Last week I had the pleasure of being the industry person sitting between Peter Fleming from NEHTA and Peter Williams form the Victorian state government department of health on a panel at the AIIA luncheon. As always the food was great, the conversation stimulating, and fun was had by all. I thought I would share my prepared notes with you for your comments, even though I must admit I did diverge from them in the interest of time.
Notes for the AIIA Victorian Government Ehealth Forum
So first to put my views into some context. Over the last 30 years I have been in involved in Ehealth in a number of ways. Whilst enrolled at the UNSW in 1979 at the school of optometry where we were fortunate enough to have an Apple II Pro computer I was involved in writing some early clinical applications. I couldn’t afford an Apple at that stage, so I bought a Sinclair ZX81 and ported some of those clinical applications onto it in the early 80s. In 1983 when I graduated and went into practice I wrote my own optometry clinical and admin system on a Commodore 64 and upgraded it on to a CP/M system in 1985 when I saved up enough money for an Osborne 01. I was the classic geek clinician, who wrote the world’s best application for a total market of one, and the customer was a really cheap bastard. After a while I went back to med school and whilst a power IT user it was more in my ability to actually hand in a word processed document, which was a rarity then. I got involved again in IT half way through my course, in a company that imported and customised more general software, took a couple of years off Uni to make some money. For those young folk in the room, back then we put 100% mark up on hardware and 500% on software, so it paid for the house and family, and I went back to Uni to finish my course a few years later. I then started working in the NSW Health system in the 90s and was a user of the still in use clinical systems at those hospitals for a few years. After that I went into the private hospital space, and became the guy who buys software as we upgraded our hospital PAS and billing systems. Then I got the bug to go back into development, after all the dot com boom told us all you needed was a snazzy piece of software and you would be a billionaire, so we developed online tools for patients, including back in 2002 a Personal Health Record which would probably now be called a PCEHR. Unfortunately there was no money in it then, so 6 years ago I got a job at Intel, the world’s largest microprocessor company as part of its Australian health group. In that role I had the great pleasure of working with pretty much every software vendor and every large healthcare provider because generally their software worked on our hardware, so it was a very symbiotic relationship.
So I think that gives me pretty much a 360 degree view of the Ehealth world from pretty much every stakeholders perspective. I won’t go back to the ancient history, but looking over the last 15 years there has been some very interesting changes. In the 90s the state governments and their public hospitals were the big customers. Yes GP land was computerising, and there was some money there, but the real big money was in hospital EMR solutions. NSW led the way, in pockets, and Victoria also had some cutting edge plays in pockets. There were a few players mulling around, ranging from small mom and pop shops through to companies better known for making airplanes, and pretty much everything in between. Ehealth was still a rudimentary concept, it was predominantly automating the administrative part of the system, knowing when a patient came in, who they were, which bed they were in, and who to bill. Clinician involvement was minimal; again mainly geeks like me who thought they knew the answer to everything, and reminisced of the good old days with our Commodore 64 which could do a database and also play space invaders. Then real clinicians starting to ask whether they could use the new gadgets to do something useful, like look after the patient. So we put pathology online, because that was pretty straight forward, and then we starting putting some test requests on line, and then we even started doing radiology on the system, which worked fine within our own network. We moved to an enterprise model, because now we had a lot of users who needed the system, and our CIO colleagues in the banking world had managed to get their systems up and running, although Peter may be able to tell us more about how painful that really was. ERP was the buzz in the business world, and the EMR became the healthcare equivalent. The debate around best of breed versus single vendor came up, integration tools became critical as each part of the hospital started using its own little solution, several hundred millions of dollars was spent, and to some degree in some places we came up with a workable solution. Of course by then the users started getting smarter and demanding more, like not just reports, but decision support tools and real time data analysis. Each state made a decision, some better than others. We witnessed the first time a state government took an EMR vendor to court in a very messy situation. NSW decided on a single vendor solution, SA did the same but with a different vendor, Victoria straddled the line by selecting a vendor but giving the hospitals choice on whether they used them. At the time we all thought the world was crashing around us, it was a massive change management program, a word none of us even knew existed when we started the journey. When the dust settled NSW had one of the largest EMR deployments in the world, however by then the bar had been lifted and if you use the HIMSS Analytics definition it is not really a full EMR. SA decided that the solution was OK but needed to be changed, Qld was still recovering from their first attempt and was seriously talking about their next attempt, and herein Victoria some hospitals had a good system, some a not so good, and others none at all. In reality, whilst we cry foul about the experience it mirrored every other large scale enterprise deployment in several other industries in the world. The classic two steps forward, one step back and a couple of body blows along the way. It was tied up in state procurement processes and what like, which is another story. But where it worked, and let’s not forget on a worldwide basis we are actually one of the success stories, it worked pretty well.
However around 2004 what was predominantly a state government thing started getting federal interest again. There had been some attempts to provide a unified eheath solution, many of us remember Health Connect but it didn’t start getting serious till the formation of NEHTA in 2004 or there about. The early NEHTA was all about herding the cats, developing the standards and getting the unruly masses of vendors to use them. I think it is fair to say that to some degree personalities came into play, and there were issues, but no one really disagreed with the idea. But it was not an overnight success, mainly because the problem was not that easy, and couldn’t be solved in isolation from what was happening in the rest of the world. Things really started getting interesting after 2007 when the new federal government decided that IT was going to be the great democratising force in healthcare, ala Facebook for Health which was one of the outcomes of the 2020 summit. Now we had a huge shift from the ERP type world of the hospital EMR deployments to a system that had to be suitable for individuals but scalable to an entire country, which had to be as sexy as Facebook, and yet as secure as the ATO, and which no one else in the world had delivered. Innovative yet risky, based on cultural demands not technologists specifications, and if it worked would revolutionise healthcare here and around the world. The fact it happened to coincide with the plan to wire up the whole country to high speed broadband was fortuitous.
Now the Ehealth world is stepping into new uncharted territory, and the gentlemen by my side have the enviable task of building the information superhighway through that territory. From a user’s perspective it is fantastic, because if all goes to plan I will have a system, as a clinician and as a potential patient that will make my care better, safer, more efficient and all that. As a developer, it is a great new challenge to develop the new killer app in healthcare. As someone who buys software, well someone else is paying in the form of the federal government so the finance guys are happy, and as a vendor there is money out there for work to be done, so all I have to do is make sure I convince them I am the right company to give the money to and life is sweet. So it sounds like Nirvana, and to be honest compared to some of the last couple of decades it is. But it’s not done yet, there is risk, some people will get their fingers burned, some companies will close down or be gobbled up, some people will die because some mistakes will happen, some clinicians won’t like their interface and won’t be willing to pay to develop their own, some people in government will be happy with the progress, pretty confident the opposition, whoever they are at any time will find huge faults with the system. But we will have moved some steps closer to a high performance safety enhanced healthcare system, which is the envy of many other countries around the world. We will have spent a lot of money, not all well. But I believe we will see a huge beneficial outcome for us all, and looking around the room, those of us with greying or receding hair will be the major benefactors.