Planting a standards stake into the ground first thing would be a seismic change for good

If you were the new health minister really wanting to do good things and make an early statement of positive change to show intent, you’d put a stake in the ground immediately on digital health standards. Here’s why.  

OK, you’re the new health minister and you want everyone to know: 

1. You know what you’re doing, and 

2. You mean business. 

What’s your first move? 

You could send no greater signal of meaningful change to the system, while taking virtually no political risk at all, by getting the Department of Health (DoH) to announce to all our healthcare providers and software vendors, that, as has already done in the US, we have an intention to much more meaningfully share data between providers and patients in the future. And therefore, we are going to require that in five years’ time everyone updates their systems in some way so they can share their patient data easily and securely via the cloud (or the web, if you like). 

What is the upside of such a move for the new Labor government? 

The upside 

• It’s a stake in the ground announcing the intent of systemic and meaningful change. You are moving early with clear intent and showing leadership from the get go. 
• The stake is actually planted five years hence, so while some people might get upset initially, you aren’t hurting anyone immediately who potentially could get hurt by such a move. You are giving everyone time to think, to organise, to complain if they like. You are being sensible and fair. 
• You are creating a massive alignment of healthcare provision, patient access and vendor input. Everyone can move forward however they like, BUT everyone must agree to update their technology to a common standard of data sharing for the greater good of the healthcare system, and patients. No one could possibly argue that such an alignment is not going to create massive cost efficiencies eventually, save lots of lives, and give patients a lot more power – as consumers they will eventually start taking anyway or disrupting if we don’t get there first for them. 
• You will immediately expose what the real problems are of such a strategy. You will force stakeholders with genuine problems to the table whereas, until now, such important stakeholders – the primary care EHR vendors, for example – have been able to ride along on seriously outdated technology, which is drifting the whole system to major problems in a chronic-care-focused future. You will create friction and action for change in the system. 
• You will have done the opposite of what both the Coalition and Labor governments have done on climate change settings for industry in the past 20 years, and put in place a common regulatory and rules framework around which we all agree the future will be built on. Among other things, such a framework will signal to major overseas and local investors that the technology our healthcare system runs on will be transformed over the next 5-10 years, so they had better get their wallets out. Which they will, as they have so massively in the US.  
• You will seriously expedite innovation in Australian healthtech and overseas investment as a result. 
• You have the success and do’s and don’ts of such a strategy in a much more messed up healthcare delivery country in the US as major guidance all the way. That is, you aren’t the first, and you certainly won’t be the last. Not if we go now. 
• You will have hit the start button on changing the platforms on which healthcare runs in this country, from 1980s-style, on-premise server-bound systems to what everyone else in the world now runs on: secure, web-based sharing and the cloud. How could you ever get into trouble for trying that? 
• The real upside here is that in five years’ time we will have data sharing in the system that will start to open the whole system up to much better patient data, around which we can design better funding for a chronic-care-focussed system. We can start altering our broken healthcare funding paradigm in a considered way. Currently we are stuck in a fee-for-service-dominated paradigm but we all know this needs to change. You can pay for outcomes only if you can measure them. With this update to our system, we will be able to measure outcomes and therefore pay for them with confidence. 
• Additional plus here: the country trusts Labor far more than the Coalition to muck around with Medicare. Probably only a Labor government can get away with it. 
• Finally, if the situation in Australia turns out to be unique, and so different to other countries that, somehow, such a stake in the ground does turn out to be the wrong strategy, no problem. Such a reality will reveal itself pretty quickly … and you’ve given this turnaround five years. Plenty of time to pivot to what you have learnt by putting that stake in the ground in the first place. The thing is, without putting the stake in, no one would have learnt anything, as nothing is currently changing anyway, so even if it turns out to be mistake, it won’t be. It will move us all forward. Shall I say it? It’s win-win (eek – trying to get the pollies on board here). 

And the downside? 

Can even the most mealy-mouthed cynic look at the list above and honestly start reeling off serious downsides to such a move by the government?  

I’m going out on a limb here and saying, if the new health minister does this, they are setting in motion a change so important and seismic that it’s going to end on a par (when people look back) with introducing Medicare in the ‘70s. But it’s far less risky politically than when Medicare was introduced, obviously. I’d want to try for that if I was a new health minister. It’s sort of a really obvious upside play with plenty of safety valves along the way. And one day, you might get memorialised – not like Gough, for sure, but remembered as a polly that really did good. 

Having said this, here are couple of issues I can think of that will almost certainly be in play. Nothing is that simple. But these issues are more about moving the obvious and likely resistance along, and sorting out some even more obvious admin issues that will immediately arise, than pointing out any big holes in the idea. 

• The local medical software industry won’t be happy and honestly, they will have every reason to be unhappy. It’s a small world out there in Australia, and capital is thin on the ground in the medical software sector – it just isn’t that big. Many won’t have enough capital to make the changes needed and stay profitable, and the government hasn’t got a fantastic track record of supporting necessary changes to software. Worse, some companies won’t have business models left at all in this new world, and unless they pivot, they will disappear altogether.  
• It’s not all bad though. In the US, even though e-Clinical Works, which is the equivalent of Best Practice, can share data seamlessly with Athena (which could be Medical Director), Cerner (our biggest hospital system), EPIC or Intersystems, it did not need to entirely reinvent its platform on the cloud. They have a cloud version, of course. But mostly, probably because of healthcare provider economics and apathy, much of their installed base remains on-prem still. But it had to put a sophisticated interface in these on-prem systems and have them all updated. It wasn’t cheap to do, even though they avoided a total rebuild and reinstall of their base. But at least it’s not “throw it all out and start again”, as some people suggest to scare you.  
• This software-industry part of the change will need to be well understood and thought through by the government. Help will be needed. But sorting out whom to give it too, when and how much, will not be easy. As an example, if you think of a great business, such as Medical Objects, that does secure messaging mostly (they are changing already) then that won’t exist in a cloud future. But when you think of how grounded and innovative the team at this company are, you can imagine that in a truly interoperable world of cloud and connected providers, a group like this will pivot to the many and big new opportunities in the middle ground of service provision in this new world. They are middle women now, in a sense. In the new world they could easily be the “new middle women”, assisting in connecting providers via various advanced understandings of the idiosyncrasies that inevitably develop between vendor software and providers in the new standardised world. In the US, there are some huge providers of this middle-connector-ware already, such as Redoxengine – read about this business here … it’s a very cool business, and when you read what they do and what is happening for them to exist, you quickly gauge how backward we still are in Australia.  
• All in all, the medical software industry will have to change a lot and it won’t be easy. But it will be much bigger and better after the fact. 
• What to do about the past 15 or so years of the government’s digital strategy, in particular its obsession with My Health Record as the centre piece of our system, and all the marketing hype that has gone with it? Well, that’s pretty easy, actually. You’re a new government, and you are about meaningful change for the better. You have permission to make the change. You show you know what you’re doing by treating My Health Record, and all who sail in her, respectfully and sensibly. It’s got a lot of good about it and in it (as does the Australian Digital Health Agency), and the public are used to it now. Lots of doctors know about it, even if they don’t really use it. There’s a lot of great data in it that we can’t get easily outside of it. So, it’s going to be useful if managed the right way. It just won’t be the centre piece of interoperability in our healthcare strategy, moving forward. It can’t be. Its design is centralised and insecure. Enabling secure distributed data sharing, as a common standards framework should do, will significantly change the game, and the dream of the original developers of the MHR concept. That’s all OK. Things change. Adapt, and adapt what you have to serve the new strategy. The new strategy is distributed data sharing, not make everyone send everything to one centralised, security risky record, and then get everyone to somehow get it back later when they need it. The MHR will have a place still and the ADHA will too, if reset a little on this new path. 
• Maybe the biggest issue that is going to be faced is an admin issue, albeit a very serious one. It’s one that we could easily overlook and if we do, we would be likely to fail. Our standards framework to manage digital healthcare standards, which this whole plan is going to rest on, is a bit of a mess. It will quickly need to be cleaned up if we are going to get aligned into the future … even five years’ hence.  
• I’m not going into the gory detail here, but we once had a regime where we could develop digital health standards and have them governed and maintained. Standards Australia helped do this. But that broke down. The job has fallen essentially to well-meaning volunteers who give up their time to help maintain complex standards such as HL-7 in Australia. But volunteers and little money is not a way forward if we are going to have our system work off common web-sharing standards. 
• We will probably need to re-establish some relationship with Standards Australia group in order to help us govern our key health sharing standards – FHIR, HL-7 and many others – which will need to be properly framed for common implementation. 
• And we will also need a group to audit Standards Australia’s implementation and maintenance of these standards, as they do in the US via an organisation called the American National Standards Institute.  
• Standards are really hard and really boring to build, govern and maintain so there is a lot of work to do here in Australia if we are going to get it right. There are only a few experts. And they tend to fight one another – it’s complex and not well paid, which doesn’t help. But, if you could pick one thing that might make this whole initiative to change our healthcare for the better fall over, it would be how healthcare standards are built, run, governed and audited.  
• This is where the DoH needs to focus its early efforts. Maybe the Australian Digital Health Agency could help too. It will need to be funded properly too – it won’t cost much for what it returns. And we need to get the right people leading it all.  
• The good news is we have five years to get it all working well, which is just about the right amount of time, given the degree of difficulty. 

So, there it is. 

We can sink slowly and inevitably into a largely unconnected future, where interoperability is just a buzz word and vendors point out how hard it is for them to innovate and change anything, or, we can, with a new government, bite down hard on this bullet now, and set in motion what could easily turn out to be the most important initiative for our healthcare system, and for patient empowerment, since Medicare. 

By the way. A lot of the above was discussed in a recent healthcare cloud summit held by Wild Health in Sydney. We had a lot of important and influential people there, and I think you’d be surprised what some of them said. A lot are onside, including I think the DoH, although that might be intuiting a little too much. If you didn’t attend the summit in person or on the stream, you can still catch each session in the video below (agenda here). My recommendation for starters is the Funding Paradigm summit, and keep an eye on Stephen Duckett, who reckons the planets might be aligning for decent reform in healthcare under Labor.