Establishing a set of standards for clinical information systems in aged care is a first step in a long, fraught journey. But we aren’t thinking a lot about the next steps.
Thursday’s release of Aged Care Clinical Information System (ACCIS) Standards by the Australian Digital Health Agency and the Department of Health and Aged Care represents a vital first step in a very long and fraught journey to a vision where the digital platforms servicing aged care are properly connected for meaningful data-sharing in real time in this sector.
You can’t get to that dream if you don’t start with standards that vendors and providers should be working with.
But given the state of the aged care software vendor sector today, the economics of building out clinical software platforms in a small market like Australia, and the government’s reluctance – some of it for good reason – to either mandate the standards in any way, or to fund any vendors to build the sort of software that people would love to have in the sector, it’s hard to see a straight line to a time when such platforms will ever be operational.
The ADHA would like a sector that is literally transformed by vendors who independently invest in building software to the new set of standards, which they know will require a lot of expensive new interoperability technology and architecture.
But is any of this thinking realistically commercial?
Commenting on the release of the standards yesterday ADHA branch manager Ryan Maven outlined precisely why starting with standards is the right step in a proposed transformation journey.
“The ACCIS Standards provide a clear and consistent direction for software developers and aged care providers on how to design and implement clinical information systems that meet the needs and expectations of residents, their families and care teams, and ensure they will connect seamlessly with all national digital health infrastructure,” he said.
But Mr Maven went on to say something that potentially needs a lot more thinking on behalf of all the stakeholders involved in the project.
“Whether it is sharing information with a hospital, general practice or pharmacy, these standards will enhance the continuity and coordination of care for older Australians, especially during transitions of care,” he said.
If aged care clinical information systems ever can share information with a hospital, general practice or pharmacy, then yes, there would very likely be system transformation that massively enhanced the co-ordination of the care of aged Australians.
But as we all sit here today, the economics of that happening, without significantly more government planning and support to the vendor community, looks highly unlikely.
You only have to look at the state of existing and vital software platforms such as our general practice patient management system network and you can see the problem.
Like Australians love to do, the general practice PMS platform network is pretty much a duopoly.
That’s come about because of the economics of building complex and risky medical software platforms in a small market like Australia.
It’s not all bad.
At least we have a PMS software platform network in general practice we can work from in another long journey to build out this server-bound antiquated technology base into something more interoperable going forward.
At least most GPs have a computer on their desk that does pretty much the same things for all of them and have some connectivity to other parts of the system, albeit that connectivity is hit-and-miss, old and patchy.
Aged care hasn’t got any of that. It has an eclectic array of many small vendors working with very different old technologies. Nearly all of those vendors do not have the capital or the experience of our two major GP PMS vendors.
Even those two big GP PMS vendors don’t have a lot in the bank to do the sort of transformation of their platforms that the government is saying they want them to do in the near term.
Another good example of the economics of modern interoperability platform builds in Australia, and one that both DoHAC and the ADHA are intimately familiar with, is our electronic script-writing exchange.
This has been our best and most successful example of both DoHAC and the ADHA backing into vendors to build important interoperable infrastructure.
But as Australian business conditions so often dictate, we ended up with only two vendors in this important part of our infrastructure.
And for reasons which still remain a bit mysterious to many in the sector – certainly the economics of running the infrastructure must have come into the decision – the government opted to kick one of those vendors out of the game altogether.
So we only have one vendor left and what looks like a pretty risky ongoing monopoly.
When it comes to aged care technology transformation, both DoHAC and the ADHA have taken the first vital step of saying, “if you’re going to do it, you’re going to need to do it like this, or we won’t play with you”.
The big problem is, who will take the risk? And, even if you get anyone prepared to take it, will they even succeed?
In order to play, DoHAC and ADHA are saying (quite sensibly) that any vendor considering taking this journey needs to realise that they must first be able to talk to DoHAC’s aged care API gateway, to the eScript infrastructure, to the My Health Record, and have modern cloud-based cybersecurity standards.
(Which means you’ll probably need to be cloud-architected, which is a big risk in itself because hardly anyone else is, so you have no one else to talk to in the system really and not much of a business model).
But there’s an obvious problem with all those things as starting specifications. At this point in time, hardly any of them – with perhaps the exception of talking to the national escript exchange – is going to make you any money.
It’s of course eminently sensible in the government’s grander interoperability plans for it to say to vendors, you can’t play unless you plan to talk seamlessly to all the things we see as important, because we’re joining everyone one up in the near future.
It’s a sort of “trust us we have a plan so if you build it everything will come” plea.
Which is fine, because it’s not a terrible plan.
It’s just not practical from any commercial point of view, at this point of time.
And if no one is able to build to these standards or wants to because of the risk, well, we aren’t ever going to get to what is an admirable vision on the part of DoHAC and the ADHA.
Can you start to see the problem we are building ourselves here?
We’re buying the materials for the foundations of the construction of a magnificent new bridge of interoperability for the aged care sector, but we haven’t given a ton of thought to who is going to take the big leap of faith to start building that bridge.
It’s not entirely the fault of DoHAC and the ADHA. They are doing a lot of work on a lot of fronts to bring together a lot of parties into a pretty good vision of interoperability.
But when you get a Royal Commission into Aged care recommending – naïvely but understandably – things like mandatory use of digital care management systems that are interoperable with My Health Record, and someone accepts those recommendations, someone somewhere has to act on them, or political problems start to fester.
You can’t even blame the poor sods conducting the Royal Commission.
Of course we should have interoperable digital care platforms in aged care. We’ve got them in banking, retail, media and travel after all. How hard can it be?
Very hard.
Between the idea of that thought, and the reality, there is so much complexity and potential grief that very few people – certainly not the people conducting the Royal Commission – have any real idea about.
You do suspect that increasingly, the ADHA and parts of DoHAC have more and more of an idea about these challenges.
But they are operating in a bit of a political maelstrom, where the gap between knowledge and understanding at the higher echelons of political power and the reality of actually building things that sound great in a Royal Commission recommendation, or a Ministerial press release, is very often vast.
The good folk at the ADHA and DoHAC have to work this gap and keep their jobs along the way – something that gets much harder if there is a change of government and would make a lot of them nervous with a federal election looming.
They are at least thinking about the problem of market failure – when the market can’t do it because the economics don’t work.
That might be why they opted to take out the only competition in the national e-script infrastructure contract.
It might be why the ADHA is putting out a tender for someone to build a white label allied health patient management platform, when we already have four reasonably good vendors in the market.
(This is not a good idea, by the way, because there are a lot more problems the ADHA has to solve before it gets to allied health interoperability, such as GP/hospital interoperability.)
The ADHA is also lining up to build a national health information exchange from the centre as a foundation for all future national healthcare interoperability.
They are doing that because of simple math. There is no commercial reason for vendors to build such infrastructure. If we are going to have it, the government is going to need to build it, a key potential problem being, the government hasn’t proven it’s that good at building centralised healthcare infrastructure that has impact – which is the My Health Record.
While the ADHA and DoHAC are currently saying that these new standards are not mandatory and that they won’t be helping to fund any vendors in building to these new standards, you suspect that behind the scenes they must have other plans.
Interestingly, and perhaps a reason for some optimism here, is that the medical software industry has decided to play nice in respect to the release of these standards.
Medical Software Industry Association CEO Emma Hossack, who is also a member of the National Aged Care Advisory Council and past board member of the ADHA, came out yesterday and said the ACCIS Standards were a result of the strong collaboration with the software industry.
That’s not something she normally says about government and her band of struggling local software vendors.
“The software industry has worked closely with the Agency, the Department and the aged care sector to develop the ACCIS Standards,” she said.
“Clear, robust standards for safety are key to keeping our older Australians safe, and the system sustainable. The industry is committed to helping the sector implement the standards, to ensure the technology they use is fit for purpose, user-friendly, secure and reliable.”
If the government really wants to realise its dream of interoperability in aged care then it has a lot more to do than just set some standards up, and it probably needs to be engaging in that “a lot more” now rather than later.
When you consider how nice Ms Hossack is being on this announcement, maybe the vendors and government are starting to do that behind the scenes.
But even those things local vendors will likely be able to do, such as upgrading general practice software platform to cloud data-sharing capability, are likely going to need some significant support – not just money – from the government to get done in the time it will be required for the government’s plans to start working.
In this respect, the government has consistently threatened to mandate standards of technology for both the vendors and providers on interoperability (as occurred so successfully in the US) and has just as consistently delayed actually taking that step.
When you’re starting from scratch like we are in aged care, then multiply the problem being faced in terms of vendor economics and likelihood of success by a lot.
The ADHA and DoHAC both have decent visions and aspirations.
But if you line up everything they are trying at the same time, and the near-term problem of actually building stuff – now the standards are being laid out well – then they might need to do a bit of prioritising (GPs/hospitals first for example) and hard thinking about the economics of just how much a poorly capitalised local software vendor sector can actually help them.