Because it’s only the biggest change to digital health since My Health Record.
The federal government is circling the biggest change to digital health since the My Health Record scheme, but unlike the MHR, this change will have a significant impact on how GPs work and make money over the coming decades.
If you want to make the eyes of almost any professional (medical or otherwise) glaze over, start talking about standards, and then how technology and innovation in any profession can’t move effectively forward without them. I’m yawning writing this.
But maybe slap some cold water on your face, strap in and give this article a go, because as boring as some of the subject matter might seem to be, the impact of it for the career of a GP over the next couple of decades might be as big as anything that an AHPRA, PSR, RTO or RACGP is planning for you.
This story has its origin in the mayhem that has been covid, and the billions of dollars that are about to be aged care.
The Department of Health, now armed with some shocking experiences of how the system performs under pressure, largely as a result of covid-19, is pondering, very carefully it seems, how disconnected our various healthcare services actually are, and how hard it has been to make progress on the very complex issues of sharing health care data across our health system, and between patients and providers.
Converging on this problem is $17 billion of proposed spending to fix a very broken aged care system, and hundreds of millions to improve the state of our mental health services.
The department’s thinking is pretty blunt.
Aged care isn’t connected to anything in a digital sense (see our article in sister publication Wild Health, Low MHR uptake mean aged care targets may be missed) as unsurprisingly its cost-conscious (and often profit-taking) owners have invested virtually nothing in terms of making their institutions meaningfully “interoperable” with other key healthcare providers, most importantly, general practice.
How do they put a rocket under this problem and get aged care connected to the rest of our modern healthcare system, and avoid wasting a significant proportion of that $17 billion on mainly manually servicing the sector?
The politics of this problem is overt. What about the My Health Record? We’ve spent well over $2 billion on that already; surely it can help?
As a GP, you might have your own views on the effectiveness of MHR, or even the ethics of it, in things such as patient consent, which the project bypassed when it decided to make the population “opt out” rather than “opt in”. If you’re not up to speed on how effective it has been in the GP sector as a bang-for-buck project, here’s a recent story we did on the quality of the healthcare summaries data that GPs contribute to on MHR, which is incentivised by the government through e-PIP.
The title probably gives the tone of things away: More than 20% of MHR shared health summary data is likely garbage.
If you’re a bit worried about MHR being a major component part of the aged healthcare fix in terms of aged care sharing important data with the rest of the healthcare system, and the very real political issues involved in that, you probably don’t have to.
Firstly, the government has put aside a lot of money – $42 million at least – to help the MHR get connected to aged care over the next few years. That will certainly help, if you believe the MHR is going to be the major game in making aged care talk to, say, general practice seamlessly, and then other important allied care providers to aged care.
But more importantly – and this is where things might start to get a little boring, sorry – the government is putting in a giant backstop, should the MHR not be the universal solution to all our health data system sharing woes.
After years of talking about the idea, it looks like the federal government is giving serious consideration to establishing a proper strategic (standards-based) framework to help align digital health stakeholders in moving more effectively and faster to an interoperable future.
Yawn.
Reeeeaaaaally.
That’s exciting (not).
Read on if you can. It actually is, and if it happens in a manner that is effective (big “if” where government is concerned) we are likely to see after just a few years some radical improvements to digital health interoperability across the spectrum of healthcare services.
But the one which will be the initial focus of this initiative, and which should be the most interesting to the GP sector, is what sort of changes in connectivity to aged care and allied care this initiative can facilitate.
The aged care sector is largely greenfield in terms of healthcare interoperability. That means if the government introduces standards for healthcare providers and their technology vendors, which provides a common framework for where everyone must aim into the future, then aged care is likely to be where all these new systems will likely be specified and introduced.
Currently general practice, which has been well served by its tech vendors for nearly 30 years now, is landlocked by old server-bound technologies (the computer and software that your patient management system runs on). The main vendors for these technologies – Best Practice, Medical Director, and perhaps ZedMed – have given great service to the general practice community over the years, but the technology is not data-sharing friendly, web friendly or patient friendly when compared with newer technology, which works on open (easy to access for everyone) application program interfaces (APIs) and web sharing architectures (cloud based).
The main vendors, while big in the local medical software game, aren’t big in a global sense, or big even as local software vendors. They have revenues of between $20 million and $90 million only per annum, which in digital transformation terms, is not much to help you reinvest in changing all your products to open API cloud-friendly versions. GPs, though they complain a lot about their PMSs, also don’t like change they don’t have to undertake, so they aren’t asking their vendors to change anything. So, everything stays stuck in the past.
Even the federal government until now has artificially propped up these older systems because when a new initiative is needed, such as collecting data from general practice for the Australian Institute of Health and Welfare (AIHW) in order to start optimising population health across the nation, it specifies older technology vendors to do the job. So the system reinforces itself.
There are other complex issues I won’t bore you with here except for one very big one.
Those technology companies that are producing new cloud-based products, which have far more potential for better data sharing, can’t really get going in general practice because the system is so dominated by older products. The cloud vendors can’t get any traction because of the cost of having to back-engineer their systems to talk to all the old technology that currently makes up the integrations on a GP’s PMS.
Most of the cloud PMS providers have failed to have any impact on general practice providers because they have to build so many backward integrations to old technology to make them functional for everyday GP work. That’s a wildly expensive sunken cost that they can’t get back.
So nearly all these vendors have stopped thinking about individual GP practices (for now), and started focusing on helping very large organisations solve closed-loop healthcare ecosystem issues with enterprise solutions.
If GPs think that’s fine, it’s definitely not.
Some of those enterprise-level solutions are entrepreneurial venture capitalists or private equity (some are backed by private health insurers even) that already are sweeping up corporate-GP-type assets, planning on leap- frogging the current general practice sector altogether, and providing GP services that are highly interoperable directly to aged care, mental health and even emergency care.
These groups will employ GPs, but they will disintermediate as much of the current GP sector as they can and automate as much as they can using cloud technologies. The GP sector can’t fight it. It currently operates in a way that doesn’t easily share data and talk to aged care, mental health and emergency non-hospital services, and there are no market or government signals pushing the sector that way.
Aged care, being so lacking in any digital services today, and having so much money on offer, is the perfect place for these enterprise groups to start. It can be a “closed ecosystem” as far as they are concerned in that they can establish interoperability in a system between an aged-care provider and their own (owned) GPs on their own enterprise systems. If a local GP can’t connect effectively, they are out of that loop.
It could be a major road crash for how GPs work and make money in the future.
But whether they have read these dynamics or not, the federal government is about to intervene to set the whole system moving more inexorably towards the future in terms of these more efficient data-sharing web-based technologies. It is going to attempt to introduce a standards-based framework for all healthcare providers and technology vendors, which will force everyone to embrace more efficient technologies into the future. It’s an ugly way to look at it, because industry usually hates it, but they are going to force us all to co-ordinate in getting to the more efficient technology by making it the law that we have to move that way.
We will all be given time to think and transition, and in some cases assistance, if the government does this properly. But we will all have to contemplate the change.
This should be a good thing for general practice, although it will be a very difficult journey for everyone overall, not the least of which will be your favourite PMS vendor, who hasn’t been forced to change so far.
If it works, all healthcare will be aligned in interoperability capability. And hopefully general practice will be able to compete more readily for aged care work against the money people who are planning now on their enterprise solutions.
But there is a lot of uncertainty to be sorted out from here.
Standards are usually imbedded in every product or service we consume. They make us innovative (they can do the opposite here too), communicate much better, much more efficient, more profitable and save our lives regularly. Yet to most of us, professionals included, they are largely invisible. We don’t give them a thought or a care.
This is in part because standards are inordinately difficult to develop and maintain, and are, to most of us, boring.
Knowing this, you might ask yourself: how has Australia managed to keep our healthcare system in relatively good shape over the past decade without any meaningful, nationally funded, robust digital health standards regime?
Possibly the most controversial element of Australia’s digital health journey of the past decade or so, outside of the enormous centre of gravity to the whole system created by the MHR project, has been the abandonment by government, and the subsequent breakdown of a cohesive standards regime in which digital health tech vendors and providers could evolve their offerings and innovate.
Ironically, it was the introduction of the Personally Controlled Electronic Health Record (PCEHR), the first name for the MHR, that led to the breakdown of our local digital health standards regime. The MHR was always a well-intentioned project (if not thought out fairly seriously), so there is nothing sinister about how it led to our not having standards. In fact, it was the huge movement in thinking and the need for new technology to be aligned at a speed that was just too fast, when the MHR concept was introduced, that led to the breakdown. Too many organisations, people and ideas clashed too quickly, and the government lost faith in the organisations and people doing digital health standards, so they stopped funding it and the regime collapsed.
That was in 2011.
Most people in digital health understand that without a workable standards framework, sharing data effectively in the massively and increasingly complex ecosystem that is healthcare is next to impossible.
Yet our local national digital health standards regime broke down seriously in 2011.
Apart from the efforts of a few largely unpaid individuals, it has not been the focus of any serious efforts to fix until early last year, when then interim CEO of the Australian Digital Health Agency (ADHA) commissioned JP Consulting and long-time standards expert David Rowlands to report on how a new standards regime might be reintroduced into the country.
That report – A Health Interoperability Standards Development and Maintenance Model for Australia – landed in the hands of the ADHA sometime early last year but was reportedly seen initially as controversial because Rowlands had been forthright and blunt in laying out the problems of the past.
The report was released publicly in May 2020, and, possibly – amid the mayhem at the agency that would have been caused by covid at the time, and the impending changeover of most of the senior leadership of the organisation, including the departure of interim CEO and long-time COO Bettina McMahon – virtually nothing has been heard of the report since then.
The 154-page report is thorough, accurate and precise in its recommendations, including a blunt but necessary history of where things went off the rails in the past.
It is possibly the most important document that exists in the hands of the government in terms of the future of a workable digital health ecosystem in this country. It is HERE in if you want to read it.
You’d think, being about standards and interoperability, it might be a bit dry. But it’s a fascinating history of how Australia has been thought leading and bold in digital health, how we have great intellectual resources and capacity, how it all went off the rails, and how it might be levered back onto some rails in the near future.
It includes an honest and blunt history of the National E-Health Transition Authority (NEHTA), the PCEHR, the ADHA; where good intentions got derailed; how, why the problem of interoperability is so complex in healthcare compared with other industries; how all industry has required standards to proceed with innovation; what has been done in other countries; why Australia has stalled and fallen behind (despite laying claim to being a world leader in digital health); and most importantly, a roadmap to re-establish a workable and agile standards regime in Australia, amid all the difficulties that would face such a task.
It’s a document than anyone in a leadership position in a major healthcare provider or tech vendor should read if they are serious about moving to the future with their organisations.
The fundamental proposition of the document is that “Interoperability is impossible without standards”. The subtext of this proposition is also in the document. If someone doesn’t fund and enforce standards, you won’t actually have an effective standards regime.
That Bettina McMahon and the ADHA management team at the time commissioned the report probably suggests that the ADHA was running out of ideas to progress big issues that it was trying to solve, such as secure messaging, and wanted to revisit the past to see if there was a better way to the future.
It was an important change of mind for the ADHA, which had in years past resisted the idea that the lack of a formal national standards regime was inhibiting progress, and in particular, that one of the new emerging global healthcare standards, Fast Healthcare Interoperability Resources (FHIR), should have a more formalised and potentially government-directed role in Australia’s digital health landscape.
Importantly, the Rowlands report notes that a standards regime would need to have a series of coordinated and managed standards at four levels, of which FHIR might be only one component, so FHIR by itself is no magic solution.
But I’m digressing and getting a bit deep and meaningful when I start ranting about FHIR.
Just over a year after the Rowlands report was officially released by the ADHA and quickly seemed to disappear from anyone’s radar (notwithstanding that, it still sits on the ADHA website HERE with a whole lot of other interesting and helpful documentation), it looks like the $17 billion aged care problem, and some other frustrating issues around COVID, has caused the DoH to dust off the report and have a deeper think about it.
The cloud technology versus older server issue I have described above can’t be broken down without some alignment of tech vendor and healthcare provider development and intent. And that can’t happen without standards. At least that is what David Rowlands is saying in his report – and he’s right.
As everyone says, in healthcare you need to follow the money. A lot of people are eyeing off aged care’s $17 billion and the federal government looks like it is thinking pretty hard on how to make sure a good proportion of it is not wasted in a healthcare system that is thus far disconnected in a manner that is pretty dysfunctional.
Last week, during a budget briefing call by the DoH to a large number of members of the Medical Software Industry Association (MSIA), organised by MSIA CEO Emma Hossack, one of the members asked the DoH representative out of the blue if the government was re-considering the introduction of a standards regime.
When the answer came back as “yes”, the collected bunch of vendors on the call were that surprised, or dumbfounded, that there was an awkward silence.
Then someone asked if FHIR would be one thing that the government was considering in such a move, and again the answer came back “yes”. More awkward silence.
According to the person reporting the call to our sister publication Wild Health, the standards question was an interjection that was not in line with the briefing going on (it was off script), and after the second answer was given, there was some more silence and then the call returned to the fundamentals of digital health funding in the budget.
The apparent awkwardness of the vendors on the line, and the failure to follow up on what is possibly the biggest impending change in digital health to the country since the announcement of the PCEHR, which has now famously morphed into the fund-sucking centre of gravity for all digital health development that is the MHR, is probably because of how big an impact such a change might have on many of those vendors.
A new and mandated standards regime would signal to most tech vendors in Australia (not all, as some are working in the future already) that the future eventually holds very significant change for them, and it won’t be easy.
Likely nearly every vendor on that call to the DoH was a long-term vendor with years of IP invested in developing systems that in the future will have to be re-architected almost entirely to be interoperable to the standard that the Australian government will require, and that will be a standard that makes Australian healthcare a lot more interoperable than it is now (which is not very).
Our local technology vendors don’t have a lot of capital to invest in redeveloping their core systems, and even if they did, the very nature of an open-systems, API-friendly, cloud-based interoperable healthcare universe, which is what such a standards regime that the Rowlands report is pushing over time, might mean that the business model on which their current product is operating ceases to exist.
In other words, some vendors, whether they change or not, won’t survive the transition.
On top of all this, these vendors, all of whom have years of invested IP built up, are facing off competition in the form of new money from VCs who are prepared to back smart new entries that are taking a bet that the system must eventually change and are already developing systems that will replace those of the existing vendors. Such players have access to the capital needed, and plan to make a loss for many years – something most of the existing vendors can’t do.
There is much valuable IP, expertise and experience tied up in this older vendor community.
As the government moves to develop a new framework for healthcare provider and tech vendor development that aligns the system towards a more interoperable future, the government will need to take this into consideration.
Some will necessarily have to fall by the wayside, as occurs in all digitally transforming markets. But if we get the introduction of a new standards regime wrong, we could end up exiting a lot of the expertise and experience that will still be needed in a more interoperable regime. Also, the change will take a lot of time naturally. We will have a spectrum of systems for five to 10 years at least in such a transition.
But overall, not moving to introduce a standards framework for interoperability as the Rowlands report suggests is not an option.
Currently the system is creaking loudly with two technology ecosystems diverging from each other: the legacy server-based systems, which currently dominate most of the landscape, especially primary and allied care; and the open API web-sharing cloud-based systems, which we are starting to see spotted around the system, especially where they can be introduced without having to talk too much to the older legacy systems.
Ironically, we see in some state governments a version of specifying to the future.
Dr Zoran Bolevich, who runs eHealth NSW, has always maintained a program of technology that optimises open APIs, FHIR and other modern interoperable interfaces in important tenders. He isn’t enforcing a standard in the sense of making it the law, like the US has with “anti-blocking laws”, but he is making it fairly clear to tenderers that they need to meet his and his state’s standard, which is as interoperable as feasible in terms of technology solutions.
A framework for change, which includes a modern, agile, and comprehensive standards regime, such as that proposed by Rowlands in his ADHA report, can include a roadmap that attempts to navigate the very large and known issues that would be faced when introducing and managing a national framework for digital health standards, moving forward.
Both the US and the UK have gone some way to showing us how.
In the US, legislation to end “information blocking” (where vendors and providers deliberately design systems to hold patient data in order to retain commercial advantage) was introduced five years ago, but not enforced in law until this year. The government understood pretty well how much disruption and commercial issues it would be creating in the vendor community by forcing them to change, so they gave them time and a roadmap, and established a framework to help vendors get to the deadline.
Despite their healthcare system being quite a mess, the US now is a world leader in marching their system towards more interoperability. Enforcing a form of standards regime was the baseline of this change, but with careful forethought for how it would affect vendors and providers along the journey.
Interestingly, the MSIA, whose members for obvious reasons mainly comprise legacy vendors, is strongly supportive of the idea of a new standards regime to move the industry forward.
When asked about the call and the awkward standards question, CEO Emma Hossack told Wild Health that the MSIA had been a strong advocate of such a regime for a few years now.
It is unclear yet exactly what the DoH or the ADHA are thinking in respect to the Rowlands report: what they might take from it, and what they might leave out or alter.
But it is very clear they are they are thinking carefully now about some form of national standards regime in the near future that is funded and enforced.
It does seem like they at the very least understand Rowland’s fundamental premise, and that of many key players in interoperability in this country that “interoperability is impossible without standards”. And they are thinking about all of this in context of the large sums of money they intend to spend on aged care, mental health and eventually chronic care.
Boring or not, GPs are in the epicentre of all these changes.
This topic will be discussed in one of the sessions in Wild Health’s up and coming Inaugural CXO Australasian Healthcare Cloud Summit, on August 10. Tickets to the live session are highly limited but the sessions will be free and live streamed via webinar. You can register HERE. If you have any other questions or input regarding the summit you can contact Talia on talia@medicalrepublic.com.au.
