10 reasons why the report on the MyHR trials feels a lot like it is what the Department of Health wanted it to be
In the ABC satire Utopia, the head of department asks a consultant to do an “independent review” of a recent project. The consultant asks: “What do you want the findings to be?”
The government-commissioned report by the Siggins Miller consultancy on the My Health Record trials is life imitating art. Here are 10 reasons why this report feels a lot like it is what the Department of Health wanted it to be.
1. A compulsory MyHR?
So far, not one key stakeholder has bought into the MyHR in a meaningful manner, except, of course, for the government itself. Not patients, not healthcare professionals, not key service providers such as software vendors or private pathology.
So, after $1.5 billion and counting, what is the government’s answer to this dilemma? Make it compulsory? Sorry.
What if the system and the concept are (or always have been) fundamentally flawed? There are lots of reasons to suggest that the MyHR idea, certainly in its original grand form, has had its time.
Several technologies are reinventing the concept of a flexible electronic health record from the ground up. More agile, more accurate and timely patient record systems have started via private providers, and they look like they will do a lot of the job the MyHR was originally designed to do.
Yet here we are considering making the system compulsory and tying all points of data in our health system to it. Without understanding its utlity in our rapidly evolving digital ecosystem better such a move risks creating ‘the mother of all red tape’. We are at the point of bribing doctors to use it via ePIP, and they still don’t engage in it meaningfully.
Do we really think the standover regulatory path will make it work? We’ve had to pay GP-patient management software vendors to write to it, because they didn’t see any use in it.
The major private pathology providers won’t touch it because they see no benefit. Patients don’t care about it, which is why we’ve decided we need to opt them in, understanding full well that their apathy will work in our favour once it’s opt out.
The argument from the DoH seems to go that the reason no one is engaging so far is because the system needs a critical mass of data. Maybe. But if no one is engaging – patients, doctors and service providers – wouldn’t you be a bit cautious about simply ‘enforcing’ the use of the system?
2. Focus groups don’t lie?
Yes, they do. They get things woefully wrong all the time, mostly as a result of poor “design”. Something of the potential design issues in the Siggins Miller work for the DoH is apparent very early on in their report. They state that “there is a consistent view among individuals that the government should make use of MyHR system by healthcare providers compulsory”’. The logic provided is twofold:
- The patient benefits are so good doctors will use it
- It’s costing a fortune, so we’d better use it
Who are these mysterious individuals? If they are supposed to be GPs, the major users of the system, then something is seriously amiss in Siggins Miller methodology.
Under certain circumstances, you will say one thing in a focus group to maintain confidence and respect, which are not your closely held views. Who else, who is in a position to judge properly, could be saying that a compulsory system on the professional provider side is a good idea? Not the pathology providers. They don’t see any upside in the system as it stands. Not the software vendors, who gave up on the ADHA when it was called NEHTA, because they weren’t listening. What about the patients? The report does have some quotes from the odd patient suggesting the system be compulsory. But there is nothing systemic in there from doctors or service side professionals.
It’s hard to see what stakeholders, other than the government, are in tune with this logic and therefore how the report could be suggesting that this is a prevailing view.
Consider the logic expressed by Siggins Miller on behalf of their focus group attendees. “If the cost to taxpayers [of the system] is as high as it would seem to be, then why wouldn’t the government make it compulsory for practitioners to use?”
Make it compulsory because it’s costing a fortune and we need to offset the cost? How does that help things if it isn’t actually a workable idea?
3. We need to spend more to make it work?
The Siggins Miller report is replete with additional spending ideas to get the MyHR to take. Aren’t we spending enough?
According to the review, nearly everyone needs more education and training to understand it better, we need to improve “user friendliness” of registration, we need to spend on making access easier, we need more data from pathology, we need more ePIP money, we need more call-centre services, we need to educate nurses and practice managers more, we need more social media, we need pharmacists to join in, we need…. we need. It’s a very long ‘we need’ list.
My personal favourite is this one: we need to “engage a suitably qualified social marketing agency, supported by dedicated content rich expertise in healthcare, to develop a multifaceted marketing strategy for each relevant market segment of healthcare providers and individuals…” The Medical Republic wouldn’t mind tendering for that piece of ‘bottomless pit’ business.
4. The evidence base?
It feels a tad ironic that the DoH engaged not-inexpensive consultants to review the “opt-out” MyHR trials and report on the MyHR progress bill themselves as “experts in evidence-based health … design, planning, review, research and evaluation”, but they don’t present tangible quantitative evidence to support their recommendations.
Tangible, quantitative evidence is available. The numbers using the MyHR system are staggeringly low so far. In quant terms, doctors aren’t engaged and they are uploading ad hoc and highly variable data (not because they’re bad citizens but because they aren’t engaged in the process meaningfully). There is no pathology data to speak of, although this is absolutely vital if a patient is really to get a view of their health.
The DoH is going to run a chicken-and-egg argument here. There still isn’t enough data and when there is, things will tip. The problem is they aren’t broaching the possibility this won’t happen and what will happen if it doesn’t. They are just ploughing onwards and upwards.
5. Real and tangible progress?
I was talking recently to a very senior manager of New Zealand’s national telehealth provider about the culture of change in the New Zealand health service. At his weekly managers’ meeting he was informed by a senior manager that their mental health support trial using Facebook had commenced and was going well. Such a trial, of course, has many potential regulatory and ethical issues. He’d not heard of the trial until that meeting. But his staff were empowered enough that they went ahead and launched it. They were empowered to get ‘shit done’. The senior manager was a little horrified, suitably. But things worked out.
It is clear from the Siggins Miller review that nothing tangible has happened since the MyHR project was rebooted under the Australian Digital Health Agency (ADHA).
This assessment will be seen as harsh by some. The ADHA only really got started in August last year. Understanding the huge challenges, the agency put much early effort into “changing” the secure messaging situation as a practical and sensible starting point to get “progress runs on the board”.
They will say they have come a long way. But they haven’t come far enough to change one thing that impacts at the level of improved service delivery for GPs and patients. At best, they have a better plan and roadmap for secure messaging and hope of change, where once there was little. But what can we point to and say “we saved a dollar here”. Nothing. Not yet anyway.
The other key job they’re on is ‘a strategy’. We still don’t have that. When I first spoke to the new head of the ADHA, Tim Kelsey, in October last year, I walked into an office which had views of Sydney Harbour that would make a top four law firm envious. I was horrified at how inappropriate this appeared, given we’d largely wasted $1.2billion on the MyHR at that point of time. Kelsey was, too. He promised to move offices. That hasn’t happened, probably for practical reasons. Leases can’t be broken without huge cost. But it would have been something tangible.
6. Technology?
If there is one giant elephant in the room of the grand MyHR plan today it’s technology. As we speak, two private operators have launched patient-based applications that stand a very good chance of usurping a good deal of the original function of the MyHR. And about five others are lining up to do it. Two of them have massive market access to GPs and probably can go a long way to achieving it at very low expense and without all the money that is being proposed in Siggins Miller for education, public marketing and training. Very simply these systems will work automatically off a GPs patient management system and they will work because there exist compelling benefits and efficiencies for both the doctor and the patient in using it. Like other digital technologies, rather than a national advertising campaign, these versions of a patient EMR might spread virally via the hub of each GP practice. Another group with some intention in this area already has 500,000 patients already using their existing appointments service.
Why isn’t this ringing alarm bells for the DoH? Why aren’t the ADHA and the DoH engaging madly with these private providers to understand the implications of what they are doing and seeing whether they can ditch half their plan now in favour of supporting these private initiatives?
Why is the ADHA maintaining that these ventures aren’t doing what the MyHR is designed to do? How do they even know? They haven’t recently talked to any of these companies recently in a meaningful manner: Best Practice, Precedence Healthcare, MediRecords, HealthEngine, Medical Director, DTX, Cerner, Welio, Clinic to Cloud, GP2U, and many more.
The tech sector is leaving the ADHA, the DoH and the MyHR behind. They are working from a very simple pretext in developing their own form of an electronic medical record: what best suits the patients, what will likely be used by both patients and doctors because it provides genuine and tangible benefit and is simple and inexpensive to use.
There doesn’t seem to be any question that the MyHR still has some role to play even if these private initiatives go viral. The private sector only operates on profitability and that never covers all the public. In the case of telehealth, treating someone with cancer versus algorithmically handing out a sick note has vastly different profit outcomes, so someone has to be the ultimate back stop. That feels like where the MyHR needs to heading, or at least contemplating. There is sure to be some data the private providers just won’t bother putting on an EMR. But the MyHR is still trying to be everything to everyone.
7. Cost
There is no practical examination of return on investment in this report. To be fair, that was not the remit of the report. But why not? There are no ideas for saving but lots of recommendations to spend more. Someone needs to report some form of ongoing ROI progress. It doesn’t seem likely. The DoH is measuring and reporting on itself.
8. Co-Design
Co-design is a fancy way of saying, when you are designing and implementing a complex system, do it with the people who have to use the system. That is a stated aim of the ADHA. Indeed, Dr Merideth Makeham, a GP and the clinical director of the ADHA, is very bought into ‘co-design’ principles and trying to apply them. Which begs the question: How do you, on the one hand, effectively design something with a stakeholder – GPs – while at the same time hold a gun to their head with a compulsory order that they use the system? To be fair, this is the consultant’s recommendation and is yet to be accepted by the ADHA.
9. Newton’s laws of bureaucracy
There are natural laws of bureaucracy. The more complex the portfolio, the stronger these laws tend to apply. Health is possibly the most complex portfolio in government. The DoH is a bureaucracy beast brought about partly because health is a life and death portfolio in the end. This beast has huge natural defences against change that threatens any of its component parts. And there are some awful examples of the bureaucracy mauling innovators and change agents. What chance do the ADHA and Tim Kelsey have, when the ADHA doesn’t even make it as a named organisation on the DoH organisation chart? Very little, we suspect.
10. Purpose
Two things generally drive success in the private sector: purpose and timing. Purpose is the most powerful of motivators. If you get it right, you can do anything. If you get it wrong, you can ruin everything. So what is the purpose of the ADHA? Is it to make the big grand MyHR in the likeness of how it was originally perceived, somewhat in the likeness of what has been achieved in the UK health system? Or is it, quite simply, the advancement of the health system to its highest feasible potential through digital technology?
The ADHA needs to sort this question out. And so does the DoH. As things stand we may as well change the name of the group yet again and call it the You Will Be Assimilated by the MyHR project agency. Digital health isn’t about a single government-controlled and -imposed electronic health record, and the ADHA feels like it remains anchored to this concept in a way that is distracting it from huge potential transformation of our health system.
The ADHA isn’t doing it deliberately, we suspect. They remain attached to the idealistic idea that the MyHR is a ‘unicorn’ type of solution. And by believing this they are blinded to the technology changes that are making the original concept redundant. Technology is intersecting with purpose and creating huge opportunities for changing our healthcare system today.
But the DoH’s failure to engage with the private-technology health sector is a sign that at least some of these big opportunities stand a chance of being squandered. It’s a big call, a politically difficult call.
Let the dream of the MyHR go with the flow of how technology is rapidly altering the landscape and see what happens. Change your organisation to be agile. Engage more meaningfully with the stakeholders – the doctors, the patients, and the technology. Say goodbye to the $1.5 billion investment so far but learn from the mistakes. Make the MyHR work for the stakeholders. Don’t make the stakeholders work for the MyHR.
