With all the “hoo haa” over the MHR in the last few weeks, you could excuse the Australian Digital Health Agency’s head honcho, Tim Kelsey, for getting just a little rattled when faced with some fast and hard technical questions about the future of the electronic health record.
But in a very small session at this week’s Health Informatics Conference in Sydney, Mr Kelsey said one thing that was either him deflecting on the run, or a pretty big admission that the current iteration of the MHR is nothing like it will be in the near future and a lot of the hard work of the ADHA could soon be redundant.
The whole thing started with a question to the founder of a new health information sharing standard FHIR, which is starting to gain huge traction in the US, and which is being touted as a major piece of the digital health puzzle on efficient and secure health information sharing over the web.
Grahame Grieve was asked, somewhat cheekily, by the panel moderator, the CEO of the Medical Software Industry Association Emma Hossack, what the utility of the fast evolving FHIR standard for data sharing might do to the current iteration of the MHR.
Before you read on here, you have to understand a little bit more about something that is seriously technical, but I’m going to simplify it in a way that might horrify the experts in order that your average coal-face doctor might quickly realise what is going on.
FHIR is a standard that is designed to translate hugely complex healthcare data which is shared throughout complex off-the-cloud healthcare databases via another standard called HL-7, and get it easily, but very securely, moving across the web interface so everyone can start sharing data like they do in normal digital markets, such as finance, travel and retailing.
In theory, it will allow consumer applications to talk to distributed databases in health, via the web, with much more security than the MHR, because it is only dealing in data that a consumer wants to share or needs to obtain through their app. And it is on their mobile, which is protected by Apple or Google, and only talking to relevant databases, not one giant central one.
The bottom line of the emerging FHIR revolution is that very soon, all things being equal, most the data being centralised in the MHR will simply not be needed to be stored that way. It will be accessed by a patient’s mobile via their doctor’s patient management system, or directly via the hospital, the pharmacist, or the pathology lab they just left. The concept is truly revolutionary.
But when you’ve just spent more than $2 billion trying to get your – now outdated – centralised record system up and running as the ADHA and the Australian government has done, that’s a tricky revolution to embrace with open arms.
Mr Grieve, who is enigmatic, intelligent and often mischievous about FHIR and how the Australian government hasn’t really embraced it with open arms like other countries (he was just last week invited to present at the White House) was very politic in his answer.
He said FHIR and the MHR was a glass-half-full, glass-half-empty set up. On the empty side, and here is the kicker, essentially once FHIR properly takes hold, much of the data being collected and stored centrally by the ADHA in the MHR, will not be needed.
He didn’t actually say those words. That would be too awkward. But he did say much of the data between a consumer and the health system will be shared directly from the apps via FHIR and the web directly with the databases that are important and distributed such as your GPs patient management system.
As an example, currently the MHR is collecting meds data from the PBS, pharmacies and some other strange places. But the most accurate and up-to-date record holder is usually going to be your GP.
On the same panel as Mr Grieve were the four very senior managers from our largest patient management systems: Dr Frank Pyefinch from Best Practice (and who also founded MedicalDirector), Matthew Bardsley from MedicalDirector, James Scollay from Genie Solutions, and David Freemantle from FRED IT (a pharmacy system).
All of them endorsed the FHIR future and all said they were developing their products into the future with FHIR built in. The implication is that they will share their information off their systems directly with patients.
Why then does the ADHA collect it all now and put it in one place?
When Mr Kelsey was asked what, in the context of the momentum and the FHIR movement and its obvious implications ( and having all the major software vendors sitting next to him on a panel), he thinks about the future the MHR, we all expected an appropriately politic and pithy answer which amounted to no comment.
But what he surprisingly blurted out was “What Grahame said”…
What Grahame said? Grahame, trying to be polite, said between the lines, that the MHR in its current iteration pretty much had to be scrapped and replatformed around this new technology.
This all passed with very little fanfare because hardly anyone was in the room. But it was a surprising and very enlightening admission.
Essentially, Mr Kelsey is admitting that the current iteration of the project is way off what it needs to be. He might not think it, but in that admission he is also admitting that a lot of the current work and cost of the MHR is going to be of very little use in not too distant the future – that is, if FHIR does what everyone is promising.
Which does make you wonder why the ADHA and the government are both batting away questions about when the government will seriously fund the development of the FHIR project in Australia. When asked about this, Mr Kelsey said that FHIR was hugely important but it wasn’t the job of the ADHA to run a standard.
What about funding the people who are developing the standard for free currently and going slow because they are doing it all for free? Would that be a good use of money?
When you think about the ADHA turning themselves into an engineering organisation running the most complex and dangerous centralised database in the country, and the utility of FHIR and the wholesale support, funding and embracing of the technology by the US government, you do have to wonder what is going on in Australia.
Mr Greive was conciliatory and more politic for once than the politician Mr Kelsey. He said of the glass half full in the FHIR scenario that the MHR that has been built by the ADHA still had a lot to offer.
“There is still a role for a government providing a secure store that stores documents for patients as one of the many places they can access to store documents and where you can connect and build innovative solutions on it as a part of an ecosystem,” he told the panel.
And there is a good degree of truth in that statement. There is a role, and there is data the ADHA is collecting that others simply won’t be able to collect because of the difficulty and cost, that needs to be shared.
It’s just that there is a hell of lot that won’t be needed. And everyone won’t need to be in a central honey pot of data with about 900,000 potential healthcare practitioners that have a way into that database.
In the future world of FHIR, patients will have their record securely on their mobile and it will be exchanging information live with various health services as they go about their daily business where those databases exist.
And if you think that is a bit fanciful still, then consider that just a few weeks ago Apple came out in the US and said that the iPhone health platform would from now be built on FHIR. That is an announcement that can’t be underestimated by governments around the world who think that patients’ data needs to be controlled and centralised with them.
Apple declaring for health and FHIR is game changing globally for governments and patients alike. If you really want health to get more patient centric, like Apple or not, they aren’t going to die wondering about whether you can do it much more efficiently and quickly than government has managed so far.
Watch this space.