27 May 2021

Government circles biggest change to digital health since MyHR

ADHA Cloud COVID-19 Interoperability MHR

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.

Possibly the most controversial element of Australia’s digital health journey of the last decade or so, outside of the enormous centre of gravity to the whole system created by the My Health Record (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.

Most people in digital health understand that without a workable standards framework, sharing data effectively in the massively and increasingly complex eco system 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 some time early last year and was reportedly seen in some respects as controversial because Rowlands had been forthright and blunt in laying out the problems of the past (he had apparently been pressured to change parts of the report to dampen down the politics but refused to do that – for good reason).

The report was released publicly in May, 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 eco system in this country. It is HERE in case you haven’t read it yet.

You’d think being about standards and interoperability it might be a bit dry. But it’s a fascinating read: an honest and blunt history of the National E-Health Transition Authority (NEHTA),  the Personally Controlled Electronic Health Record (PCEHR), the ADHA, where good intentions got derailed and how, why the problem of interoperability is so complex in healthcare compared to 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 their 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 only be one component part, so FHIR by itself is no magic solution.

So why bring all of this up now, just over a year after the Rowlands report was officially released by the ADHA and seems to have been filed so far in the ‘reports we do nothing with’ basket (not withstanding , it still sits on the ADHA website HERE with a whole lot of other interesting and helpful documentation)?

It looks like COVID-19 may hae played a role in both delaying the proper attention that the Rowlands report deserved, and, in perturbing the whole healthcare system in a manner that the report suddenly became a lot more interesting to the federal government, to the point where they now look like they are going to act on the report, at least in part.

The other likely factor that the government might be putting together in their thinking on going the way of a standards regime for digital health is that the budget has committed $17 billion to fixing aged care over the next four years, and lot to mental health, but it’s more than clear that much of that money will be wasted without aged care being connected and interoperable with other key parts of the healthcare system, especially general practice.

That can’t happen properly 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 (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 move, and again the answer came back, “yes”. More awkward silence.

According to the person reporting the call to 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 Personally Controlled Electronic Health Record (PCEHR) which has now famously morphed into the fund sucking centre of gravity for all digital health development that is the MyHR, is likely because of how big an impact such a change might have on many of those vendors.

A new standards regime, along the lines of the one outlined by Rowlands, which would include FHIR, HL7, and SNOMED as at least one of four main component parts, would signal to most tech vendors (not all, as some are working in the future already) in Australia that the future eventually holds very significant change for them which 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 which 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).

That’s a very difficult proposition for those vendors, as Australia is a complex and reasonably different regulatory regime, so healthcare software is naturally specific to meet the needs of our system.

But our market is in global terms very small, and that means it’s a lot harder to make a living as a medical software vendor. If you are making money, in relative terms you aren’t making a lot compared to vendors in the UK or the US, and especially in relative terms to those companies such as Cerner which have managed to globalise the hospital EMR market, and increasingly connected components of that market.

The bottom line is this for those vendors. They 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 which are taking a bet that the system must eventually change and are already developing systems which 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 which 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 be needed still 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 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.

The big issue for the country is that the massive gains in interoperability, efficiency and cost that can be achieved with the cloud-based systems is being held back by the base denominator of having to eventually talk to the legacy systems.

If the complex core systems in general practice don’t move to cloud eventually, a whole lot of services are retarded by having to integrate backwards with non-cloud-based systems. These server bound systems are not agile, usually exist in many versions across the user landscape which new systems have to address, and are very unfriendly in terms of interoperability.

A big problem of having your healthcare system continue to be dominated by such legacy systems is that when the government wants to introduce something new, they necessarily have to use this existing infrastructure. This is especially so if the government has made no commitment to change to more effective technology, which so far our government hasn’t done.

So big contracts, such as data gathering for the Australian Institute of Health and Welfare (AIWH) are specified by the government in tenders to the legacy systems. That makes the development of more functional and interoperable cloud infrastructure much harder. The whole system then gets stuck in the past.

This is happening now. During COVID the federal government specified major contracts, such as vaccine booking, to old technology. Imagine if the government set itself a standard, and all the vendors, so they had to specify to the future as well, and even incentivise those vendors who could build more effective cloud based solutions?

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 face 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, 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.

But she qualified the comment by saying that the planning and implementation of such a regime had to have as an important baseline that takes into account the situation and needs of the local vendor community in making the transition. Even then, she acknowledged that not all local vendors will make it through the transition, saying that some will just not have the money or the business model that sees them make it in tact to the other side.

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 it 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, including FHIR founder and global standards consultant, Grahame Grieve, that “interoperability is impossible without standards”.

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.