7 February 2018
The ADHA/RACGP’s brain fart on clinical information systems
One poorly worded press release and years of building a trust relationship between the software industry and the ADHA and RACGP is headed for the rocks
Most media releases we get from the Australian Digital Health Agency (ADHA) are reasonably tame and sensible, usually announcing a new stage ticked off in the timeline of their ambitious and detailed National Digital Health Strategy. It is doing OK with it.
But when yesterday’s release came in simultaneously to several of our journos, there was a collective murmur of angst, followed by a heated argument between two over what was going on. What had the agency said?
Although you suspect it was not anyone’s intention, the release essentially announced that the RACGP had joined forces with the ADHA to help the clinical information software vendors (folks like Best Practice, MedicalDirector, MediRecords and MedTech), communicate much better with their clients. Apparently they need help.
The release reads:
The Royal Australian College of General Practitioners (RACGP) has announced a new project that will see the college working closely with GPs and software developers to ensure [Clinical Information Systems] CISs are useable, secure, interoperable, and ultimately fit-for-purpose.
RACGP President Dr Bastian Seidel said the project is aimed at opening a dialogue between the medical community and software vendors.
So the RACGP was going get the software vendors to “open a dialogue” with their clients of 30 years or more?
It got worse, again, probably unintentionally.
“This project, supported by the Australian Digital Health Agency, is aimed at opening a dialogue between the medical community and software vendors to determine and develop the minimum clinical software functionality requirements that meet current and future healthcare needs,” says RACGP president Bastian Seidel.
Thus reinforcing the first point about the vendors needing customer help, but then announcing the RACGP was going to add software architecture skills to its ever-expanding remit over the GP landscape.
The reaction from the vendors was predictable.
The erudite and politic Emma Hossack, the head of the Medical Software Industry Association, was unusually forthright.
“Around 95% of GPs in Australia are clients of our members. If there was any possibility that the systems which they buy to help them with their practice were not secure, the Australian Commission for Safety and Quality in Healthcare would have been involved. That is not the case,” she told The Medical Republic.
Likewise, if clinical information systems were not already fit for purpose, seamless and secure, our members would have been alerted by their clients or the government. In other words, these systems – largely developed by GPs for GPs – have a market willing to pay for them because they work.”
And on the subject of developing minimum viable requirements, Hossack said:
“It is always concerning when you read about the government wanting to set prescriptive standards and interfere in a market when it is working so well. We hope that is not what is intended.
“Examples like the NBN, which our PM said some time ago may not have a business case, could be an example as 5G and other innovations leapfrog over government-built infrastructure. Innovation requires agility which for obvious reasons the government cannot, and should not have to, provide.
Likewise, competition and productivity can be severely hampered by government, as we saw with the live-meat trade fiasco. If the industry is to be more vibrant, then great care needs to be taken not to impede it with red tape which could have unintended consequences.”
Hossack, and the local software vendor community weren’t alone in being taken aback by the media release.
Some of the larger global system vendors contacted by TMR, but who were not prepared to go on the record, were not impressed either.
One vendor told TMR the ADHA did not engage a lot with the major global EMR companies anyway. She said this was already pointing to something being wrong if you considered the whole hospital clinical information environment was dominated by the global vendors.
“If you consider the importance of information being shared in ED, why don’t the ADHA have a more meaningful engagement with us?” she asked.
She said the release was a confirmation that the ADHA wasn’t able to comprehend the relationships between the vendor community and end users.
The ADHA was initially surprised to hear the software industry was unhappy.
Bettina McMahon, Executive General Manager, Government and Industry Collaboration and Adoption at the agency, told TMR the ADHA was working tightly with the software community and that the release was put out with its imprimatur.
She said the release followed a meeting between the agency, the RACGP, and key patient management system suppliers and the MSIA two weeks ago, where all parties had mapped out a way forward and that involved the MSIA members working with the RACGP to develop “minimum requirements”.
But Hossack says this was not the wash-up of the meeting. She said that although their members were very clearly open to working more closely with both groups to improve clinical systems, those that attended were there to understand what the ADHA and RACGP had in mind. Most vendors that attended left still wondering what the ADHA and RACGP had in mind.
“The Medical Software Industry Association is keen to work on problems with ADHA,” she told TMR.
“[But] show us the business case. Is there a survey of 10,000 unhappy GPs? Is there a privacy, security or safety incident we are responsible for?
“If not, then it would be excellent to see ADHA engaging with the RACGP about areas like Pillar 6 of their strategy which involves workforce education. It is incumbent on the buyers of software to know what they need and what they are getting. If they are not being taught the basics during their training it is an ideal area for ADHA and the RACGP to co-operate.”
None of the vendors wants a bad relationship with either the ADHA or the RACGP, so not all were prepared to go on the record. But all contacted by TMR expressed dissatisfaction with the tone and intent of the ADHA release.
Part of the issue is that the term “minimum functional requirements (MFR)” which is used in the release – the RACGP says it is going to help the vendors develop some – is a very definitive term in the software industry. MFRs for a GP clinical information systems are pretty obvious – for instance, they all need an up-to-date drug interactions database, and they all need to talk in some way to Medicare. These have largely been in place in most of these systems for many years. So what new is the RACGP going to bring to the table on such a basic customer-facing problem, even if the environment is changing with technology enablers like the cloud?Are the software vendors not up to the task of managing minimal requirements?
ADHA chief executive Tim Kelsey told TMR that it was the vendors who had asked that the RACGP lead this initiative and that MedicalDirector and other vendors had actually asked the ADHA to fund the work which was being announced in the release.
This was at odds with Hossack in terms of what the release said at least. And it was clear that whether some of the vendors had asked the ADHA to fund this work and have the RACGP involved, or not, many of them were now not happy about what was going on following the release.
“The agency is here to facilitate innovation by industry – certainly not to oversee the industry,” Kelsey told TMR.
“I have personally met with some of the key vendors who want some definition of standards. Perhaps this isn’t how everybody feels. This is all part of the evolution towards a safe, interoperable healthcare service,” he said.
But talk to Hossack and something is being lost in translation – certainly with respect to this release at least, and potentially in respect to the recent meeting between all the AHDA, RACGP and vendors.
“The agenda for the RACGP/ADHA/MSIA meeting was not to discuss standards but simply to discuss the possible minimum requirements for software systems. It was agreed before the meeting that we may all agree there was no need,” she said.
“In Australia, we have many organisations which are custodians of standards, for example, HL7 and Standards Australia. Then there are the organisations like the RACGP which can create standards for their profession. Then there are government agencies which can work with these organisations where necessary in the public interest.
“Neither ADHA nor RACGP has the imprimatur to create standards for the medical software industry. Indeed, as we see with so many digital projects both here and overseas, government intervention in these complex areas often results in failure and waste. Nor, despite what Tim Kelsey suggests, was there any reference to a defined set of clinical information system standards in the ADHA Digital Strategy. There are many references to standards for interoperability in the strategy, but nowhere does it refer to what is being suggested in the media release.”
When asked if we need “defined software standards” or minimal requirements for clinical information systems, Hossack had this to say:
“The agreed outcome of the meeting was that the RACGP and or ADHA would put together a business case because none was forthcoming at the meeting. There were no complaints by the Australian Commission for Safety and Quality in Healthcare, no petitions from thousands of GPs saying the systems were not fit for purpose and no hint that our members’ systems they were anything less than privacy and security positive.
“Experience in the area also shows that many of these systems currently interoperate not only with the government systems like MBS and PBS and MyHR, but also with third-party systems including APPs. The industry is not only meeting the market, but leading the market. The proof lies in the fact that 95% of all GPs in Australia pay for and use clinical information systems. These same GPs, on the other hand, do not avail themselves of government systems which are free which they may deem to be less than useful.
“The MSIA has yet to see the business case for any intervention into minimal requirements for clinical information systems. In the meantime, we have concerns about unnecessary red tape which will lessen innovation, productivity and militate against the ICT procurement taskforce government response. Unnecessary intervention in an area which is manifestly working could well have unintended consequences.
“It would be marvellous to see ADHA and the RACGP working to achieve in areas which are known to be deficient like workforce education on software, which of course is pillar 6 of their strategy. The UK has taken the lead with this with their NHS Digital Academy (http://www.imperial.ac.uk/study/pg/medicine/digital-health-leadership/ and it would be great if our doctors were given such an opportunity to enable them to discern more easily which of the superb array of clinical information systems in Australia most suit their practice. The MSIA would be very happy to work together with ADHA and the RACGP in this area.”
That seems a pretty clear position from the MSIA. And it’s not what anyone would read into yesterday’s release. And while the bigger global vendors would not comment formally, they agree.
Below is one of the slides presented by the MSIA at the group meeting two weeks ago. It seems to be putting the MSIA position in a reasonably clear manner. And it doesn’t mention standards and specifically says “no requirements” please.
So is this all just a brain fart on the part of the ADHA and the RACGP? A hastily concocted press release with some poor wording, a little bit too much wishful thinking thrown in, and possibly, that age-old issue of needing to be seen to do something.
It might be, at least in part. But to get things that far out of whack for a community so integral to your core strategy is careless on a best-case interpretation.
Clearly industry, the AHDA and the RACGP aren’t on page as things stand today. And there ares ome broken fences to start fixing.
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