30 November 2021

Get SMART, or get pinged?

Comment KnowCents PSR

The latest expectation from the PSR adds to a growing list of vague ‘standards’ doctors must comply with.


Every country has different tax laws and currencies, but accounting is universal: wherever you are, financial statements will look the same and include much the same content. 

Not so in health; after the MBS review changes, our new definition of a 12-lead ECG in no way aligns with the definition in many other countries, for example. 

The OECD has called upon countries to set the conditions “for greater harmonisation so that more countries are able to benefit from statistical and research uses of data in which there is a public interest, and from international comparisons”. 

But here, the government agency responsible for compliant medical billing is adding to the already ill-defined raft of “standards” littering the landscape.

In a rather alarming development, the PSR now appears to want doctors to use SMART goals – Specific, Measurable, Achievable, Relevant, Time-Stamped – in the context of chronic disease management plans. I was recently asked to prepare an online course on SMART goals for GPs and when I asked why, the response was that the PSR wants doctors to use them so as to be able to drill doctors on the details of how they planned to achieve better outcomes. 

Doctors are unlikely to know about this until it’s too late: until they are being asked by how much exactly they had planned to get this patient’s blood pressure down, or what precise metrics they were using to measure improvements in that patient’s diet and exercise.

The inability of doctors to know what is right or wrong in relation to Medicare compliance is fast reaching a tipping point, and there is a pressing need to harmonise our critical health datasets, including the MBS, with international standards.

Leaving the PSR behind for now, what follows is a quick tour through the standards landscape. I’ve invited a guest into the column to give you a better idea of what is being done: Heather Grain, one of the world’s leading experts on health terminologies and health informatics, with over three decades of experience. 

My doctoral journey led me down a standards rabbit hole. I needed to know who writes health classifications and codes like MBS codes, and whether that work is underpinned by standards. 

Further, given each MBS code becomes a law, do statutory drafters do a final sign off? Are there any globally accepted implementation and use standards for codes and classifications? How is health data governed internationally and how can standards (if they exist) be harmonised with the regulatory framework of health payment arrangements which differ between jurisdictions?

The research led me to a place I had never before visited, where global organisations had been hard at work creating health system standards for decades. It was predominantly the domain of those working in the area of health informatics, a profession that has been evolving and maturing over the past 20 or so years.

I found the OECD health data governance statement, to which Australia is a signatory, which supports a globally consistent health data structure; the Joint Initiative Council for Global Health Informatics Standardization, which has been working on health data and governance standards since 2007; and the WHO referenced ISO (International Standards Organisation) Health informatics standards, in which Australia’s own Heather Grain is working. 

There were also the WHO’s approved standards and code systems such as ICD10, SNOMED and LOINC, plus the HL7 messaging standard. And, from 1994, the Open EHR Foundation, worked with the ISO community, to create the ISO standard for EHR interoperability.

In addition, I found that the work of standardising the international language of health had been completed with both the American Medical Association and WONCA aligning their terminology products (their MBS equivalents) with SNOMED.

So, it appeared that both the structure and format of health data was becoming standardised globally, and the content, or words that would flow through that structure were also the subject of international standards. It seemed to me that plenty of international standards existed: we just weren’t implementing them.

Heather Grain:

The reason that it is relatively easy to switch your accounting system over from Xero to MYOB is that these systems are underpinned by consistent international accounting standards. The chart of accounts is basically the same anywhere in the world.

International health sector and standards organisations, including ISO, have been working to create similar health standards for decades.

Poor standards specifications, poorly drafted codes, and a lack of requisite skills at the design table continue to be a problem in the health standards space, but great progress has been made over the past decade.

I am the current convenor of the ISO  TC215 Health Informatics – Semantic Content Working Group. Our work informs global health data governance standards in cooperation with the Joint Initiative Council for Global Health Informatics Standardization. 

Writing standards for the health sector is very challenging, largely because of the many stakeholders in health information. For example, the current standard we are working on, states the following:

“Health information governance standards are relevant to a wide range of individuals, organisations, and governments.

  • Patients who depend on accurate, available, and secure data
  • Clinicians and professional organizations who need accurate and accessible information, knowledge, and records
  • Decision makers who need to know what is required and assured of appropriate governance
  • Software vendors who need to be able to develop fiscally viable, safe and appropriate systems
  • Information governance practice implementors
  • Regulators
  • Health information and informatics professionals
  • Governments
  • Public health
  • Population health
  • Educators
  • Researchers and analysts
  • Health information custodians and similar organisations.” 

Our focus is always to facilitate consistent capture, and interoperable use of health-related data, to support the proper functioning of health systems. It’s a bit like writing the chart of accounts, but for health. 

Our ISO teams comprise mostly health data scientists and clinical terminology experts, as well as others who are experts in writing standards. All group members must meet the basic requirements for terminology workers described in standard ISO/TS 22287:2019, but even this does not go as far as we now realise it must. When this standard is next reviewed, it will be significantly extended beyond the current scope.

There is much work still to do, such as standardising instructions on the use of code systems, but many health data standards are now readily available for use in all countries. 

Dr Margaret Faux:

Now back to the PSR: this agency has neither the skills nor the legal authority to be tinkering with standards. Doctors should not be falling foul of Medicare’s already opaque “standard” on “adequate and contemporaneous records” by failing to implement an unregulated SMART goal.

Modernising Medicare will require acceptance and implementation of international standards for health data capture, format, structure, and content. These standards won’t solve all our compliance problems, but they will certainly make the system fairer, and I expect our judiciary would like them too.

May the good work of the international health standards community continue apace.

Dr Margaret Faux is a health system administrator, lawyer and registered nurse with a PhD in Medicare compliance, and is the CEO of AIMAC, which offers courses and explainers on legally correct Medicare billing

Heather Grain is the convenor of the international ISO TC215 health informatics semantic content working group, a former chair of the SNOMED international education working group and a co-chair of HL7 International’s vocabulary committee; she is an international leader in the development, implementation, management, and governance of terminologies, health data, education and standards