4 March 2020
e-Scripts project portent of FHIR potential to transform locally
Web sharing resource Fast Healthcare Interoperability Resource (FHIR) shares many political characteristics in Australia with the climate change debate. It’s a bit of an inconvenient truth that sooner or later you sense will catch up with the federal government and local vendors because it’s an increasingly obvious answer to so many issues of complexity in sharing health care data, especially with consumers.
Whereas the standard has been recognised for its potential in the US and parts of Europe, and pushed to the forefront of efforts to open up health data sharing, especially with consumers, Australia has somewhat stubbornly resisted FHIR’s attraction as a fast developing universal go between on data trapped in vendor legacy systems and within other more complex standards structures such as HL-7 and CDA.
Until now, Australia has had a firmly ‘steady as she goes’ approach to the standard – not ignoring it for sure, but not recognising it and pushing it properly either .
This is in part because its underlying utility transgresses most of what we’ve placed most of our Federal government digital bets and money on, in the centralised command and control structure and platform of the My Health Record project, and in part, and perhaps more pragmatically, because the local vendor market has invested so much so recently in other expensive and complex technologies, that changing too quickly could prove commercially fatal for some companies.
But perhaps like drought and bushfire, eventually something comes along and stings you into reality.
There are many vendors and government projects now specifying some sort of FHIR interface in solutions, and lots of trials, but the rapidly evolving e-scripts project is one where FHIR has been front and centre of getting to a practical solution quickly, and one which very soon will be having a major and meaningful impact on our healthcare system. It will likely increase patient compliance significantly, reduce all those errors created by paper, and make the lives of patients and pharmacists alike far more efficient.
In the e-scripts project, the use of FHIR feels like it has come of age in a way that both government and most local vendors can no longer ignore. In fact, part of why both groups won’t likely ignore this project, is that the success of this complex project is based on the government, through the ADHA, and some key vendors, mostly eRx (part owned by Telstra Health) and MediSecure, collaborating effectively to bridge some very complex data sharing issues across the country.
The project should start returning to the system later this year as it moves into production once the key vendors do development work to talk to the system, and various consumer based applications, some driven by the pharmacy networks themselves, come on line.
On spec, one might wonder what the big deal was in this project, given that technically, all prescribing is already electronic. The major patient management systems all talk to the centralised script exchanges of eRx and Medisceure (eRx has approximately 90-95% share of this exchange) and the exchange talks to all pharmacies. Until now, a patient still needed a paper script in order to fill their script, but behind the scenes, a check on that script was point to point electronic between the pharmacy and doctor.
But now legislation has been passed which means the paper won’t be needed. That means passage of data via the consumer’s mobile, or mobile app provider, directly into any pharmacy in the country. It’s a game changer for things like compliance.
There is a lot of new complexity in this equation. Without a paper script, somehow the system now needs to put the patient at the centre of controlling the transaction, and give them the ability to choose how and where they fill their script.
In this new paradigm two new complex variables had to be managed. The patient management systems of doctors need to talk directly and securely with a patients mobile phone, or that information needed to be given to third party consumer apps such as MedAdvisor, so they could help the patient manage the process. This introduced a whole lot of new third party systems that needed to exchange data with eRx and MediSecure, and then talk directly to the dispensing systems within all the pharmacy chains. At the same time, many of the pharmacy chains wanted, and needed to be able to offer their patients a service that would at least replicate something like their existing relationship, where a chain would keep the patients script on file and talk to them when the script was needed.
All these existing systems now needed to communicate in real time securely. FHIR was an ideal go between interface for so many third party systems. It’s like a universal translator – a babel fish for various vendor systems using all sorts of combinations of standards and technology to present and process their data.
To do all this effectively, a standardised technical framework around which each vendor system – doctor side, patient side and pharmacy side – would be able to talk to the script exchanges was first base. The Australian Digital Health Agency took the lead on developing this framework with eRx and MediSecure, and in doing so, they were developing what is probably the first major nationwide application of FHIR technology where it will be facilitating everyday communication of data between consumers and the healthcare system.
The key role of the ADHA in the project can’t be lost on the many critics of the organisation. But most of the criticism has focussed on the My Health Record project, and its centralised command and control strategy, including forcing most Australians to unwittingly become a record holder of some sort. Not on this project.
The two projects are in many ways at odds with each other – each taking very different roads to consumer engagement. They describe a sort of split personality at the government agency charged with delivering the best roadmap for effective digital transformation of healthcare in the country.
On the one hand, the e-script project is showing all the flexibility and agility that is feasible with FHIR technology, especially in its ability to synchronise with older legacy systems and make them talk alongside newer systems to patients and doctors alike, in a highly distributed manner. While the My Health Record (MHR) project is a bit adrift now in an old model that predicated its strategy on key exchanges of information being hubbed in a centralised government controlled record.
That probably doesn’t make the MHR a ‘dead duck’ project just yet – given the nearly $2 billion in expenditure so far, you’d certainly hope not.
The e-script project hopefully might inform the AHDA and others about the how they approach the next phase of the MHR project, which is currently undergoing rounds of consultation on what new technology the project should move to for its delivery platform.
If the ADHA go the way many think, and simply specify this next stage of the MHR as simply a technology replatforming based around the same thinking and strategy, then the specification for what the project should be doing likely won’t change much, and it feels like that will set the future of the project as the past.
It would likely doom the government to more spending on an idea that already most people see is not working and slowing getting further and further away from the point of meaningful doctor and patient digital engagement day to day.
The ADHA and the government has been very reluctant to measure the meaningful engagement data of the MHR, because they likely know already that things are panning out as they’d hoped. After all, if for instance, no specialists use the MHR, what’s the use of GPs uploading information. And if GPs only upload information because their practice managers need them to in order to make the practice ePiP targets for income, then real engagement at this most important level is lost anyway.
There are real issues with the MHR today, and the replatforming of the system offers the ADHA a big opportunity to ‘reset’ the project in a way that aligns with how the rest of the world is going in creating distributed information that consumers can access and control in their day to day healthcare engagements. The replatforming also aligns conveniently with a change of guard at the ADHA. Immediate past CEO, Tim Kelsey was charged with doubling down on the MHR when he turned up a few years ago. That pressure might not be on the new CEO, and given the significant shift in how technology is being deployed, perhaps the ADHA masters in Canberra will listen to new leaders if they suggest a change of plan.
FHIR founder Grahame Grieve told Wild Health that the replatforming opportunity for the ADHA may turn out to be make or break for the digital health future of Australia.
“Currently we still don’t have a vision for the future of [digital] health in Australia”, he said. But we need to stop and develop one around what the replatforming opportunity might really present us, he told Wild Health at the recent HL-7 conference in Sydney.
“We need a long term framework, which is around things like enabling peer to peer communication between providers and between providers and their patients…we need an ICT information framework that supports all this”, said Grieve.