The Australian Digital Health Agency (ADHA) has only been around for 18 months, but the My Health Record (MyHR), in its various incarnations, is closer to eight years old. That’s if you start from its first appearance in the Budget of 2010-11 after the-then health minister, Nicola Roxon, announced it as the “key building block of the National Health and Hospitals Network”.
At the time the ADHA was announced, there was a significant degree of scepticism around whether it could deliver, given how moribund the project had become. It’s been so long and so hard that several “alt MyHR” organisations have grown large and influential, and they are invariably now very negative about the whole project.
The degree of difficulty, given the past, and these committed conscientious objectors, remains very high. The agency can’t breathe the wrong way without being criticised by someone.
The ADHA said nine months ago it was on track to show significant and meaningful progress. So we gave the agency 10 tasks back then that we thought needed addressing in some way if there was going to be evidence of substantive progress.
Today, we are marking the agency and discussing what that mark means for the future of digital health and for the MyHR.
Below we provide a refresher on each task we set the ADHA and assess each one out of 10. We then do a little weighting and explain the reasoning for that.
Prior to making this assessment, we visited the ADHA with a long list of questions, and the agency was kind enough to sit with us and go through that list.
Much of that list arose out of the monthly statistics the agency publishes on its website. We didn’t understand most of that data. We wanted to gauge what really were meaningful measures of progress for the MyHR and the agency.
To do this, you really needed some hard markers on what might represent measurable progress.
The top four would be:
• At least halve deaths through medication errors each year (we have 230,000 currently)
• Significantly reduce the re-ordering and mistakes in pathology and imaging ordering (Note: We couldn’t get a figure out of the agency as to what “significantly” represented, but we are going to say 25%, which if you consider how much money that is likely to take from the big pathology providers, and how powerful these companies are, is a suitably impressive target)
• Return a big chunk of time to doctors via system efficiency. Again, we didn’t get a number. But there are estimates out there that suggest a saving of up to 20% of a doctor’s working day.
• No fax machines in the healthcare system
The agency tells us that such tangible targets are the responsibility of the Department of Health, not the ADHA, so it doesn’t set any. Is this just classic bureaucratic buck passing? It doesn’t matter. Here we go:
1. The Siggins Miller report recommended the MyHR be a compulsory part of health professionals’ jobs. We said the ADHA shouldn’t do this, but should make it so obviously useful that health professionals just use it anyway.
Five points for not making it compulsory. GPs have quite enough red tape to deal with without being forced to upload summaries to the MyHR, especially given they don’t see much use in it. But only one out of five points for making the MyHR so useful to GPs and other clinicians that they use it regardless of getting paid to do so.
We say this because our journalist Felicity Nelson spent weeks deciphering some of the mass of confusing statistics the ADHA publishes each month and what she found was that only 6% of clinicians actually use the MyHR regularly. This is opposed to the nearly 39% who regularly upload health summaries, which tells you what a little monetary incentive does.
2. Significant and meaningful data will reside in the MyHR and will be apparent within the next few months. By nine months, there will be enough actual data for the MyHR to be very useful to patients and doctors alike.
Mark 3/10 (Weighted mark 5/10)
Significant meaningful data does not exist yet in the MyHR if only 6% of clinicians find it useful. But we think maybe we should take into consideration all the work in progress the agency has under way and have weighted this mark accordingly. It has:
• Started in earnest getting pathology reports into the system. It has nearly all of NSW public pathology reporting and more states are coming on board. Even private pathology providers are joining in. Sonic has reporting up and running in some states and are promising the ADHA to roll its reporting all the way through its network. Primary Health Care, we are told, is going to follow soon. The target by the time the big day of “opt out” comes in October is to have more than 70% of pathology reporting going into the MyHR. We estimate it currently has 5%. That’s a big jump and we don’t think the ADHA will make it, but it’s a great ambition.
• It loads PBS data for medicines and it is now loading data direct from pharmacy systems. It has a commitment from all the pharmacy software vendors that all systems will be uploading prescription data by October. On top of that, ADHA has worked with this medication data to sort it and prioritise it into an easy to read table that is rapidly available in the record. This is very useful.
• While not really using the MyHR for everyday practice, the PIP program has at least incentivised GPs to upload health summaries, with around 40% of GPs now doing so regularly. If you ask the agency’s chief medical adviser, Dr Meridith Makeham, about this she will tell you that uploading a health summary takes only one to two minutes. But she’s the benchmark, we guess. Sit with a GP who is just learning how to do this, and whose summary notes aren’t so great, and you’re talking anywhere up to half an hour, which probably makes the overall average time taken somewhere between four and eight minutes. That’s too long. The system will need to change.
• Hospital discharge summaries are now starting to flow into the record as well. We don’t have a figure on the total percentage of all summaries that are going in. It’s like all the ADHA statistics. They are very hard to actually work out in relative terms. If you look at the statistics, the agency says that so far 1.6 million discharge summaries have been uploaded. But what does that mean? Is that 1% or 10% of the total potential summaries? And just how useful a hospital discharge summary is in the current form it is being uploaded is an important question. Like the medication schedule that has been developed, a one-minute, easily digestable summary format is required.
• There is a lot of other information now going into the system, such as immunisation schedules.
• There is virtually nothing going in via specialists or allied-health professionals. And sadly, that is not likely to change in the near future. That’s not the fault of the ADHA, but something needs to be done about it if we really want an efficient system.
We’ve weighted this point kindly, because although they’ve not got a lot of useful data yet, the ADHA seems to be on track on this point.
3. The data will include a lot of pathology data
By rights the ADHA is on track to get a lot of useful pathology and imaging data going into the MyHR. If that 70% figure by October is even close, it will be an amazing job. So you might think this mark is a little harsh. But the reality is, the willingness of the pathology companies to participate meaningfully in this project is still up for debate. These companies have in the past, and still do, hold back a lot of progress in digital medicine, especially in the realm of interoperability. They hold back by retarding the systems that talk to GP patient management systems. They do this because GPs are their resellers.
If their patient management systems really could swing easily between pathology providers at the touch of a button then their reselling channel would be a lot less stable.
Reducing pathology testing today means pathology revenues fall. This is just not feasible: commercially, politically, or otherwise.
But as ADHA CEO Tim Kelsey points out, all these companies, particularly Sonic, Primary and ACL, are sophisticated and they know they can’t hold onto their old business models for ever. He says they are planning for new revenue streams via new technologies such as genetic testing. He thinks that they are willingly participating in digital evolution of the system and won’t hold the program back in the end.
4. A much better user interface for the public and healthcare providers
Mark 2/10 (Weighted mark 3/10)
There hasn’t been much improvement on this front, especially for healthcare providers. The system is still clunky. It’s not even cloud based, because the government can’t decide whether it is better at security than Amazon or Microsoft are. But we’ve weighted this mark a little because the agency already seems to be on this issue and planning for the future correctly. It is about to go into a platform review where it will consider much better functionality and architecture for the MyHR, including better use of things like FHIR and maybe even blockchain.
5. The MyHR will talk to specialists, pathology, and interoperability via secure messaging will become seamless
To be fair, this was a huge ask in nine months, especially the interoperability component. The ADHA has a few big issues on that front and seems a bit stuck in the mud. It’s an important issue, especially for our target of giving time back to clinicians to do what they do best.
It is thought that up to 60% of specialists are not computerised. In terms of this part of interoperability and getting rid of fax machines, it is hard to see how any progress can be made. The ADHA can’t do everything, and if specialists don’t have computers it’s pretty hard to achieve digital interoperability efficiencies.
6. ADHA will work tightly and synergistically with the private technology sector in optimising the system
This mark might have been a pass mark until the RACGP meeting a few weeks back that brought together most key members of the MSIA (our leading software vendors) with the ADHA to talk about better systems and standards. Somehow that meeting ended up in a media release that angered most members of the MSIA because it had suggested that they needed to be better and were not close enough to their customers. Also marked down is the ADHA relationship with the major global EMR vendors. Many of these major vendors are not close to the agency. This despite these vendors being in charge of all hospital-based systems that need to talk effectively to the MyHR.
7. The ADHA will facilitate tech vendors innovation not compete with it
The ADHA has a stated position of being the facilitators of innovation and it makes a lot of noise about it. But there might be a “can’t see the forest for the trees” issue emerging, and if it does, this mark will become a fail. That is, as cloud systems spread, most especially around the GP patient management systems, a lot of what the the MyHR is attempting to do, will be done anyway by these software vendors. Patients will have their up to date medical record on their phones via their local GP’s patient management system. So where does that leave the MyHR? We don’t think the ADHA is really embracing this issue. It might render more than half of what they are doing today redundant. The agency doesn’t think so. It keeps telling us we need a central record with everything on it.
8. The Department of Health will establish transparent costings and targets for the MyHR so we can all easily assess its return on investment
Mark 1/10 ( Weighted mark 3/10)
This one is easy. Everything is still very confusing, to the public and to healthcare professionals. If you want evidence, then try to decipher what the monthly statistics reports on the MyHR actually mean.There are no hard goals and there are no relative measures of progress in these reports. Statistics such ase 31 pathology groups uploading records and 1.6 million hospital discharge summaries are completely meaningless unless we have a relative measure against a potential total that could be uploaded. This needs to get much better. But in fairness this is more the department of health than the ADHA, so we’ve weighted the mark a little.
9. There will be a rational and effective education, training and awareness campaign of both for the public and for healthcare professionals
Unbeknown to many, the ADHA has been spending quite a lot so far on the GP side of things, mostly via the PHNs and the RACGP and AMA. This is a great place to start, but given PHNs are variable in quality and effectiveness, it probably isn’t the be all and end all of getting doctors to listen. As far as consumer awareness is concerned, the agency recently announced that rumours it has no money to promote to the public are wrong and that campaigns will start later in the year to co-ordinate appropriately with the time the “opt-out” goes nationwide.
10. That progress has been so good that most of us are convinced the project is on track and is the right way to go
This point is not to be confused with the idea that having a well co-ordinated centralised medical record will help the system. Most people (with some notable exceptions) think this is a basically good idea. This is far more directed at what the MyHR is itself and how it is being rolled out. It feels like a summary mark of all the past points, which makes it a fail, but we don’t think that. We think we are not all on the same page yet, but there has been enough progress and there is enough good intention in this project to persist a bit longer.
Total unweighted mark: 42/100
Total weighted mark: 47/100
Summary marker’s closing comments
Nine months ago, we said anything over 50% would be a spectacular job, given the degree of difficulty faced by the agency. It has as good as achieved 50%, which says this is an organisation that is moving on its target and goals, probably in a much better way than the predecessor agencies.
But a conceded pass puts this whole project still in a grey area. There is much more work to be done. The ADHA says that by October it will have useful information in the MyHR and things will literally start to buzz. It is possible. This will be a big taste test.
The major issue we see is that technologies such as blockchain and the cloud are racing along a lot faster than a project like the MyHR, managed by government, can keep up with. There is a very real chance that ground-up privately built systems will do most of what the MyHR was originally supposed to do.
The ADHA will tell you it never intended it to do everything and that it’s a facilitation play, not the beating heart of the system. That isn’t true. It was in its original concept designed as the whole solution.The ADHA has adapted its story. Which is a good thing.
It definitely sees the part the MyHR is going to play is changing. If you talk to anyone in the ADHA you know they are passionate and committed.
They believe in what they’re doing and they are working very hard. They might even believe it too much. But you don’t often get that passion and culture in a government department. The critics need to work with the agency, not against it. At least for now.
The ADHA does need to change and adapt more quickly. And it needs our help to do it.