Australian status in E-Health would quickly show we are a full 5-7 years away from being able to successfully conduct such an ambitious project – lacking the people, implementation skills and technical infrastructure to make it work.
Eighth, Australia does not have a National E-Health Strategy that positions a proposal of this type sensibly. All elements including the doctors and nurses, support staff, technologies, partners and training need to be co-ordinated and managed. This is a strategic national effort which will take many years – not something to be rushed through COAG on the opportunity of a Government change.
Lastly, from what is known of NEHTA’s benefits work, there are a lot of assumptions based on effective Clinical Decision Support. Systems with these capabilities are still largely aspirational at this point of time in terms of widespread use and it seems likely NEHTA’s benefits case will be little more than wild guesses dressed up with flash graphics. COAG beware!
How should NEHTA actually be proceeding?
First NEHTA should engage with COAG to fund the development of a genuinely inclusive and practically based National E-Health Strategy. This could address many of the present uncertainties about what is practical, what is possible and what might work.
Second it should review, refresh and release all the documentation associated with HealthConnect Version 1.
Third the reality of the costs and benefits case needs to be subjected to hardnosed analysis through proof of concept implementations that can be shown to deliver in the real world. Hand waving assumptions should simply not be accepted.
Fourth NEHTA should release, for public review and discussion, the current business case so we all know what is planned, what will be the outcomes and can bring the Health IT Communities expertise to bear on the entire project to maximise the chance of cultural, technical and financial success. This should lead to a much more robust plan being approved late in 2008 – and having some chance of success when implemented.
Fifth – at the very least – the Shared EHR should be piloted in one State (it needs a pilot of that scale I believe to be credible) and once all the issues are resolved – a move to national implementation can be commenced. Just jumping in with the whole country is clearly crazy.
Shared EHR’s have been very problematic in large countries with success seemingly being confined to the smaller states such as Denmark etc.
Before I conclude I need to say I would really like a Shared EHR to proceed in a planned strategically rational fashion – just not in the unsound and ill considered way proposed by NEHTA which I feel is doomed. I know how hard this will actually be and I fear NEHTA does not have a clue.
If NEHTA goes ahead with its present plans, and COAG is silly enough to approve the request, I am convinced it will be an un-remitting fiasco some 2-3 years out and there will be blame and blood-shed everywhere.
See if I am not right.
David.
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