2 March 2023

Australia’s digital health problem as explained to a six-year-old

Government Insights Technology

I’ve never worked for a tabloid newspaper, but I’ve had a few (admittedly old) friends who have over the years. Almost all of them were told by their editors early on to write as if they were explaining things to a young child.

This wasn’t because everyone who reads the tabloids is dim-witted. It’s a simple and effective way to create the greatest understanding of the concepts being written about.

Many people in the business of healthcare reform might become defensive when talked to about technology like they’re a kid. But they shouldn’t be.

The differences between modern, web-based, distributed data-sharing technology and very old, on-premise server-based technology (which can still talk to the internet by the way) can be confusing. Or they are so subtle at times that they make the differences in impact hard to believe.

This can make it difficult for lay people to comprehend the significant implications of letting the older technology persist in our healthcare system for too long.

To quickly illustrate how big the problem with our health technology base in Australia is, last March in the US, I walked nearly three football fields of digital health software vendors (more than 1100 exhibitors) at the largest digital health conference in the world. I could not find one that was unable, in some way, to share the data generated in their system via a modern cloud-based application interface.

Here’s the very obvious and increasingly embarrassing problem for Australia: If I was attending an equivalent digital health conference in Australia that same week – the Australian Institute of Digital Health (AIDH) annual conference and exhibition, or the Australian Digital Health Festival,  for example – and I walked the floor of their exhibitions to see which vendors in Australia can do what all those vendors can now in the US, the reverse would be true.

I would almost certainly be left with a surreal, parallel-universe feeling.

Maybe five per cent of the floor in Australia would have the same modern, web-based sharing capability of the three football fields’ worth of vendors in that US exhibition.

So far, most of the healthcare leaders in this country have not questioned why there is this polar difference in the installed technology base between us and the US and a few other countries, like Denmark and Israel.

One possible reason for this state of affairs is that when you mention the US healthcare system, people point to the disaster that it is for whole swathes of the US population. Understandably, they dismiss the idea that something being done in the US healthcare system could be better than what’s being done in Australia.

But these people are making the mistake of conflating outcomes created by a long history of a dysfunctional and fragmented payments and insurance regime with the innovation and leadership at play around technology in this country.

The US healthcare system is a disaster and not one to try to emulate in many respects.

This disaster created so much angst within the US government that decades ago the Republicans and Democrats became alarmingly bi-partisan about the idea of trying to fix the system in any way they could. The easiest quick fix they could come up with was working swiftly on changing the technology base of the whole system so it could share data between providers and patients far more seamlessly across the web. 

If you mention Denmark in the same way as the US in terms of technology, then often you will get a different reason to ignore the Danes’ progress: “Oh, they’re a very different government structure and really small. We’re nothing like them…”

Anyone in Australia who tries to explain away the three football fields story by saying something like, “the US is a disastrous healthcare system that no one should be looking at” or in the case of Denmark, “they’re just different from us” is either naive or playing some sort of commercial or political stalling game.

The US, Denmark, Israel and quite a few other countries now have an installed base of technology in their healthcare sectors that can share data between providers and patients a thousand times better than we can here.

Our technology position in comparison to these countries is now bad to the point of being almost inexcusable.

Essentially, nearly every software vendor at that digital health conference in the US has either built a version of a web-enabled, data-sharing babel fish (the universal translator from Hitchhikers Guide to Galaxy in the form of a small fish that you stick in your ear) around their old software platforms. Or, they have completely rebuilt their old platforms so they are the babel fish for healthcare data sharing.

As a result, any of these vendors can share data meaningfully with any other vendor, which means that in the US every healthcare provider can share data seamlessly with each other (not perfectly, but enough) and with their patients.

We are a full generation behind such capability in Australia.

There are some important questions here for Mark Butler, the Department of Health and Aged Care, and even for each state and territory health department and minister here:

  • Is this vast and widening chasm we now see between our installed health technology base and that of so many other countries’ advanced healthcare systems still an acceptable state of affairs?
  • How did we get here, what is still wrong, and can we start fixing this situation quickly?

I suspect one problem with asking these questions is that we have a lot of people in positions of influence in health policy and reform who either do not accept that this problem exists or worse, do not even realise it exists.

With that possibility in mind, let me take you one level down into the three football fields problem in an attempt to scare you a bit further about how obviously this problem does exist here.

At that three football field digital health conference (HIMSS 2022), there were many working demonstrations of the technology in play in the US. One of the most impressive was from a group called Commonwell, which is one of the largest health information exchange (HIE) hubs in the US. (An HIE is a centralised technology connector and standards group that helps the process of connecting one provider to another and to their patients across the US.)

Several times a day, the Commonwell demo used live examples of patient journeys in the US, complete with various medical mishaps and health system engagements, as a patient travelled their journey, illustrating how the new ecosystem was working.

The demonstration featured nine separate software vendor stations, representing EMRs of hospitals, GPs and other important provider systems like pathology and pharmacy.

Some of those vendor brands many people in Australia would recognise – Cerner and Allscripts (now Altera), for example. They were each running data through various hospitals across the country.

Others most wouldn’t (Athena and e-Clinical Works, for example) but they have equivalent vendors in Australia running EMRS for general practice, allied health and some other points of patient data generation in a typical healthcare system. So, the equivalent of our Best Practice, Medical Director, FRED and CorePlus, among many others.

In the demonstration, a patient might have travelled from Washington state to Orlando, Florida for a conference and got sick at the conference. As the patient interacted with very different software platforms across geography, the relevant data needed for a transaction was polled by the provider dealing with the patient in one geography and sent to them by each different vendor system across geographies, as required (usually via HIEs like Commonwell), and to the patient themselves. That patient had on their mobile phone live what was actually happening to them.

The demonstrations were real-time live demonstrations. The data was actually travelling live and hitting each different system and the patient’s mobile app.

Relevant data from one side of the country generated in a hospital EMR was, if required, being backloaded into a patient’s major data repository at their primary care provider on the other side of the country – again, in real time.

This process can fall over in the US and there are lots of complexities still being ironed out in this evolving ecosystem. The volume of data and number of transactions now taking place is immense. 

It’s not perfect.

But it is working, and across the US it is already being used on a massive scale.

It should not be that surprising to healthcare leaders in Australia that a system like this would actually work because the underlying technology facilitating this ecosystem – data sharing across distributed hubs of data across secure, cloud-based, web-sharing applications – has for many years been common in other sectors that require fast, secure, high-volume, high-fidelity and  complex information exchange, such as finance and travel

Now let’s see how this works in Australia.

It doesn’t.

To start with, 90% of our primary care installed technology base works on on-premise, server-bound technology which at its peak use in most industry sectors in the 90s and can’t share data in a manner even close to the way the US systems talk to each other.

These systems use very old, very inefficient, asynchronous connections for the limited talking outside their applications they actually do.

Yes, you can connect a Medical Director or a Best Practice to the web and download and upload data, and talk to outside applications that work off the cloud, like appointment engines. But you can’t share data seamlessly within each product (so even in the same practice sharing is hard), between each product (from one practice to another) and outside primary care (to hospitals, pathology, pharmacy or allied care providers).

In other words, general practice – the major pivot point of our future proofing via the Strengthening Medicare Taskforce plan – is land locked technology-wise and can’t really participate in the most important goals of that plan.

GPs can’t work in virtual integrated teams with anyone really, so all the talk about integrated care teams we are hearing at a political level in the last few months is just that. Talk.

We all love the concepts of outcomes-based care and integrated care teams and patient-centric medicine, and a lot of us discuss its potential, but none of it is possible in Australia with our current installed, fragmented technology base.

Even in our hospital system, which has spent a fortune in the last decade on upgrading its core systems to more modern EMRs, sharing data in the way it’s being shared in other countries overseas between hospitals and outside them to primary and allied care, is not feasible.

Even though many of our large hospital EMR vendors in Australia are US-based, and therefore have been forced in the US to make their systems share data across the web and to patients seamlessly, via proper cloud-based interfaces, that has not so far been a requirement of our healthcare providers of any Australian government.  

So even though we have an increasing number of hospitals with reasonably advanced installed digital EMR bases, nearly all of them aren’t even enabled to talk to other hospitals – even ones on the same EMR product – let alone what The Strengthening Medicare Taskforce says is vital to the future of healthcare reform, general practice and other community-based healthcare providers like pharmacy.

So, in essence, most of our hospitals are land-locked data systems as well.

It gets worse (of course).

As well as a federally-led program to create a single health record (the My Health Record service) for every citizen, which so far has cost us over $2 billion and hasn’t got a lot of traction, nearly every state and territory has their own program for their own version of an individual citizen health record. So a lot of people will soon have a My Health Record from the federal government, and Another Health Record from their state government as well – ironically, neither are owned or controlled by the patient).

The aim of most states and territories in doing this is, in fact, reasonably sensible in the context of where they find themselves: they want to make sure they can share records across the state within their public and private hospital system and across radiology and pathology. 

An obvious question that people in power should ask about these state based digital health record programs is, why aren’t they just using the My Health Record?

The answer is that the My Health Record isn’t fit for purpose to use at the state level for what the state’s want to do. That and a lot of state IT health leaders will tell you privately that the My Health Record is a fundamentally flawed project now.

You can achieve a degree of success doing as a state building your own citizen health record because each state controls most of the digital health infrastructure in hospitals in their state.

But if you look at what is going on in the US, Denmark and other countries, doing this is starting to make less and less sense for Australia.

For starters, even if you did achieve a good single digital health record within a state, you’d only be able to share that data within your state hospital network, largely within your sophisticated, big (and usually urban) hospitals that have good EMRs. Of course, if someone goes across a state border … well, that’s not going to work usually.

In some of the larger states, the problem of connecting these newer EMR systems in hospitals with general practice is at least being looked at. But it’s being addressed currently by using a very old technology solution – secure messaging networks – to talk backwards to the old on-premise GP systems.

The states are probably opting to use this technology because, at the moment, it is the only way to talk to GP systems as a whole for things like referrals and discharge summaries because all these GP systems are so old and would not talk to them across the web properly.

Notably, by specifying the use of this old technology and running big programs to roll these old messaging networks out across each state, state governments are effectively reinforcing and locking in very old technology infrastructure in general practice, potentially for years to come.

I’m sure state health planners would prefer not to do this, but because GPs are financially constrained, independent private businesses, not usually tech savvy, and have a lot of other things on their minds, they haven’t got a lot of choice if they want to get to them en masse.

Even if states succeed in rolling out widespread secure messaging solutions to talk to general practice, it’s messy legacy tech which doesn’t work very well, even when it’s in place.

Collateral damage created by this dynamic is that any local vendor that has built a cloud-based EMR and patient management system to share data is actually locked out of the ecosystem because there are so few of them installed at the level of general practice that the state government planners don’t bother catering to them.

In other words, if you are a modern, innovative cloud technology provider who has invested in the sort of technology the country desperately needs, and which we see working so well in the US and other countries, you are disadvantaged significantly in this ecosystem.

It’s actually a bizarre situation now. We are building out new networks which reinforce very old technology and which will likely significantly stall the ability of Australia to do what the US and Denmark are doing.

If you think about all the rhetoric from healthcare leaders on how we are going to build connected care teams and develop data streams to enable more outcomes-based funding, knowingly making it much more difficult for modern, local, cloud-based EMR providers to operate, let alone innovate, is pretty crazy.

I am on the board (a non paid non executive director) of one of these vendors (Medirecords) so I have had a front row seat to this unfolding dynamic. Being on this board I am of course conflicted in some respects pointing this dynamic out but anyone who gets the three football fields problem should realise that this problem is very real regardless. Medirecords is doing fine regardless of these market factors (hint: it isn’t really in the GP market much anymore), but that is different (albeit interesting) story.

A possibly good live example of the sort of dysfunction we are prepared to keep living with  in our system, when we may not need to, is the recent moves in Tasmania to “transform” and “integrate” the entire state’s healthcare system.

If you read the Tasmanian digital health strategy it says all the right things: the state needs to move to being able to share patient data between providers and patients seamlessly in order to create co-ordinated care, manage an emerging chronic care crisis, and deliver a much more patient-centric experience.

But the formal beginning of the rollout of this plan looks very much like same old, same old.

The state has called for expressions of interest for what is effectively a statewide hospital EMR system (and an ambulance system).

The state does need to upgrade its hospitals to more modern, digitally-enabled EMR platforms – it currently still runs what are effectively, paper-based systems in its hospitals.

But a hospital EMR system is not statewide integration of care. It’s just upgrading your big hospitals to be more digitally enabled internally, and a little more capable of sharing data outside when they come to it.

There is no plan to integrate primary care, pharmacy, pathology and radiology, allied care and other key elements of the state’s entire healthcare system.

States, of course, aren’t funded to help manage primary care and pharmacy (health out in the community). They are funded to build and manage hospitals, so it’s not really that surprising that their digital health program is unfolding nothing like the wording of their digital health strategy might suggest.

The unfortunate thing about what seems to be going on in Tasmania is that in such a small and compact state, with only four big hospitals and 144 GP practices, taking on at least the integration of general practice and hospitals in one go is entirely doable.

In Denmark, the government realised early on that primary care didn’t have the cohesion or the capital to transform its technology base. So when the government started radically altering how the hospital sector operated to make it significantly more fit for purpose and efficient, it reached out to GP bodies and fully funded the primary care sector to upgrade in alignment with their hospitals to create a whole-of-system integration effect.  

Tasmania could easily do this.

Although the Apple Isle’s declared spend of $150m on its hospital EMR and digital ambulance systems is probably not enough to get even those systems done, with only 144 GP practices in the state, bringing general practice along by getting them on integrated cloud-enabled systems at the same time as digitising their hospitals would likely cost in the realm of just $3m to $4m.

In terms of bang for buck and bragging rights about which state is actually integrating all points of care, wouldn’t setting this relatively small amount of money aside in your plan and giving it a go as you upgrade your hospital sector make a lot of sense?

With a bit of left-field thinking and not that much money, Tasmania has the chance to be the Denmark of Australian healthcare systems.

But it doesn’t look like this is going to happen.

Another example of possible waste created by a state is the recent Victorian initiative to install what they say is a health information exchange (HIE) with a view to being able to share patient data across its state. Last month, we learnt that the state awarded $10m to a big global EMR provider for the first part of this plan but to do everything they are planning is going to cost large multiples of that.

If Victoria succeeded with the plan, at the end the state might have a system in which most of its larger hospitals could share patient data better with each other and Victorian patients. But, like Tasmania, Victoria isn’t contemplating anything much outside its big hospitals so there will not be seamless integration with primary and allied care or pharmacy.

Are you starting to get the picture here?

If you are one of those people who has been largely OK with how we are going with digital health infrastructure in Australia until now, or hasn’t thought that much about it because it didn’t seem that important, does any of this really seem like an acceptable situation to you?

Still not convinced or confused?

Some of your disbelief and confusion might be because we seemed to have spent so much on digital health over the past 10 years in Australia and surely something must have come of that.

I’m not just talking about the more than $2 billion on the My Health Record here.

If you add up all the digital health infrastructure spend by states on EMRs, and then on trying to build their own versions of My Health Record intrastate, $2 billion is a fraction of our entire spend nationwide.

So how have we spent so much and achieved so little relative to the UK, Denmark and other countries?

Trying to answer this question may not help a lot here since it’s a politically charged question and a lot of people get upset when you talk about it because a lot of jobs and careers are vested in the idea that Australia is getting it right in digital health, not wrong.

But we are getting it so wrong. That makes it worth at least touching on why and how, with a view to our trying to understand why moving on starting to get it right is so important now.

An important starting pointing understanding why we are where we are is that we have a great healthcare system currently.

It’s especially great at managing acute care, which is what it has mostly had to do since the ‘70s when the basics of our modern system were put in place.

But it’s not what it needs to do going forward and everyone knows this.

We are rapidly moving to having to manage chronic care in the community as our major focus and we can’t do that without a different technology base which generates and shares a lot more data easily across the system.

Most people are realising this because the system is starting to strain in all sorts of ways – the breakdown of the bulk-billing model and Medicare is a pretty obvious example.

But even with obvious cracks starting to open, if anyone stands up and says, hey, big iceberg ahead everyone, there is plenty of evidence of the system working today for those insecure or uncertain enough about the need for change to say that we shouldn’t worry so much since our track record and great system says that we’re an unsinkable ship.

The US, which has literally been in the burning platform paradigm for years, has had the opposite problem to us, which is the key reason why it has moved so smartly and swiftly to re-platform and adapt its entire installed technology base on more appropriate modern technology.

Usually, the yanks are behind us on stuff like this, right?

I’m going to suggest that even the biggest digital health infrastructure optimists in Australia today are starting to smell smoke, which means it’s not long before there is fire (or to mix metaphors, we actually hit that iceberg).

All of this is to say that we could get away with the last 15 years or so of trying things and failing, and saying to everyone – largely for political expediency – that we’re doing a really great job in digital health, even though we haven’t been.

Very few people joined the dots or cared.

No burning platform. No one needed to get it.

But everyone needs to get it now.

My Health Record and its predecessor, the PCEHR, explains a little more about why so many of us remain way too complacent about this huge problem.

When My Health Record started as an idea more than 15 years ago, as the PCEHR it wasn’t a terrible idea for its time. But this project, which morphed into My Health Record, somehow became an excuse for not looking harder at what was going on in the wider world of healthcare data sharing.

We spent so much on it, and bet so many careers on it, it became very difficult to out it as the wrong architecture and idea for sharing data efficiently in a modern health ecosystem.

“Everything good here, everyone, look at this mega central My Health Record thing we’re doing…”

A while back, it became pretty clear that My Health record was not going to be the best way to share healthcare data efficiently in this country.

But we became obsessed with a bad idea surrounding this database: that if we put everything into it, including uniquely ID-ed citizens and all their health data, we wouldn’t need to change our installed technology base like far more advanced countries were doing.

Here, very quickly, is why it has been a bad idea to place all our bets on My Health Record:

  • No giant, all-encompassing database of everything ever will have everything when and where you need it.
  • All giant, all-encompassing databases will be hacked one day.
  • Health data is so widespread, complex and distributed within a healthcare system that a much better approach to storing and accessing the data is to leave most of it where it is generated, but make sure the systems where it is generated are capable of extracting relevant, immediate, meaningful data and communicating it with any other system, and a patient. (This, by the way, is essentially what the 21st Century Cures Act in the US was created for in that country.)
  • The technology has existed for a while now to be able to connect widely distributed databases and share that data securely over the web, so why wouldn’t we use that technology?
  • The idea of a database that has everything on everyone isn’t just a dangerous concept security-wise; it’s also a very inefficient concept technically. You have to make sure everyone spends time putting data in, and time getting data out and if you have to incentivise or force people to do it if it’s not working for them (which is what has occurred with My Health Record), the data is usually going to be pretty bad and lead to the old adage, garbage-in, garbage-out. It’s just very old thinking these days in terms of data fidelity.

My Health Record is not a really bad database and a write off that will embarrass lots of people.

It will still have some ongoing use, but if that use is to be the hub of most meaningful healthcare data exchange in Australia, then that would simply be stupid and dangerous.

Yet, in the recent release of the Strengthening Medicare Taskforce report, somehow someone convinced all the reformers and leaders on that taskforce that My Health Record is still the way to go and that we just need now to “modernise” it.

I’m hoping that at least a few of the non-technology-oriented taskforce members wondered how much more money we might need to modernise something we’ve spent $2 billion on in the last 10 years, including at least $300m or so last year.

But maybe not.

My Health Record can still play a role in Australia moving its installed healthcare technology base to where countries like the US, Denmark and Israel have gotten theirs.

But if Australia does go the way of the US and other countries in aligning all their vendors and providers on a more appropriate technology base, in the end My Health Record is going to end up as one of thousands of distributed databases in systems all over the country that talk to each other and patients in a network.

If you get away from the idea that My Health Record should be the centre of most meaningful health data exchange in our system, the idea of My Health Record doesn’t actually compete with the idea of aligning all our vendors and providers on modern, cloud-based, data-sharing technology.

In fact, part of “modernising” My Health Record is wrapping a FHIR interface around it so other modern systems can talk to it.

When you think about that, it’s a sort of tacit admission from its owners (all governments, via the Australian Digital Health Agency) that the idea of moving everyone to this sort of modern, cloud-based, data-sharing technology is the real way to go.

Such a process would just mean My Health Record would eventually become part of a far broader and far more functional Australian data-sharing ecosystem.

In this respect, whatever value My Health Record really does have for Australians and the healthcare system should become far more evident over time.

One thing that might happen is that many current sources of important data generation – general practice for instance – would no longer need to spend additional time and money worrying about formally sending data to My Health Record.

As one example of how inefficient and expensive this process can be, currently the government has had to incentivise GPs and GP practice owners to spend time collating and sending data in the form of patient summaries to My Health Record every month.

Most practice owners I talk to would not bother doing this if they were not paid up to $50,000 per year by the government to do so.

But the process is fundamentally flawed:

  • A large proportion of practices automate the process and send batches of summaries which fulfil the minimum requirements to get paid, but are largely nonsense in the context of the actual patient situation with a particular GP. It’s a box ticking exercise for many practice owners in order to earn their ePIP.
  • Practices are only required to send a portion of their summaries, so even if the data being sent to the database is meaningful it’s far from comprehensive
  • The data is almost always old by the time it hits My Health Record.

Currently, the government is spending an inordinate amount of time and money trying to get every type of healthcare provider to build their system to talk to My Health Record and then take the time to collate and send data to it.

But if each of these providers simply upgraded or built their systems to talk to all other systems via modern, cloud-based  data-sharing technology, as they have done in the US and Denmark, none of this would be needed. Everyone could talk to everyone else.

That a lot of so-called My Health Record stakeholders don’t see a return on their efforts to get their data into the system after so many years is pretty telling. And that’s despite many of them getting paid to do it.

As a result, we know the data that gets there is very often patchy, old or not very useful. There’s no love in the process because stakeholders don’t buy into My Health Record.

If you take this problem and scale it to the whole country and all providers having to send data to the middle, which is what the government has been trying to do for years with My Health Record, you are just scaling a giant clunky mess.

Yes, parts of My Health Record are useful. But some parts that are useful are also not easily accessible, partly because lots of data formats are used and these can’t be atomised or easily and quickly accessed, and a lot of the data simply isn’t of any use to the vast majority of health system encounters of a patient.

What about the alternative being discussed here of a system where all the technology in the country is aligned in some way to facilitate universal access to distributed databases across the system via web-sharing technology, on demand when it’s needed?

Here’s an idealised way in which that might work:

  • A patient’s GP has a version of Medical Director or Best Practice (or other patient management vendor system) which has an installed babel fish web-sharing application or it’s a ground-up-built cloud application so it shares data across the web using secure, modern, cloud technology as a part of its core functionality. (Note that Medical Director has a cloud version of its software, Best Practice is working on a babel fish-like product for its on-premise version of software (Halo Connect), and there are a few ground-up-built patient management cloud products in the market already, such as MediRecords, Clinic to Cloud and Gentu.)
  • All the data on that GP’s patient management system is now accessible to the patient via their mobile app, if and when they need or want it and, vitally, accessible to other parts of the system such as hospitals and specialists on demand should the patient be visiting that part of the system and need certain data to optimise their visit.
  • The data transfer is all in real time and from the source where the data has been generated in the system so the fidelity of the data is very good – certainly exponentially better than what we have in My Health Record now, which accepts old, fragmented and a lot of meaningless data (including from GP practices trying to get their ePiP with minimal effort).
  • Neither the hospital in this example nor the GP has to spend time and money sending the data of these encounters to a third-party data base – for example, My Health Record. And the government doesn’t have to spend extra money trying to incentivise people in the healthcare system to take time out of their already overly busy days loading data to a central database.
  • Note: with this system, one day it might be that a database like My Health Record is used to collate third-party, non-patient-identified data for very powerful population health purposes. But if these systems are cloud-enabled, this process will likely be “hands free” since the compliance is in place and it would not be a drag on providers’ time and money.

When I say the above scenario is “idealised”, if you are in the US, Israel or Denmark, this scenario is largely already in play and working.

I’ve already seen a lot of this stuff working casually in the US, like a patient opening their mobile app to see everything they need from their local GP and hospital live (albeit these patients tend to be members of rich HMOs, but that’s a particularly US-centric health equity issue; the point is it can be done and is being done a lot already overseas).

Why would we not want this sort of system to be working in Australia?

If you clear away obstacles created by legacy policies, bureaucracy, politics, commercial interest lobbying and a few other things (that’s a lot of clearing I know), I’m sure most people in our healthcare system would.

If you could ever explain this situation to patients, although we probably never could, they certainly would.

Can you imagine how upset patients would be with us if they did understand all this and realised we had allowed everything to drift for so long into its current state?

But enough looking backwards.

How hard would it be to start Australia on this journey and how long might it take now for us to get there?

Starting the process is very simple and would cost virtually nothing.

All the federal government would need to do to get started is follow a version of the journey  the US federal government took with the 21st Century Cures Act.

The starting point is to announce to all our software vendors and all our providers that at some point in the future, they will need to have upgraded their technology base, or created adaptions with babel-fish-like applications around their older technology, to a certain set of standards.

The timeframe for this in the US – from formal announcement to requirement to comply or maybe go to jail for not complying – was five years, but many years before that the US government had been moving important pieces into place.

In simple terms, the government would be mandating that every software vendor and provider in the country get out of the ‘90s technology wise and into the 2020s within at least five years (and hopefully less).  

There is a fair bit of complexity in the process of deciding which standards would apply and at what level for what provider, but making it easier for us now is that other countries have already done it so we have a few roadmaps to work with, complete with where they went wrong along the way so we can avoid pitfalls.

This, of course, is the easy part.

You can imagine that upgrading a whole country from 1990s-like technology within even five years is at once going to cost both providers and vendors a ton of money, which many might not have, and create quite a few logistical implementation issues along the way.

But again, we know the process can be managed by governments with the right plan because it’s now been done in a few places overseas. So let’s not dwell on this important issue too much at the start.

Notably, the Department of Health and Aged Care has been looking at this idea for a couple of years now, and even threatening to come out and do it .

There were rumours of a start on the process by Christmas 2022, but it looks like this may have been postponed by a delay in releasing the Strengthening Medicare Taskforce report.

In an update on February 9 to the information about GP grants attached to this report, there’s a very telling line on how GPs will be allowed to spend grant money which reads:

Enhance digital health capability – to fast-track the benefits of a more connected healthcare system in readiness to meet future standards.”

To deliver this promise, I assume the federal government is going to need some “future standards”, right?

So, it looks like something is going to move in this area soon.

Also worth mentioning here is that a lot of work has already been done by some very clever and eminent experts on how we would structure and run such future standards and a process like this in Australia.

This report – A Health Interoperability Standards Development, Maintenance and Management Model for Australia – which was commissioned by the Australian Digital Health Agency and delivered in January 2020, lays out a plan for delivering such a process across Australia.

Notwithstanding that it looks like the federal government may be about to pull the trigger on some sort of standards and alignment of technology process, there are still a few things that could significantly disrupt such a process we will need to be careful.

Covid got us some way to the people in power that count starting to worry a lot more about how fragile our healthcare system might actually be. But there remain a whole lot of other top-of-mind political issues to fix before healthcare, such as the cost of living.

And there are plenty of people in power, both in state governments and the federal government, that still either aren’t familiar with the story being told in this article or still don’t buy it.

One problem that might also be in play is that if the federal government, via the DOAC, moved on the idea of mandating a future standards regime for all our installed healthcare technology base, as occurred in the US, without proper buy-in from the states and territories, then the states and territories might not play ball and decide to wreck the whole process from the start by simply not co-operating.

The states and territories spend the most on healthcare technology, so a mandate to upgrade it all within a set period of time would certainly create quite a bit of worry within each state and territory government.

One irony is that this spend on healthcare is mostly on hospitals today, and if you got this process going well enough you would almost certainly in the mid-term need fewer hospitals and spend a lot less within a state on delivering healthcare, or at least you would improve your health system exponentially with all the additional money you would have saved.

Another problem facing the federal government beyond the politics of trying to wrangle the states into an expensive process of upgrading their technology base in health is that each of the states has built out its own strategies, dreams and plans for the health of its citizens, often with grand, statewide transformation strategies, which many administrators and bureaucrats have bought into and are proud of.

Dictating alignment of technology strategy in this environment will be tricky. There’s no easy answer to this problem other than it will need strong leadership.

A sense of purpose and understanding at the highest levels of state and federal leadership, even beyond health portfolios, will likely be required – the sort that I’m suggesting still doesn’t seem to exist.

You’d think given the posturing recently of the NSW and Victorian state premiers about reforming healthcare and helping GPs, and the sort of rhetoric we see in state digital health strategies like that in Tasmania, there might be a window of opportunity to work this problem out with most of the states and territories.

With no easy solution to the problem of the states and territories, one thing the federal government could try is to throw a bit of caution to the wind and come out and mandate a future standards and technology regime for everyone, regardless of what the states think.

And then see what happens.

The act of putting this rather large stake in the ground is not going to cause any immediate system stress or cost, but it will almost certainly flush all the detractors and non-believers into the open.

Once in the open, maybe they can be engaged and brought into the tent somehow.

At the very least, you’d have a much greater definition of the challenges you really do face in attempting to transform the entire system.

Such a move would also quickly flush out a lot of the logistical and commercial problems that both vendors and providers would face if they were given a firm and legally binding timetable to upgrade all their technology.

The real problems of moving forward in the way countries like the US, Denmark and Israel already have would be a lot clearer for the people at the top who would need to manage things.

And no matter how controversial such a move might end up being, at least we will have started the real process of meaningful technology reform to our healthcare system.

If you’ve made it this far, and you’re interested in learning more about the ideas and issues discussed in this article, most of them will be raised and discussed at the upcoming Wild Health health leaders reform summit in Canberra on May 3 and 4. The summit has drawn an array of senior healthcare leaders and influencers, including people like Stephen Duckett (former federal Health Secretary and current board member of Healthdirect); Hans Erik Hendriksen (former CEO of Healthcare Denmark); Dr Nicole Higgins (president of the RACGP); Dr Danielle McMullen (vice-president of the AMA); Jay Rebbeck (international co-commissioning expert); Elizabeth Koff (CEO of Telstra Health and immediate-past health secretary of NSW); and many more.

Check out our speakers and agenda and get your tickets HERE.

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Brian Sullivan
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Brian Sullivan
1 year 2 months ago

Very well said – excellent analysis

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