Plans to create seamless data sharing for much better system efficiency might look on track, but they’ve yet to hit the real and substantive funding, business and policy blockers that could still sink it all.
This week’s $1.7 billion blunt force election drop to public hospitals in some respects underlines the urgency with which the government and its respective agencies pushing “sharing by default” need to get their skates on.
Demand for public hospital services is escalating rapidly with little sign of slowing down and without some more lateral efficiency fixes to the problem there is an obvious limit to the idea of just pouring more funding onto the bonfire (I nearly said bin fire).
“Sharing by default” is a pretty grand and lateral plan but there’s some danger in the narrative that’s it’s so big and complex it’s going to take quite a bit of time to take – of course there’s a lot of truth to this narrative.
It is going to take time, and it is going to be very hard for the various government departments and agencies executing it to neatly connect project initiatives with concrete outcomes, particularly in terms of impact on the hospital crisis that is upon every state and territory.
One problem is that in this grey it can be easy to hide a lack of meaningful progress. If it’s not happening, project heads can skip onto another job or department in a few years’ time when eventually someone does a review and discovers all the good intention and work isn’t actually working.
The My Health Record was, in its early days, an ambitious and highly detailed project plan with a lot of benchmarks and a lot of big outcomes and promises, none of which ever really eventuated. But we sure saw a lot of big numbers in between anyone admitting it wasn’t having a lot of impact. In blunt terms we took about 10 years and more than $2 billion to work out it was neither a great idea in the end (given the technology frame it was based on) or being executed well.
“Sharing by default” and all the plans associated with it, including The National Healthcare Interoperability Plan (NHIP), are similarly ambitious and detailed, albeit, they seem a lot more aligned to current technology trends and overseas experience and evidence of potential success.
Late last month the ADHA came out with a “we’re on track and doing well” check box update on the NHIP, suggesting we might be a third of the way through it, which had a worrying touch of My Health Record deja vu about it.
This week or next The Modernising My Health Record bill should be put to and pass parliament. But the bill is pretty loose in that it doesn’t go anywhere near what the US did with 21st Century Cures Act and put a stake in the ground that says to both healthcare providers and the medical software community that within a certain period of time they will need to be able to share meaningful patient data to all points of the system on demand, or else (in the US of course, “or else” meant, jail time).
The bill is introducing the idea that the government is eventually coming for you in the manner of 21st Century Cures, but it still hubs sharing around the My Health Record, which even the ADHA has admitted will not be the main game in sharing going forward – likely a national HIE linked to a distributed FHIR and open API technology on all platforms plan, will be – but, it’s got quite a few “get outs”.
The government’s immediate target is getting pathology groups to share in real time via the My Health Record. It’s a step, but in the scheme of things, a small one when you compare the seismic change that 21st Century Cures created in the US for interoperability across that whole system.
This is not to say the ADHA or the government isn’t on track or can’t pull it off.
But it is to say that we aren’t actually hitting any real substantive benchmarks of progress and success yet, so we’d best not get cocky early on. We have some dizzyingly wicked market, funding and political issues to navigate very soon if the government and the ADHA are going to make the progress they say they want to make.
Hospitals are in trouble and will continue to be without some substantive lateral intervention soon because of the following:
- a rapidly ageing population with
- increased burden of chronic disease
- increased diagnoses of mental illness
- inadequate access to primary care (GPs and allied health)
- flow-on effects from wait times to access other systems, such as aged care and the National Disability Insurance Scheme
- workforce retention and a global shortage of health workers
Our “sharing by default” plans have the ability to significantly impact all these areas.
But not if we don’t become bolder faster.
Some big tests on bolder are coming very soon.
We are likely to see a few big ones this year.
Obviously, from the above list, we understand the problem is multi-factorial. On almost all of those dot points we have some big hurdles where the government and its agencies are both going to need to be bold and smart to navigate the digital fixes it is planning.
For arguments sake I’m going to home in on just one rapidly approaching and reasonably wicked issue that is almost already on us (I’ll look at some others in the weeks to come): the seamless sharing of information with the GP community.
In 1995 I did a business acquisition plan for the Reed Elsevier group recommending we acquire a rapidly emerging electronic patient desktop for GPs called Medical Director. I still remember the main slide and the few words on the slide emphasising just how important the acquisition would likely become in the future (we owned the Australian Doctor group).
The slide was a hub and spoke of the whole healthcare system indicating healthcare data flows and the importance of various channels. The main and most important hub in bold at the centre of the whole network of the system (which included hospitals) was GPs. Even back then everyone knew that the secret to system efficiency was better connectivity between GPs, hospitals and other important nodes like specialists, pharmacists and community health groups.
The words on the slide were something like: “Medical Director is set become the main data transactional gateway in the entire health system. Whoever owns this node will be a gatekeeper with the subsequent commercial possibilities such a position would bring”.
The slide was actually prescient of all the major global software data platforms such as that run by Apple and its iPhone ecosystem and Amazon and its suppliers.
Today, Best Practice is that hub for GPs writ large. Arguably Genie is the same for specialists. Medical Director is in there, but its share of GP desktops is something like 20-25% compared to the estimated share of Best Practice of 70-75% – so BP is the gorilla.
All these PMS systems make money from two major sources: subscription to their software and “partner revenues” whereby they charge applications outside their core functionality a percentage of the revenue they make by allowing access to their doctor networks using integrations.
It’s the same business model as iPhone and a major business model for a lot of vertical software platforms: you establish an audience people want to get to which you pretty much have exclusive access to, and you charge anyone who wants to get to that audience.
It’s not sinister or unusual business model (hmmm…. not in the sense that everyone does it, but I’ve never been a lover of Google, Amazon or Apple). It’s major software platform revenue model.
So how is this a problem for “sharing by default”?
Because the idea of “default” doesn’t really sit easily alongside a gated distribution income stream.
More pointedly, if “sharing by default” is really going down the path that the US government went so successfully with 21st Century Cures, there should eventually be a mandate to both healthcare providers and their software providers that there will be no gates on sharing patient data. It will be by “default”, not by who pays who.
There are of course nuances here and likely ways to navigate the problem.
On the one hand you want these platforms sharing important patient data in real time on demand to other parts of the healthcare system that demand it, without having to worry about who has or hasn’t paid to play.
On the other, depending on just how big these revenue streams are for these vendors (it was big very early with Medical Director we know and reportedly is now just starting to become big with Best Practice and Genie) you don’t really want to be destroying their business model.
These are all long time and well-developed platform vendors important to the running of the system. Of course, you might have said that about Cerner or EPIC in the US before the government their decided they needed to change their ways.
21st Century Cures was not as nice to vendors as we are being so far. But the US government had a much bigger problem with the major hospital EMRs actively blocking information sharing in order to create more sales. The more information confusion, the more revenue they could generate back in the day. So the US government was relatively unforgiving, albeit they gave everyone plenty of time to adjust and a lot of help as well.
If to some people it seems fairly obvious where DoHAC or the ADHA could insist on sharing and leave a lot of paying applications in place, it does get a little murkier for most of the many integrations paying these platforms when you introduce the need for cloud functionality into the equation.
Take a booking engine for instance, of which we have two major ones – HotDoc and HealthEngine. Both pay the toll to get to the doctors on these PMS networks. But increasingly these applications are gathering patient data outside of just when and where they want to make a doctor appointment. Are they in or out of the “sharing by default” mandate? If they’re in, is there no more toll for these vendors?
Another problem is that a key “sharing by default” strategy, and a very sensible and important one, is that within a period of time, all software platforms will either need to be cloud architected from the bottom up, or have appropriate “middle wear” applications developed, so that their sharing is via the cloud, not via old server bound technologies such as how most of our secure messaging protocols work now. The cloud is generationally more secure, cheaper once everyone is doing it, and far more efficient in how it works.
In the US, as near to 100% of medical software platform vendors are cloud enabled in one way or another to meet the requirements of 21st Century Cures Act data sharing.
So far in Australia, it’s almost the reverse – about 80-85% aren’t cloud enabled – which is a pretty big hurdle in itself for DoHAC and the ADHA to contemplate.
All of the PMS vendors above have a cloud transition plan. Best Practice is hard at work with a middle wear application called Halo Connect, which will reach into the old software and extract what an external application needs in a format that can be shared more efficiently via the cloud.
In this one example of system transition complexity, you can get an idea of just how much lies immediately in front of the “sharing by default” movement.
Theoretically the Modernising The My Health Record bill is a harbinger of the sort of change everyone has to prepare for.
But as far as these software vendors are concerned, it’s not really calling them to task clearly yet, in the manner that the US government did with the 21st Century Cures Act.
On this particular issue we know the government is working behind the scenes with a view that if they can get the vendors to play ball enough, they might be able to avoid a big stick.
The problem with this might be time and trust.
Without a big stick there is an argument that the vendors will be vendors. That is, they will do what’s best for shareholders and what’s best might be to delay as long as they can and obfuscate as much as they can within the boundaries currently being given to them.
Notably, and for good reason, most big vendors are key participants at all the government driven projects to move our medical software platforms to the cloud, such as Sparked, being run by the CSIRO.
On the one hand they have to be there. On the other it’s a good spot to try to manipulate the narrative your way as much as possible.
A big question for the government and the ADHA might be, are the boundaries too loose still, and is the timing not tight enough?
The ADHA once told us it was going to reign in and align all the secure messaging providers for a far more efficient system of data sharing. After years of apparent collaboration and meetings nothing really happened and most of those providers still go along their merry way with much of the same system inefficiency.
Business thrives on inefficient systems.
Information blocking in the US was a poster child of data sharing inefficiency and the US government, with strong bipartisan support from both major political parties, eventually put a hard stop on it.
GP data sharing and the platforms they use is just one of the difficult tests that all our grand “sharing by default” ideas and plans is going to run hard up against, likely this year.
If we are going to push for meaningful alternatives to giving up near an election and lobbing more money at a problem we know we can’t solve with money alone, we probably need to go much harder now.
The role of sharing by default in delivering system efficiency, including mandating standards and technology for data sharing, will be a key topic at the upcoming One Healthcare System Summit on June 17-18 in Canberra. HSD readers can get 12.5% of all ticket types using this code. You can see and buy tickets HERE. Tickets are also still currently at Early Bird rates.