At 8:12 am +1000 7/6/07, Tim Churches wrote:
David More wrote:
Hi Ken,
"My own view is that the last 10 years of reports (starting with NHIMAC's
Health On Line, Electronic Health Records, Electronic Decision Support,
etc.) adequately laid out the grand plan of where we wanted to go.
It was also self evident, without needing "lessons" from expensive
Health Connect trials, that key building blocks were required to get
there, such as standard terminologies, national identifiers, etc. I have
no argument with NEHTA's agenda in this regard."
Ken I think the question we need to address is..If we had an OK
plan - in 2000 or so -
what happened?
What happened was that funding was provided for a lot of pilots, but
without clear plans for how those pilots were to be rolled out
nationwide if they were a success. The golden rule of pilots: if you
aren't sure how to extend a pilot if it turns out to be a success, then
don't fund the pilot. Some of the pilot funding also went into
development of software infrastructure, which could have been re-used,
except that the funders failed to think about IP licensing issues, and
some of that is now proprietary (eg the openEHR-related implementation
developed by DSTC and now sold as a commercial product) and others were
left to rot in a filing cabinet somewhere.
But the main problem was that funds and commissions to do the hard slog
work of standards development, codeset development, re-usable
reference implementations and so on were not forthcoming. Pilots are
much sexier than standards, but they generally don't have much
long-term impact and have a very low "value multiplier". Standards
and codesets etc have huge value multipiers.
I would suggest it is due to a lack of understanding of the
approach required to actually
have something happen - combined with realization in Government it
might cost some money
and so had to be resisted.
A lack of understanding and costs a lot of money - yeah, bit those are
truisms - `twere always so.
Hence - while we need the building blocks - we also need an
approach to implementation and
funding that suits our health system, clinicians, business
conditions, benefits flows and
so on.
Well, the building blocks need to be funded properly, and on an ongoing
basis because they are never finished - they need to be continuously
maintained and improved and extended. They are urgently needed. And they
can't all be done out of the little NEHTA office in Brisbane, nor by
volunteers meeting every few months at Standards Australia.
That - and a credible business case has been missing I reckon -
hence the inertia.
Everyone accepts the general business case. Specific business cases for
specific projects and funding streams, sure, but a general one for
health IT - nuh, waste of time in my opinion. What will impress the
politicians and senior bureaucrats is some actual, concrete progress,
not Yet Another Business Case document. They see several of those
every day. Generate teh evidence that health IT makes a difference,
don't just write about the paucity of evidence in teh literature.
Also the arguments regarding the safety of our health system have
not bitten here in the
way they seem to have in the US..hence the relaxed go slow
approach adopted by NEHTA and
the lack of urgency.
There are certainly health outcome and health system efficiency
opportunity costs of going slowly. IT people (including NEHTA, I
suspect) focus on the opportunity costs of implementing systems and
writing software "too early", meaning before standards are set in
concrete or before strategies are neatly aligned and so on. Two problems
with this: a) the systems they delay because all is not ready are
dynamic and perpetually changing anyway, and will never be completed or
finished - the lifecycle is continuous, or ought to be, not one of
"install now, replace in a decade" - because health care and medicine
are subject to continuous change so unless IT systems also change
continuously they will be by definition irrelevant or inadequate within
a year of installation; and b) the opportunity costs of having to
upgrade software and implementation on a rapid cycle are piddling
compared to the foregone efficiency gains in our $80 billion per annum
health system caused by delaying implementation. IT people need to see
beyond their small IT budgets to the entire health system expenditure.
Another point is, of course, that the conduct of all the trials
was deeply flawed as far
as one can tell.
One can't tell, because trials are so rarely reported, either in the
peer-reviewed "black" literature or in the "grey" literature as report
monographs. They are just filed away in a cabinet in Canberra and
elsewhere, it seems.
Tim C
Pilotitis was recognised as a problem many years ago. Still hasn't
been fixed, probably because the value of an informatics "program"
has not been suffificiently well proven or built-in to provide surety
to the people signing off on the money. (Wasn't that what killed
MediConnect? - the beancounters.)
Therefore the "grand plan" should be a "system (not IT system but
system in the generic sense)" that delivers value. Any grand plan
that documents specific programs or outcomes will fail, because it
assumes the planers know where the value is - which they can't.
Governments are most unlikely to be able to create" systems" while
they require planning documents and budgets with specifics.
Governments could contribute to the development of a market for
informatics/information. They manage to facilitate many other markets
in a more hands-off manner. Facilitating development of a new market
is probably beyond the ability of the bureaucracy, until some
academic writes a thousand page book all about it.
Michale Porter's "The Competitive Advantage of Nations" is one such title.
http://www.amazon.com/Competitive-Advantage-Nations-Michael-Porter/dp/0684841479/ref=pd_sim_b_3/104-5426363-4776758
His writings on clusters are also popular with govt bureacrats.
http://polaris.umuc.edu/~fbetz/references/Porter.html
Maybe they have been reading his new book "Redefining healthcare"....
http://www.hbs.edu/rhc/index.html
Ian.
--
Dr Ian R Cheong, BMedSc, FRACGP, GradDipCompSc, MBA(Exec)
Health Informatics Consultant, Brisbane, Australia
Internet: [EMAIL PROTECTED]
(for urgent matters, please send a copy to my practice email as well:
[EMAIL PROTECTED])
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