Connectivity isn’t a tech problem, it’s a people and business problem.
In 1995 I worked for a large global information services group wanting to get into the medical publishing game by acquiring one of either of the major medical newspapers of the time, Australian Doctor or Medical Observer.
But instead of presenting a standard acquisition strategy for either of these major assets I worked with a particularly creative agency head to present a much grander plan.
The key slide in the presentation was a series of hubs and spokes, including all the major nodes of healthcare – hospitals, allied care, specialists, pharmacy, and the like.
The major hub for all key information transactions in a new world of evolving chronic care management, even back then, was general practice. And the key acquisition wasn’t the two newspapers (they were there, but secondary) but a fledgling electronic script-writing application that was just starting to take off called Medical Director.
The plan, in a typically naïve and narrow corporate winner-takes-all manner, suggested that Medical Director would one day be the major gatekeeping application for all the key data in healthcare, and therefore was the key to everything.
Fast forward to 2023 and that slide might still pass muster in any boardroom presentation today, with a few adjustments. Medical Director did garner a 90% share of GP desktops once and sold for $340 million to Telstra Health just two years ago. But now Best Practice, whose founder also started Medical Director, is in the picture in a big way as well.
General practice is the key transactional data hub
The point to this little anecdote is that at all points in time from as far back as 1994, connectivity to general practice has been the key to evolving the healthcare system to focus on managing chronic care using value-based care models.
In this respect, the My Health Record (MHR) has always been somewhat of a distraction (an expensive one) to the grander plan.
But quietly (and collaboratively) certain elements with the DoHAC have managed in the past year or so to pivot the plan from being MHR-centric back to the main game – creating effective and open real-time connectivity hubbed around general practice, and – maybe more importantly – patients.
The unofficial announcement that this change has taken place came a few weeks ago with what most people in the sector – doctors, administrators, tech vendors and managers alike – would have probably seen as some sort of esoteric and nerdy project around very hard to comprehend web-sharing standards for data in health.
That announcement was of a joint initiative between the CSIRO, DoHAC, the ADHA and the Australian arm of international health standards body HL-7, called Sparked.
Officially, Sparked is a federally funded project to build out “core” Fast Healthcare Interoperability Resources (FHIR) standards for healthcare vendors and providers in Australia via an internationally tested protocol developed by the HL-7 organisation, termed FHIR Accelerator.
Actual real-time and seamless data-sharing in health
Unofficially, the project is one big massive pivot of federal strategy on connectivity in healthcare to what the US has done via the 21st Century Cures Act. The Cures Act primed the health system siloes into talking to each other far more seamlessly and in real-time via forcing the adoption of a series of standards for sharing data.
A lot of doctors and administrators still don’t quite understand what FHIR is and how it works. At this stage it’s not a requirement that they do, and it may never be. After all, who has any clue how their iPhone actually works, even though it has revolutionised how we communicate and work with each other.
Whole ecosystems of connectedness have evolved around the technology for everything important we do, including banking, travel and online shopping.
Notably, healthcare isn’t really there at this point of time.
FHIR, with some other important standards thrown in around it in the right configuration, should start to change this situation for Australian healthcare, if the US experience is anything to go by.
A simple way to view FHIR is that’s it’s like the Babel fish in The Hitchhiker’s Guide to the Galaxy.
You wrap it around your application and far-flung database and it is a universal translator. You don’t need anything particularly centralised, like the My Health Record, if every app and database has FHIR wrapped around it the right way.
This description is going to make quite a few tech people cringe significantly, but for now it’s what most people need to think about the technology in order to start embracing it as this new strategy unfolds.
A people problem not a tech one
Whether this massive pivot will eventually work, is mainly a people problem, not a technology one.
A people and a business problem.
Business needs a path to be able to buy in here as well or nothing will move forward, and given health is our biggest government spend after defence, there is a lot of money tied up in healthcare businesses.
Those in the know don’t like to point it out but Sparked, in the end, is going to upend the business models of some very big and long established businesses (and small ones too), including but not limited to pathology groups, diagnostic groups, secure messaging groups, general practices (possibly in particular the big corporates), allied health groups, a wide variety of software vendors and a whole lot more we haven’t even thought about yet.
Creating liquidity of and to some extent equity in, healthcare data has very big implications for all stakeholders. It’s almost impossible to predict what your pathology business or general practice might look like once such liquidity is in place, other than perhaps we have seen in the US, which is at least 10 years ahead of us in this process.
If you talk to those in the know in DoHAC about what they are doing, you do get the sense they have a pretty good idea about how seismic this change is likely to be in the end and how many complex and stubborn moving parts they are going to need to meaningfully engage with to get to the other side.
Big pathology, for example, is not a lobby group you want to upset too much too quickly if you want to stay in government.
But most everyone who is smart senses this is an inevitable journey now, albeit it will still be a long one.
And most stakeholders, even big profitable incumbents who would prefer not to risk any change, such as the big pathology providers and the dominant GP patient management vendors, realise now that they can’t stay forever in the olden days of things like server-bound GP PMS systems or point-to-point bespoke secure messaging systems.
Modern cloud-based real-time connectivity is a part of our normal consumer lives now. Healthcare, no matter how highly regulated and risk averse it loves to be, can’t hold out any longer.
The world is catching up.
How long before we see change in Australia?
How long is this all going to take and where is our starting point? How long is a piece of string?
It took the US more than 15 years from the point at which that government determined things simply had to change. Being such an inefficient mess of a healthcare system created much more of a burning platform for the US, so Australia, as much as we have stuffed a lot up in terms of interoperability over the years, should not be that down on itself for being so far behind.
Sparked has an initial objective of getting core FHIR standards agreed among the vendor and provider communities within two years. This is much faster than the US, which gave itself five years for this stage.
General practice connectivity is the key
The gang at DoHAC has also done something very clever in setting another parallel goal of building out a national e-request platform along the lines of our e-prescription infrastructure which will incorporate the new core FHIR standards as the basis of its operation.
As innocent as building out a new FHIR-based e-requests platform might sound, it’s bigger than Ben Hur.
Because for a project like this work, all our GP PMS systems will need to be either rebuilt ground up as FHIR applications, or, have an FHIR-wraparound built around their old core architectures. Some work on this has started in earnest with Best Practice and Medical Director, which indicates that some vendors now accept this future as inevitable.
Even bigger, every pathology vendor will need to have FHIR wrapped around the technology at their end for it to work.
It’s probably the most ambitious and important project as far as the efficiency and equity of our healthcare system that has ever been undertaken, perhaps short of Medicare itself.
It’s clearly not going to get done in two years, but that DoHAC is trying to parallel run this as the major real-life test of its FHIR standards push is one giant line in the sand for every stakeholder in the system.
For those stakeholders who think they can resist, or that it won’t end up impacting them much, might want to consider that this whole initiative is being modelled on the 21st Century Cures Act.
The Cures Act was a very clever strategy run by very capable people. It all started with asking the stakeholders what they needed to make things work. In the end, it was always backed by the teeth of legislation, which once introduced jail terms for stakeholders who didn’t play ball.
Any cynics who think big pathology is too big to move or incumbent EMR platform providers can’t be shifted, should examine the whole US story so far.
It’s far from over but without question the Cures Act has turned connectivity upside down in a good way in the US and opened up a possible future for that system that many people thought was never possible.
Like the US, DoHAC is going to legislate when it is ready.
Surely if the Yanks can do it, we can do it. And faster. Just like the America’s Cup, right?
