Feels like we have a smarter more invigorated ADHA with an actual plan, but between a plan and execution a lot can go wrong, focus being one key thing.
If you have followed the Australian Digital Health Agency over the last 10 years you’ll have been at various times disappointed, despairing and even angry.
A few years back when it changed CEOs to a bureaucrat from Services Australia with little background in healthcare, many people thought the Agency, having failed so badly over the years, was going to be quietly disbanded and inserted back into the Department of Health and Aged Care somehow.
At the Hellenic Club in Canberra yesterday the ADHA held an “information session” which might be seen in one of two ways in the future: either as a landmark of when meaningful change in digital health really started to happen, or a point at which things were understood, important promises were made, but never kept.
No matter which way it turns out, yesterday’s session said a lot about the good ways in which the Agency has changed in the last few years.
The most important change is that the Agency’s people understand what the problems are now. In some respects you can see that in the detail of their many published plans. It is something that became even more obvious yesterday when they started putting their, at times confusing, laundry list of initiatives and goals into better context for what they think is going to happen in the next few years.
The other strong sense you get about the Agency at the moment is that the people working there believe in what they are doing, and they have the energy to do it. You also get this feeling around the digital health people in DoHAC, which obviously helps.
We published the introductory remarks to the information day by Agency CEO Amanda Cattermole (that bureaucrat) yesterday in full, which is something we would never have done in the past because speeches like this were mostly politics and bluster based on propping up some bad logic. Logic which was often warped by the centre of gravity that the My Health Record exerted on everything the Agency did.
In many respects there was nothing really game-changing about the CEO’s speech yesterday. It could be still be viewed like any other ADHA CEO speech you’ve seen in the past: noble and important goals, lots of promises about important programs to achieve those goals, and the usual political overlay to make everything seem like things have been always good and are going to get better.
The difference this time might be that what Ms Cattermole outlined yesterday is a plan that demonstrates that, at the very least, the Agency has done a lot of research and thinking and now properly understands the many wicked problems we face in trying to transform the system.
The speech also outlined the basics of a plan to attack those problems.
We’ve been critical of the ADHA over the last few years and, by default, of Ms Cattermole.
But one thing yesterday demonstrated was that she has at least managed to put together and lead a group of people who intimately understand the issues, have some good ideas (too many ideas probably, see below) of how to attack them, and who are motivated to attack them.
That in itself is a giant leap forward for the Agency from its past.
The problem now, of course, is execution.
It’s a big step to outline the actual problems and then to put in place plans to overcome them. It’s quite another to actually navigate your way through the mire of what are whole sets of wicked problems facing the many system stakeholders who will be significantly disrupted by the proposed changes coming.
How for instance will big pathology respond to a plan to cut out something like 25% of their current testing volume?
How will the Pharmacy Guild react in Canberra when they realise that the logical and productive endpoint of e-prescribing is that bricks and mortar retail pharmacy is no longer required to deliver everyone a prescription?
How will all our software vendors, especially our local ones, behave in the transition given that what is being proposed, though obvious, necessary and logical, will put massive financial strain on their business models and might require them to reinvent their businesses entirely in order to get to the other side?
How will adversarial and opinionated GPs react when they are told that their current server set-ups in backrooms are way too insecure and have to be upgraded to minimum standards by law, and, that this will mean they can’t turn the electricity off at night in their practices?
There are some early wins for the Agency already in their grand plans, the most overt being just how fast and effectively the Sparked group has been working to lay the groundwork for all our vendors in terms of harmonising a set of standards and coding, in preparation for them having to do a lot of new development work.
But we’ve hardly started, and this is a perilous journey for lots of stakeholders from the politicians through to the vendors and finally the providers and their staff as well.
It’s such big change. And one of the reasons for yesterday’s meeting might have been scene-setting for the stakeholders of just how big a change it will be.
One message to the crowd was that everyone needed to be on the change bus if change was going to happen.
Of course, appealing to everyone’s sense of right and community would never get enough people on that bus.
So another underlying message yesterday – sometimes not so underlying – was that while getting on the bus is definitely going to be painful for many and a wild ride, not getting on isn’t an option.
A key trigger for that is that the government is going to mandate legislation around minimum requirements for the data-sharing capability of technology used by providers and put a timeframe on that mandate, which means anyone who doesn’t conform, likely won’t have a future in the system.
That is what happened in the US with the 21st Century Cures Act so the government and, increasingly, stakeholders in Australia know it’s been done already in a far more messed up and complex system. And our government is likely to learn from the mistakes the US has made and upgrade how they execute their mandates.
Another big trigger, which might even create more urgency for vendors and providers to upgrade their platforms, is cybersecurity.
At several conferences now key government people have alluded – off-stage – to the fact that government requirements around security in the end (not just health driven) will be a major driver of technology upgrade, quite apart from a mandate to have platforms which are able to share data more seamlessly over the web.
On several occasions now, including yesterday, the timeline on security being in place has been given as less than two years.
So, the Agency has some overt regulatory sticks that are now in play to help all those people who don’t want to get on the bus – the ones who don’t buy into the “do it for the greater good” plea that the Agency was pushing yesterday – to get on it regardless.
With all this in place a lot is going to come down to leadership and execution on the part of the Agency.
They’ve done really well against the odds to get to where they are now over the last few years.
But execution is a very big and different management and leadership skillset.
Just over a week ago, the Agency put out a tender to get someone to help them on this front: to help them assess far more precisely, given their plans, what capability they can and should build in-house, and what they are going to need to leave in the hands of the external consultants and integrators, given the complex nature of their plans.
Maybe this is a sign the Agency recognises the challenge of its next operational phase.
If there were one big criticism that could be made of what is going on with the agency here (we wouldn’t want to have a story about the ADHA without just a little criticism) it would be this.
If you look at all the plans of the Agency and all the initiatives it is attempting, it is very obvious it can’t do it all, even if it had 10 years.
It’s like the consultant who wrote the plans for the Agency took on what everyone wanted in the consultation phase and made sure they ticked everyone off so no one would be unhappy.
There is no way we can do all the things in these plans, even some of the most important parts, at least for now. If the Agency tries to do this it will almost certainly fail in the most important things it can achieve if it focuses.
Yesterday the panel at the information session was asked to name the top five initiatives of the near 100 or so they have laid out in their comprehensive plans, give them a priority, and explain the logic behind doing that.
The question was fobbed off.
“Everything in the plan is important and has to be done,” was the gist.
If the Agency truly went down this path it will fail for lack of focus and resources. No corporation in history could pull off everything the Agency says it wants to do in the timeframe it suggests it can.
I don’t even think it needs to narrow the near-term objectives to five things. It probably needs just two:
- a national Health Information Exchange, working in tandem with an FHIR-enabled My Health Record, to facilitate real-time sharing once provider platforms can share data;
- mandating data-sharing standards in law (not strictly the job of the ADHA but the impact will require deep agency engagement with the vendor community), putting a short timeframe on vendors and providers to comply to the standards and having in place a comprehensive plan to help local vendors cross the divide between their legacy platforms and modern ones they are being asked to build.
What these two initiatives do is really what the Agency has always been there for – getting meaningful data flowing seamlessly and in near real time in the system.
Most of the rest on the Agency’s long laundry list of initiatives either falls under the above two initiatives, is noise, or will be sorted by the market if the agency can get these two things working.
Here are two examples of hard-to-explain noise that the Agency is planning, one of which is already in their tender schedule for this year:
- the agency is tendering later this year for a white label allied health practitioner management system that will connect to the My Health Record;
- the agency is planning on developing an all-encompassing health app for consumers with all the data that will be accessible as a result of these plans.
The first initiative is impossible to understand in terms of priority. We can’t connect GPs to hospitals today. Allied health is a herding cats exercise in the ether, and the Agency wants effectively to start to compete with four or five existing vendors, because those vendors don’t currently connect to the My Health Record? Or might not be ready to connect to the HIE when it starts coming online?
If the Agency mandates standards on data-sharing technology, this problem is going to be solved in the long run.
The existing vendors will need to comply and be able to share data in the system or they will be out. And if there is a commercial hole there it will be quickly filled.
Only when and if this all fails should the Agency contemplate building a government-owned management system for the allied health sector.
It’s a really bad idea in the context of what really needs to be done. It will also entirely freak out the whole local vendor community who will quite rightly ask, if they can do it in allied health, will they do it for GPs and other areas.
The second initiative feels like it might be over-reach from Services Australia based on how they are expanding all their services to the public on Medicare, tax and Centrelink.
That for now, is not the Agency’s job.
If the Agency gets those two things done above – makes meaningful health data easily and cheaply in accessible in real time – the market will do the app. And if they don’t then Services Australia can step in and do it, if it makes system and economic sense.
So, while you have to admire how far the Agency has come from the days of mindlessly publishing meaningless data about My Health Record usage and pinning everything on that infrastructure program, there surely is some hard work and thinking to be done still.
There’s a lot of energy and enthusiasm in key staff at the agency, which is great. But the journey they’ve signed themselves up for is not going to be pretty.
In leadership and management terms they need to become very hard-arsed very quickly.
Yes, you have to say and do a lot of things you know you will never really do in order to maintain political appearances while you get the important stuff done, and that could be part of what is going on here.
But there are some serious distractions on the procurement schedule now.
That’s an immediate worry.