How to make GP digital health gravy

A short critique of our Gravy Day digital health blueprint.

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On 21 December last year DoHAC published what should rank as one of our most important health planning summary documents for decades: the Digital Health Blueprint

2023-2033. So I wrote a quick song …

Hello Dan, it’s Jeremy here, I hope you’re keeping well
It’s the 21st of December, and they’re ringing the Blueprint bell
If you turn out to be a saviour, we’ll be out of here by July (2033)
Hope to kiss patients on Christmas Day (2033), please don’t let them (continue to) cry…

GPs will be familiar with the song but probably not Dan(iel) McCabe, who is the main man inside the Department of Health and Aged Care running a pretty good new digital health agenda for the country, and one which will eventually impact GPs in a big way.

So what’s with the timing on something so important?

I was Christmas shopping at the time the plan came out, as I suspect were most other people who might have found it interesting.

We at TMR had largely stopped all our news services to go on break. We do still break big news over Christmas if it’s big enough, but even though this is a very important document, there wasn’t exactly any breaking news in it.

I did eventually read the blueprint and its associated action plan over my break. When East of Eden starting to get really slow (after the 350-page mark if you haven’t read it yet), I’d stop every now and then and read a bit of the blueprint, until eventually I’d read it all.

Maybe this explains the timing.

People need to be relaxed and have nothing much else to do to get through an important summary document like this, thus allowing them to savour the ideas a bit longer and ponder what might really come of it.

That’d be my get best attempt at a “get out line” if Mark Butler sent a WTF email though to my boss on the timing of the plan’s release – which if he didn’t, he probably should have.

If you haven’t read it yet, and everyone – including GPs – should at least try, here’s a tip: skip the blueprint and read the action plan first.

The blueprint is the sort of political PR aspirational puffery that might turn away the most hardened digital health nerd from persisting even with the far more important action plan.

For those non hardened nerds who want to save even more time and not even give the action plan a decent go (I’m going to assume a lot of GPs might be in this category), here it is in shorthand (note, my interpreted words not the blueprint’s):

By 2033 we want:

• Patients and healthcare providers to be able to share meaningful and important health data in real time anywhere, anyhow
• We want to empower both providers and patients to make much better health decisions in real time using this meaningful information
• We want to make the system transformationally (not a real word, but it fits) more efficient, not just for cost but convenience, for providers and patients

We’re going to do that by:

• Improving the relevance and functionality of the My Health Record significantly
• Getting technology vendors and providers to play ball by quickly agreeing to sets of standards which would enable modern web-based sharing technology to be implemented nationwide and create the ability for meaningful real-time data sharing
• Aligning the states, the federal government and emerging private providers on healthcare data sharing standards, data privacy and sharing legislation and technology so it all works for providers and patients

Of course this is a somewhat kindly (and horrifically simplified) summary (and you probably can’t see the word GP in there, but you’re there big time, believe me).

The first thing I’d say is that to at least have a government with these collective goals and some plan to achieve them – no matter how insanely wicked many of us know the detail under it actually is – is probably a very important starting point for transforming health in Australia, and a not a point we’ve been at, probably since someone pretty clever thought of Medicare (Medibank back then) in the early 70s, and how that might help things along much better for quite a few years.

On the other hand, given just how wickedly complex the issues are, you soon realise that what detail there is is not the detail required to inspire a lot of confidence that this plan is achievable, even given its 10-year horizon.

The action plan does list quite a few actual projects, either in play already, or in planning (way too many in planning), and most of them do go to the overall goals above, some even with just a whisper of co-ordination, which is another glass-half-full observation of the document.

They include (with some short observations in brackets):

• modernising the My Health Record (“modernising” says it all given we’ve spent over $2 billion and 10 years on it for no net meaningful result so far)
• enhancing digital medication management (expand a pretty good start on e-scripts across hospitals, aged care and so on)
• creating national standards to support real-time data sharing (doable big goal with a lot of power to change things quickly; question is, when?)
• create e-requesting for pathology and imaging in the mould of the national e-scripts service (big issues here emerging with software vendor resistance, especially GP software vendors – more below)
• create a national Health Information Exchange capability (sounds good but no one is sure how it could happen, given how eclectic our state-federal system is; and if it could do what is being suggested it might, why would you need the My Health Record?)
• equip the health workforce digitally (whatever that means, and, the key issue here, what workforce? We need digital faster precisely because we know we are never going to have the workforce we’re predicted to need)
• fix mental health with lots of cool new digital apps (I’ll expand below)
• get genomics fixed in Australia and integrate that infrastructure to the whole plan (noble goal and a smart thing to do, but probably completely unrealistic given the major basic interoperability issues to overcome first and the government funding paradigm)
• fix aged care with all of the above (it’s getting silly now, the plan is far too sprawling, but you can’t not mention aged care in a digital health blueprint)
• and a throwaway par about AI and health (I guess there had to be one as this is a digital plan and AI is going to help at some point if we get it right).

You may have recognised that some of really cool things in here that we’ve done already (electronic scripts for instance) are not the product of superior goals and planning from the past, but accidents of a pandemic that forced us all to drop our weird bureaucratic and protectionist behaviours for a couple of years.

But everything in this list (bar perhaps the My Health Record) all go to a set of collective aspirations and goals which are mostly sensible.

You may also have again noted that there is still not a lot about general practice. But keep reading. If the government does what it can do now fast, general practice is going to see a lot of change in how it interacts with the rest of the healthcare system and its patients within a couple of years.

Back to my awkward reinterpretation of the first verse of a Paul Kelly classic for a sec.

Can we afford to wait 10 years to achieve some of the key goals in this plan?

It’s a question I think everyone in charge should be pondering a lot harder following the release of this blueprint.

We know the time frame is not the government giving themselves tons of wiggle room to protect themselves. If you include some of the big throwaways in the blueprint at the end – “we’re gonna fix aged care and mental health with this here plan” – 100 years might be a better time frame.

Even if we look at the basic obstacles this plan faces in just getting data sharing, standardisation and technology alignment going, 10 years is pretty optimistic.

Ten years can also easily be argued a wise time frame if we are to avoid large scale and very expensive screw-ups given the complexities, politics and interdependencies associated with healthcare provision. Mind you, if anyone ever wants to get honest about the ROI of more than $2 billion for the My Health Record, it’s pretty hard to see how anyone today could engineer an ongoing mistake that big again.

So, it’s sensible to plan this long, right?

I don’t think so.

Here’s why:

• Some parts of our system are going to crash almost certainly soon without bolder faster action. The most immediately identifiable collapse is within most aspects of our health workforce. All areas of workforce are vita and stressed but if our general practice network collapses our system will collapse entirely and the time frame for fixing that will be a lot longer than 10 years.
• Ten years is good and bad for healthcare planning. The bad side is that a lot of organisations and people can keep doing average and even bad things, often driven by natural commercial pressures, without being outed in such a long-term plan. Such constant long-term resistance can be very destructive in the end. Being bolder makes everyone clearer about what is going on and provides very little room for bad actors to hide.
• We’ve wasted maybe 20 years in Australia trying to get our act together in digital health and we find ourselves a very long way behind. We should learn from our many and large mistakes, trust our new plan and instincts, and not be afraid to be a little bold. We owe it to Australian health consumers and providers.

I think most people looking at where we are might recognise a climate change-type problem in our healthcare system.

Nearly everyone’s livelihoods and security – perhaps except GPs who are getting slaughtered anyway, so haven’t got a lot to lose through change – are tied in some way or another to the system not changing, or at the least not changing fast.

But everyone can also see the crisis coming in all sorts of ways.

If you work for government and you make a blunder, the political ramifications usually create havoc for everyone downstream, so “steady as she goes” is how this dynamic tends to shape behaviour – it’s not bad people. In fact, there’s a lot of good people around at the moment.

Commercially, no one has been totally honest yet about the dynamics in play in our system.

At the high end, the billion-dollar pathology players have zero incentive to change – if meaningful information starts to become easy to share, especially with GP patients, their revenue models don’t work very well, so they do have a very big business issue that they can’t simply ignore.

So far it’s been a game between these companies and the government as to who blinks first.

If you’re wanting a yardstick for how determined and bold our current federal government might be, watch this space.

At the end of the day the government has a nuclear option to make these groups change their ways: if you don’t join in – Sonic, Healius and co. – we are going to stop paying you.

That is political dynamite, of course. These companies are very powerful in Canberra and they have a lot of levers they can pull come election time given who they ultimately service, how many people they employ in the regions, and how much tax they pay (at least they pay tax).

The other significant commercial players, albeit a lot less powerful in terms of money and politics, are the duopoly of Best Practice and Medical Director in general practice patient management platforms, and the near monopoly Genie is attaining in specialist platforms.

All these companies have the ear of government and all are usually deeply involved in strategy and policy development at the government level.

This is both good and bad.

Good because they really do know a lot and can actually help, bad because no matter what they think or say, they have a deeply vested interest in shaping the market in the manner that suits them.

After 30 years or so of building third-party integrations around their core products, these platforms are insulated currently from competition.

But standardising on modern web-based sharing protocols and architectures would quickly break this protection down for these groups (not as much for Genie which is further down the cloud path), and rip away a good chunk of their revenues from the third parties who are charged for access to these platforms – providers like HotDoc, HealthShare, Healthengine, secure messaging providers and so on.

But unlike the pathology providers, who you suspect think they can hang on to their long-term revenue models through brute political clout, you get the impression the PMS providers do see the writing on the wall that cloud based interoperability presents them with.

That’s not going to stop them from trying to shape the market the way that suits them and going slow.

Both MD and BP are backed by giant corporations (Telstra and Sonic respectively), so although their revenues and cash reserves as individual businesses are minuscule compared to the path groups, their enterprise owners could afford to push through and take the hit of re-engineering faster if the government steps on them harder.

The government certainly should step on them harder, probably by legislating tech standards for data sharing between providers and patients much faster.

Interestingly BP is 30% owned by Sonic, one of said big pathology offenders, so it’s an interesting position for them, particularly given that BP these days has upwards of 70% of GP desktops.

This slice of the market is now so big that the government will want to be cautious they don’t crash these businesses without having some back up. This helps reinforce this duopoly.

So far, what we’ve seen is the government work very closely with these three providers to close off any potential for innovation in these platforms and that is not good for providers or patients.

An example is how at least two state and federal governments mandated the use of antiquated secure messaging platforms integrated with these old PMS platforms to talk to hospitals for referrals. By doing this they locked in BP and MD and if you weren’t on these platforms as a GP you couldn’t talk to a hospital the way you needed to. Even then, the technology is antiquated and doesn’t work well.

Quick declaration of interest here: I’m an unpaid non-executive director of a cloud-based innovator company (Medirecords), although I’m going to lay claim to not being all that conflicted these days because this particular provider has found a significantly bigger market across the broader healthcare system in cloud-based health sharing technology – something that goes to just how flexible and agile these new technologies might end up being if they were allowed to be introduced into general practice.

What are some things the government could do in this blueprint much faster?

Mandate data-sharing standards faster

While it was important to put aged care and mental health into a plan – they desperately need to be addressed – the name of the game here is interoperability: the focus for now should almost entirely be on sharing meaningful data seamlessly in real time between technology, providers and patients.

Notably, the government knows it can do this because the US has already done it by mandating standards, and its working to create transformation in that system – a system we all know is highly messed up.

If the government gets traction on this, both aged care and mental health will be in a massively better starting position to tackle as we get to them.

As an example of what change such an initiative might bring, most mental health is done by GPs in Australia, but it’s largely invisible – most of it is never recorded in an MBS item. Moreover, this work remains almost entirely disconnected from the more than $650m in funding the federal government gives to PHNs (and more to other non-GP groups) to tackle the problem.

With interoperability working better, you can connect GPs to mental health initiatives outside general practice properly and start transforming the current dysfunctional paradigm.

Same for aged care … wow, when you want to you can really oversimplify stuff.

Specific to a focus on getting interoperability moving would be to move much quicker to legislate for technology and data-sharing standards and let the big PMS system vendors know it’s happening faster not slower, so they should start working a lot harder on getting us to the future.

Maybe even give them some money to do it if it that’s going to help them over the line, but do not do it in a way locks out agile newcomers who have already embraced the cloud, as the government has so far done (and as result stifled a lot of value and innovation).

Put the no-play-no-pay option on the table of the path vendors

Put the nuclear option seriously on the table with the pathology providers now while you’ve got some time left until the next election.

Do it in secret if you must, and have a very good political backup plan, but do it.

These services are fundamental to system integrity and to meaningful data sharing. If you don’t get these providers in line quickly fundamental information won’t be shared properly in the system so the system won’t change.

To be clear, threaten them but nicely, and be prepared to pull the trigger on your threat if they keep acting up, as they clearly have been doing so far.

Make an actual national single digital front door

If government wants a third big idea, here’s one that I was a little surprised the elves in the Department of Health and Aged Care failed to recognise is under their noses. It’s already (dysfunctionally) in play, but it could be game changing, and it was a weird miss as it clearly belonged in the blueprint’s laundry list of all the stuff we are doing.

Sit down with the states, legislate if you have to, but create a single digital front door (SDFD) for patients across the whole country in a co-ordinated and smart manner, from which you can triage everything – GPs, pharmacy, allied and yes, mental health too.

The irony of the term SDFD is that we have about 50 of them across the country at the moment run by one health fiefdom or another, creating a significant amount of overlap and waste.

Health Direct has been nudging towards this national true SDFD concept for ever and, probably because of covid, is finally making some progress.

Today, NSW is trying to co-ordinate with Health Direct for a SDFD in that state. Even then, some PHNs in NSW are still trying to do their own special ones which are competing with that effort.

Meanwhile in Victoria, you have some fantastic virtual EDs emerging and a complete mess of groups competing for patients replicating the SDFD concept way too many times across different hospital networks.

One key senior manager running one of these services recently told us there was no reason not to actually only have one front door in that state, and that such a service would create massive synergies and relief to regional workforce issues. So if you can do that, why not do it for the whole country?

Shouldn’t Canberra step in and fix this one?

Someone in the capital should sit down, map this mess out nationally, and get nasty (but also nice) with some sensible legislation.

A bit like interoperability now, there is no technical issue at hand here. It’s all people in health fiefdoms competing. Again, usually good people with warped organisational signals being sent to them.

The government needs now to be bold with the low-hanging fruit in digital health (low-hanging doesn’t mean easy, by the way).

Take the risk and pull some triggers on some of these key issues much faster than your current blueprint is suggesting you will.

I’m pretty sure that even if you somehow screw up, people will still respect you for having a go, when we obviously need to have a such a go now.