e-Health in Australia

Like the USA, progress on Australia’s e-health strategy (and many other strategies that require national standards, e.g. railway gauges) has been dogged by the country’s federated government structure (Federal, State or Territory ). Despite this,Australia has one of the best Healthcare systems in the world.

Despite early engagement in e-Health Australia has failed to integrate what at the ‘State ’ level is a sound technologically based advanced health system (including local health records systems).

As far back as 1993, Australia had established a broad agreement called the National Health Information Agreement (NHIA) which gave rise to the collection and exchange (largely manual) of health related data, information and common analytical tools across the various jurisdictions.

In addition, the NHIA established the first governance mechanism to oversea the development of statistical standards in health (including a data dictionary containing metadata for a range of health services) and national information projects.

This was followed throughout the 90’s by a series of health initiatives:

1995: The National Health Information Development Plan, which promoted the development of high priority health information and equitable cost-effective service arrangements.

1998: The establishment of the National Health Information Management Advisory Council (NHIMAC). The NHIMAC’s role being to advise State health ministers on options for developing a uniform approach to more effective information management in the health sector.

1999: Saw the publication of ‘Health Online’ by the NHIMAC. The focus of this report was:

1999/2000: The Australian Health Ministers established a National Electronic Health Record Taskforce and funded a two year program to assess the value and feasibility of ‘Health Connect’ which was designed to ensure the adoption of common standards by health systems operators (and hence suppliers) and ensure the exchange of vital health information between health care providers. Health Connect (launched in 2000) was to create a National Health Information Network to integrate patient records from hospitals, Doctor’s surgeries, nursing homes, medical centers and pharmacies.

2002-2005: saw various trials of Heath Connect were conducted across Australia . These trials highlighted the deficiencies in health information thinking and approaches to technical governance and in 2003 prompted the establishment of the Australian Health Information Council (AHIC) and National Health Information Group (NHIG) to better coordinate advice to health Ministers on long term health information issues.

In particular the NHIG was meant to advise and assist on ways to improve the overall management and resourcing of e-health projects.

Frustrated by slow progress the eHealth program came under constant criticism from many quarters, not least the health care practitioners themselves.

This prompted a further review in 2005/6 at which time the NHIG was made the principal advisory committee for the health Ministers – the National Health Information Principal Committee (NHIMPC) in an attempt to improve coordination.

2005: saw the establishment of the National eHealth Transition Authority Limited (NEHTA) – a jointly owned (by the States) limited liability, non-profit making company; to support and oversee the adoption of eHealth in the Australian health sector. This was the first practical attempt by the Australian health Ministers to establish a true delivery organization for significant national eHealth projects, including:

2006: the Council of Australian Governments (COAG) agreed to accelerate work on the creation of an Electronic Health Record (EHR), with particular emphasis on determining healthcare IDs for individuals and providers; agreed clinical terminologies and compliance to nationally agreed standards for future government procurements of eHealth systems in a two year timeframe, i.e. by 2008 .

2007: There was a further review which resulted in an extension of the NHIMPC’s remit to cover eHealth as well as information management with wide stakeholder representation . The focus for the committee and its various sub-committees was:

Despite all of these efforts, criticism continued to mount with accusations of $100million wasted in stalled and failed attempts to create a national EHR with the medical fraternity advocating spending on:

2008: Finally, a National e-Health Strategy for Australia was developed in 2008. The consultant’s report highlighted the marginal progress on the exchange of electronic health information to date, and the limited coordination of e-health planning and innovation.

The report went on to say that ‘to capitalize on this once in a lifetime opportunity’ – Australia should embark on a strategy of national e-health coordination and alignment.

The strategy outlines four detailed work streams:

Governance

Change & Adoption

E-Health Solutions – Information Flows, Service delivery Tools and Information Sources

Foundations

The report outlines the dependencies that exist from Foundation to Governance.

Governance

Despite expectations from the medical fraternity (ever critical of NEHTA) that NEHTA would be replaced this has not happened and it continues to drive implementation of the new strategy . Under new governance proposals a proposed new e-Health entity, the report says should be responsible for:

Strategy

Change and Adoption

e-Health Solutions

Foundations

The $1.5 billion program is set to run over three phases –

Phase 1: Connect and Communicate i.e. establishing the foundations for information sharing,

Phase 2: Collaborate, i.e. joint care planning and multi-disciplinary healthcare,

Phase 3: Consolidate i.e. establishing e-health as business as usual and extending innovation, e.g. targeting 20% telemedicine consulting.

The National Strategy 2008 has been roundly endorsed by the National Health and Hospital Reform Committee established by the Prime Minister in their subsequent reports and final report of 2009 and the Royal Australasian College of Physicians has proffered its general support for e-Health and a SEHR (although with some caution as to the lessons to be learned from the UK experience particularly relating to security and privacy concerns).

Findings Analysis

The main challenge facing Australia is implementation and gaining acceptance across multiple jurisdictions. With a litany of stalled and failed attempts to introduce the e-Health measures required across all healthcare providers and jurisdictions it appears that the Federal government has grabbed back the reins from the Council of Australian Governments (COAG).

In addition such a succession of delays and false starts has begun to exasperate even the most ardent opponents of change (most often from clinicians) and consensus and there is now a greater willingness to get on with the task in hand by all stakeholders.

Whilst it has often not been in the interest of suppliers to unify systems, the low level of investment in IT by the healthcare sector (no doubt brought on by indecision over the way to move forward) is seeing greater cooperation by the industry.

In addition, the recommendations regarding NEHTA’s staffing difficulties made by the Boston Group are now beginning to improve the skills base, enable NEHTA to utilize its budget fully , raise the quality of its output, provide greater transparency, adopt a more consultative stand point and generally face up to the national challenge presented to it.

Strengths

Armed, at last, with a comprehensive National e-Health Strategy, increased resolve on the part of all the stakeholders, highly competent healthcare practitioners, increased demand from the public, stronger federal leadership, strengthened implementation and delivery capability (NEHTA and possibly its evolution into a new supra-health entity), considerable background work already done, e.g. standards, IDs etc., a pragmatic solution for SEHR, recognition of the need for greater consultation and improved methods of effecting change and adoption, e.g. Social Marketing, coupled with a ‘late start’ advantage and the accumulated knowledge from both Australia and internationally – Australia may be better placed now to pull the strings together into a coordinated national effort.

In some ways, the relatively low level of IT investment to date in the healthcare sector may prove advantageous when trying to provide the interoperability required by the e-health strategy.

Left longer it is certain that the States would have moved unilaterally making subsequent interoperability very difficult.Australia is also ‘blessed’ by a very high level of urbanization (around 80% concentrated in 6 major cities) making infrastructure development relatively easy – however this has to be balanced by the large distances separating the cities and the remoteness of rural settlements.

Weaknesses

The jurisdictional divide coupled with a culture of interstate rivalry and a powerful and cynical health fraternity not used to collaborating at a national level will remain a major challenge for the Federal government.

Further, the Australian e-Health strategy has done relatively little to engage the private sector in healthcare or the healthcare IT industry – a fact that severely weakens the strategy.

At an implementation level the ability to run a national program across multi-jurisdictions has not been evident to date – and is evident even at a State level . This has to some extent been recognized by the inside out approach proposed in the National Health Strategy and Guided Market approach proposed by the National Health and Hospitals Reform Committee.

Opportunities

Australia is not alone amongst sizeable countries facing the difficulties outlined in implementing a National Health Strategy across a patchwork healthcare landscape and multiple jurisdictions. Like these other countries, e.g. Canada, Korea - it has decided to completely refresh its e-Health strategy and Governance – whether this will prove to be a sufficient makeover, only time will tell.

There are still criticisms that the strategy was rushed and is insufficiently different from the past strategies to prove anymore effective. Certainly the opportunity to learn from past experience at home and abroad is there – the question is have they?

Threats

The world e-Health programs in general and shared EHR in particular has proved notoriously difficult to implement in sizeable countries – particularly where there are multi-jurisdictions.

Could the accepted wisdom be fundamentally flawed? If so the conventional nature of Australia’s new e-Health strategy may prove no more effective than it previous efforts – going some way to justifying the claim by many clinicians that the new strategy provided little that was new and had insufficient time to prepare the best strategic approach.

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