3.1 Strategic PrinciplesThere are seven principles that underpin and inform the proposed strategy and approach.
• National infrastructure - Deliver core elements of enabling national E-Health infrastructure once, rather than duplicating development costs and efforts and increasing the likelihood of rework
• Stakeholder engagement – Actively engage key health care stakeholders in the design and delivery of E-Health solutions
• Incremental approach - Build long term national E-Health capability in an incremental and pragmatic manner, focusing initial investment in those areas that that deliver the greatest benefits for consumers, care providers and health care managers
• Recognising different starting points - Balance active support for care providers with less developed capability, while not constraining the ability for more advanced participants to progress
• Leverage - More effectively leverage and scale E-Health activity across the country
• Balancing alignment and independence - Drive alignment of national E-Health activities whilst not unnecessarily limiting the ability of health care participants and vendors to implement locally relevant solutions
• Relevant skills – Ensure sufficient numbers of skilled practitioners are available to support delivery of the national E-Health strategy.
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3.2 Strategy OverviewIn order to address these principles four major strategic streams of activity have been identified.
• Foundations – Establishing the core foundations for electronic information exchange across the health sector. This work stream is fundamental as, without the basic ability to securely share health information there will effectively be no national E-Health capability
• E-Health Solutions – Stimulating the delivery of E-Health solutions to the key users of health information. This work stream facilitates the delivery of specific computing systems and tools to address the high priority needs of consumers, care providers and health care managers
• Change and Adoption – Fostering consumer, care provider and health care manager adoption of E-Health. The aim of this work stream is to focus effort on achieving a ‘tipping point’ of stakeholder adoption of E-Health solutions as quickly as possible
• Governance – Ensuring the effective leadership, coordination and oversight of the national E-Health work program. This work stream focuses on the establishment of appropriate national E-Health governance structures and mechanisms.
FIGURE 1: E-Health Strategic Work Streams
Implementation of the four strategic work streams needs to be undertaken in a tightly coordinated and concurrent manner in order to effectively deliver the national E-Health work program. Each work stream is highly dependent upon the success of the others.
Appropriate E-Health foundations, in the form of computing infrastructure and consistent information standards, rules and protocols, are crucial to effectively sharing information across geographic and health sector boundaries. In this regard E-Health foundations can be viewed as analogous to an ‘information highway’ – unless the system is connected up in some uniform and rules based way, then information cannot move across the network.
Foundations alone will not be of any value unless consumers, care providers and health care managers have access to specific computing solutions or tools to enable them to view and share appropriate health information. E-Health solutions will be the tangible means by which users can benefit from the building of a connected information network.
The implementation of national E-Health solutions will similarly be pointless unless consumers, care providers and health care managers are motivated to use these solutions. This is a two way relationship as the quality of the underlying E-Health solutions will also play a critical role in driving stakeholder take-up and support of the E-Health work program.
Finally it is unlikely that any of this can be achieved unless supported by a governance regime which provides appropriate coordination, visibility and oversight of national E-Health work program activities and outcomes.
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3.3 Foundations Work StreamThe Foundations work stream focuses on implementing the basic infrastructural building blocks required to enable the effective electronic sharing of information across the Australian health sector. These include the implementation of consumer and care provider identifiers, establishment of standards, rules and protocols for information exchange and protection, and implementation of underlying physical computing and networking infrastructure.
Why do we need national action?• It will be significantly more cost effective to develop these foundations once at a national level rather than duplicating effort and expenditure across Australian States and Territories
• National consistency of standards, protection legislation and identifiers is required to ensure that information can be effectively shared and protected anywhere across Australia. Any deviations in approach across the country will pose a direct risk to the nation’s ability to seamlessly and securely exchange health information
• There is strong international evidence that nations such as New Zealand, England, Scotland, Denmark and Canada have only made significant E-Health progress at a national level once they have established appropriate E-Health foundations.
What can we leverage?Since 2005, the National E-Health Transition Authority (NEHTA) has had responsibility for developing core foundations for a national E-Health system. Work to date includes defining clinical terminologies and information messaging standards, and designing unique consumer and care provider identifiers for use in Australia. At the same time, the Commonwealth and State and Territory Governments are working to develop a proposal to establish a nationally consistent regulatory regime that will provide effective, streamlined and transparent privacy arrangements for health information.
What do we need to do establish the foundations?Establishing the national foundations for E-Health requires focused activity in five key areas:
• Identification and authentication – There is a need to design and implement an identification and authentication regime for health information as soon as possible as this work will be absolutely fundamental to the nation’s ability to securely and reliably access and share health information. Australia should seek, as far as possible, to make the allocation of the consumer and care provider national identifiers universal and automatic.
• Information protection and privacy – The establishment of a robust privacy and regulatory regime to authorise specific E-Health initiatives, and ensure appropriate privacy safeguards and consent processes for access to and use of health information and participation in E-Health initiatives. Accordingly there is a need to focus on completing the development of a nationally consistent regulatory framework and implementing this framework in a timely manner.
• National E-Health information standards – There is a need for a national program of E-Health information standards definition to underpin the consistent and accurate collection and exchange of health information. This will involve accelerating the implementation and adoption of the E-Health standards that NEHTA has commenced and identifying and prioritising the next tranche of required national E-Health standards. A consistent and inclusive process for the development, endorsement and implementation of national E-Health standards should be established together with a three year rolling national E-Health standards implementation plan.
• Investment in computing infrastructure – A key barrier to E-Health take-up is the relatively poor quality of computing infrastructure (PCs, network connectivity and core patient, clinical and practice management systems) across many parts of the Australian health sector. There is a need to establish mechanisms to encourage care providers to invest in the implementation and maintenance of an acceptable baseline of computing infrastructure.
• National broadband services – A key foundation of the national health information highway will be access to national broadband services that provide connectivity between all Australian care providers. There is a need to engage and collaborate with relevant government and telecommunications organisations to extend planned broadband connectivity infrastructure to all Australian health care providers as soon as possible. As part of this process, there should be a focus on ensuring that national communications infrastructure will be fit for E-Health use and is priced in a manner that does not discourage the sharing of health information across geographic and health sector boundaries.
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3.4 E-Health Solutions Work StreamThe E-Health Solutions work stream focuses on the national actions that are required to encourage the development and use of high priority E-Health systems that improve the efficiency and effectiveness of Australian health care delivery. These E-Health solutions represent the tangible means by which consumers, care providers and health care managers will electronically interact with the health system.
A great number of individual E-Health solutions have been implemented, or are in the process of being implemented, across the Australian health sector with limited coordination, standardisation or integration. The focus of this work stream is to harness and align this significant national E-Health activity to drive towards a desired set of national outcomes.
Why do we need national action?The intent of this work stream is not to constrain market freedom through centrally controlled purchasing policies and implementation models, or to assume central responsibility for the commissioning and directing of E-Health solutions development. The reality is that it would be extremely difficult, and of questionable value, to try and centrally manage the vast amount of disparate E-Health activity occurring across the Australian health sector.
However, there is a strong recognition that this activity needs to be much more strongly aligned than at present to:
• Avoid the costly duplication of solution development activities
• Enable the more effective leveraging and scaling of successful solutions
• Improve the ability for E-Health solutions to exchange information across geographic and health sector boundaries.
This can be achieved through a nationally coordinated focus on mechanisms such as targeted financial investments, stakeholder change and adoption programs and solution compliance testing and certification regimes.
Where should we focus?At a national level, there is a need to encourage the development of solutions in priority areas that will provide the greatest tangible benefits to Australian consumers, care providers and health care managers. National consultation and international research have identified the following set of high priority E-Health solutions in three categories – electronic information sharing, service delivery tools and health information sources.
• Events summaries including discharge summarries, specialist reports and notifications
• Test orders and test results
• Care plans
|Improving the capability of patient, clinical and practice management systems to support key electronic information flows between care providers. These key information flows provide a basis for improved care planning, coordination and decision making at the point of care.|
|• Consumer demographics|
• Current health profile
• Current medications list
|The key datasets that provide the summary of a consumer's key health data and their current state of health, treatments and medications. These datasets will improve the quality of service delivery and will ensure that consumers do not have to remember or repeat this information as they navigate the health system.|
|• Decision support for medication management|
• Decision support for test ordering
|Encouraging development of specific tools that improve the quality of clinical decision making and can reduce adverse events and duplicated treatment activities.|
|• Chronic disease management solutions|
• Telehealth and electronic consultation support
|Encourage development of specific tools that improve the management of chronic disease and the accessibility of care delivery.|
Chronic disease management solutions enable timely identification and monitoring of individuals and support management of their condition by providing automated reminders and follow-ups. Telehealth and electronic consultation tools enable improved rural, remote and disadvantaged community access to health care services.
|• Health care reporting and research datasets|
• Health information knowledge bases
|Implementing improved datasets for health care management that provide accedd to longitudinal and aggregated information for analysis, reporting, research and decision making.|
Providing access to a set of nationally coordinated and validated health knowledge sources for consumers and care providers
|• Individual electronic health records (IEHRs)||Implementing IEHRs that provide consumers with access to their own consolidated health information and provide care providers with a means to improve the coordination of care between multi-disciplinary teams. IEHRs can also support the collection and reporting of aggregated health information.|
How do we drive national alignment?Driving national alignment in the development of high priority E-Health solutions requires two key actions:
• National investment fund – The development of high quality, scalable Australian E-Health priority solutions should be stimulated via tightly governed access to a national investment fund. This will require the development of rules and criteria to guide the allocation of investment funds and the definition of appropriate governance, process and control mechanisms.
• National compliance function – The establishment of a national compliance function to test and certify E-Health solutions as being compliant with national E Health standards, rules and protocols. This will drive the development of national E-Health solutions that comply with E-Health standards and can be integrated and scaled across the Australian health sector. Certification criteria should be based on the principle of setting progressive targets to be achieved over a rolling three year timeframe.
What can be delivered nationally?This strategy is advocating a market driven approach to E-Health solutions development, however there are two pieces of high priority E-Health solutions infrastructure where a national approach to implementation appears worthy of serious consideration.
• Health knowledge portals – The implementation of separate internet based portals for consumers and care providers that will provide access to a set of nationally coordinated and validated health knowledge sources. Although these knowledge sources exist in some form today, they are fragmented, not always consistent or up to date, and involve significant duplicated effort and investment to maintain.
• Prescriptions service – The implementation of an electronic prescriptions transfer service between care providers and community and hospital pharmacies. Establishment of a nationally integrated service will allow consumers the freedom to fulfil medication scripts at a pharmacy of their choice, regardless of location.
How should we approach the implementation of individual electronic health records?An Individual Electronic Health Record (IEHR) is a secure, private electronic record of an individual’s key health history and care information. The purpose of Individual Electronic Health Records is to provide a consolidated and summarised record of an individual’s health information for consumers to access and for use as a mechanism for improving care coordination between care provider teams. The IEHR can also be used as a key information source for longitudinal and aggregated health information, in conjunction with other health sector data sets, to support more informed health care reporting and research.
As part of the national E-Health Strategy it is recommended that Australia adopt an incremental and distributed approach to the development of IEHRs. This is a pragmatic approach that:
• Focuses initial effort on enabling the flow of quality and relevant health information across the Australian care provider network;
• Supports more effective management of IEHR implementation costs and risks;
• Reflects the complexity and fragmentation of the Australian health system and the relatively early stages of IEHR development in Australia; and
• Supports the timely delivery of IEHR capability in those parts of the health sector that are ready to move more quickly.
This approach comprises four key phases of activity.
1. Connect Care ProvidersThe first step in the journey towards the building of national IEHR capability is to connect care providers across the Australian health system so that they can effectively access and share consumer health information. This step requires the implementation of national E-Health foundations such as consumer and care provider identifiers, standards, rules and protocols for information exchange and protection, and underlying physical computing and networking infrastructure. Current plans are to implement an initial set of these core information exchange building blocks at a national level by 2010.
2. Enable Key Information FlowsThe next step should be to enable the flow of priority sets of information between care providers to provide a base of comprehensive and reliable information on which IEHRs can be built. These priority information flows include referrals, event summaries, prescriptions, test orders/results and care plans and should incorporate consumer health datasets such as demographics, current health profiles and current medications lists. This step involves the definition of national standards to facilitate the exchange of this information and changes to patient, clinical and practice management systems to support the flow of these priority information sets between care providers.
FIGURE 2: Key Information Flows
3. Facilitate the Development of Distributed IEHRsOnce some of these key information flows are established between groups of care providers, secure repositories can be developed in a distributed manner across the health system that can accumulate the information in these flows into a consolidated record for each individual. As additional information flows are established, these can be incrementally added into the consolidated record to increase the richness of information available in the IEHR.
IEHRs can be used to provide consumers with access to their own personal health information, tailored care plans and a personal health diary to record observations on their state of health. Reporting and analysis tools can also be built to support analysis of de-identified and aggregated datasets based on the information contained in these repositories.
FIGURE 3: Distributed IEHRs
4. Review and ConsolidateOver time consolidation of the IEHR record repositories could be considered to reduce operating costs, rationalise infrastructure and simplify operational management.
What are the implications of this IEHR approach?Adopting an incremental and distributed approach allows different care provider networks to progress towards the establishment of IEHR repositories at different rates based on the extent to which infrastructure foundations and key information flows are in place. Distributed repositories will most likely be developed across geographic regions by large care provider organisations and care provider networks. However, this strategy also recognises the potentially important role that non direct care delivery organisations such as Microsoft, Google, Medicare and health insurers might play in creating IEHR repositories that allow consumers to electronically access their personal health information.
The key challenge associated with a distributed IEHR strategy is ensuring that the health information contained in these repositories is consistently secure, private and accurate and can be found, shared, transferred and reported on across multiple national repositories. Accordingly all IEHR repositories must be based on consistent national data standards and fully comply with data protection legislative requirements. This may need to be supported by the establishment of a formal licensing regime to regulate the operators of IEHR repositories.
Individual’s health records will need to be accessible from anywhere in Australia and components of these health records may reside in one or more repositories. There will therefore need to be a central indexing or addressing mechanism established that allows E-Health solutions to determine in which repository an individual’s IEHR, or components thereof, are located.
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3.5 Change and Adoption Work StreamThe Change and Adoption work stream focuses on what needs to be done to encourage and enable participants in the health care system to adopt E-Health solutions and change their work practices to be able to use them effectively. The aim of this work stream is to enact national strategies to drive the adoption of E-Health in Australia to a self sustaining tipping point as quickly as possible.
The majority of E-Health adoption and change activities should be undertaken and managed at local and regional levels across the Australian health system. There is a need, however, for some national strategies to accelerate the adoption of E-Health in Australia across the health sector. This includes a coordinated program of awareness, training and education, and incentive and compliance programs. The targets of these programs are consumers, care providers, health care managers and vendors, with a particular focus on driving the adoption of E-Health solutions across Australian consumer and care provider communities.
Why is change and adoption important?Global and Australian experiences clearly demonstrate the critical role health care participants play in determining the success of E-Health initiatives. These experiences also show that realisation of care delivery benefits is directly related to the extent that participants are willing to use E-Health solutions to interact with the health system.
Although unlikely to happen in the short term, there is global evidence emerging that consumer demand for access to better health information may become the real driver for the adoption of E-Health solutions in Western democracies. Until very recently Australian consumers have not been meaningfully engaged in the E-Health debate and there has been a consequent lack of pressure for action from this critical stakeholder group. It is apparent that Australian consumers will choose the nature and timing of their own involvement in the EHealth agenda and will not utilise solutions unless they are accessible, user friendly, trustworthy and clearly add value to their lives.
Where E-Health has been successfully implemented in this country, it has typically been led by pockets of the care provider community. In the majority of cases, however, there has been a consistent and significant underestimation of the effort required to engage and support care providers in the adoption of E-Health solutions. These E-Health initiatives have demonstrated that care providers will not adopt E-Health without clearly understandable benefits to themselves and to their patients, or if any solution imposes inefficiencies within the care delivery process.
Based on this experience, there is an emerging realisation that winning the hearts and minds of Australian health care participants will be a critical factor in determining the ultimate success of the national E-Health agenda.
What are health care participants adopting?E-Health solutions are the tangible IT systems and tools that consumers, care providers and health care managers will use to interact with the health system. It is through the adoption and use of these E-Health solutions that benefits will directly accrue to health care participants. The efforts of this work stream therefore need to focus on ensuring that consumers, care providers and health care managers are aware of these solutions, are educated in their use, and are encouraged and motivated to adopt them.
What do we need to do to drive change and adoption?Driving change and adoption requires focused activity in five key areas:
• National awareness campaigns – A key mechanism for driving change and adoption is making consumers and care providers aware of the E-Health solutions that are available to them and the benefits that use of these E-Health solutions may provide. This may involve mechanisms such as media campaigns, solution demonstrations and web based communication of E-Health status and success stories. As part of this process consumers should be actively encouraged to access and use emerging individual electronic health record solutions with a particular focus on those segments of the population that interact frequently with the health system such as mothers and infants, the elderly and those with chronic disease
• Financial incentive programs – Awareness and education campaigns should be supported by an appropriate incentive program to actively encourage care providers to purchase and implement high priority E-Health solutions as they become available. It is recommended that incentives be based on financial payments which are linked to the actual use of E-Health solutions and targeted at key private sector care providers (e.g. GPs, clinical specialists, community pharmacists, and diagnostic service providers). Incentives should be funded nationally and, where possible, should use existing national funding mechanisms such as MBS and PBS claiming through Medicare Australia
• National care provider accreditation – While incentive mechanisms may be used as a short term mechanism to drive E-Health adoption, the longer term focus should be on embedding the use of E-Health solutions into the day to day operating practices of care providers. A key means by which this can be achieved over time is by making adoption and use of E-Health solutions a national requirement for professional accreditation of care providers. This will involve liaising with care provider professional bodies to define appropriate E-Health accreditation criteria such as the establishment and maintenance of acceptable levels of computing infrastructure and the use of high priority, standards compliant E-Health solutions
• Vocational and tertiary training – There is a clearly identified need to ensure sufficient numbers of skilled health IT resources as this is looming as a critical barrier to the successful implementation of a national E-Health work program. The building of Australia’s E-Health skills capacity and capability will require the national coordination of changes to vocational and tertiary training programs. The emphasis of these changes should be to strengthen the understanding of the importance and use of health IT as part of care provider training programs and to increase the number of specifically trained Australian health informatics practitioners. This last action should involve consideration of the establishment of nationally recognised tertiary qualifications in health informatics in a similar manner to countries such as the United States.
• Stakeholder reference forums and working groups – The best E-Health outcomes will result from the continuous engagement of a broad range of interests representing public and private care providers, professional, government, vendor and community groups. To achieve this, it is recommended that stakeholder reference groups be established to provide input into the appropriateness and completeness of E-Health foundations, to prioritise E-Health solutions activity and to provide insight into the effectiveness of adoption and change approaches. In addition it is recommended that national professional body working groups be established to determine and oversee the changes required to professional education, training and accreditation programs.
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3.6 GovernanceThe governance work stream focuses on establishing the framework for effective management and oversight of the national E-Health strategy and associated work program.
Current Governance ArrangementsThe current national E-Health governance arrangements have supported improved coordination between Commonwealth and the State and Territory Governments in the oversight of their respective health information management responsibilities. However, the current arrangements are not sufficient to provide effective governance of the national E-Health agenda. This is due to factors such as a lack of organisational capability or capacity to deliver the national E-Health strategy and work program, a high reliance on collaboration between disparate committee, sub-committee and working groups, and the relatively limited representation of key health stakeholders in decision making processes.
Governance PrinciplesThere are a set of governance principles that should underpin the design of a national E-Health governance structure.
Clarity of accountability
|Ensure clear decision making accountability and provide all stakeholders with clarity regarding their roles and responsibilities|
|Provide widespread visability of the progress of Australian E-Health activities|
Appropriate stakeholder representation
|Provide a forum for represntation across all key stakeholder groups|
Ensure broad ownership and a balanced approach to the delivery of E-Health
|Implement a governance model that will not be unduly impacted by changes to the political or stakeholder environment|
Support for activity at multiple levels
|Recognise that E-Health governance will need to support initiatives that deliver E-Health capability at differing levels of granularity|
Effective leadership and coordination
|Effective leadership and coordination of the range of activities that need to occur across all national E-Health work streams|
Balance local innovation and national outcomes
|Continue to encourage local innovation while ensuring that the development of E-Health solutions supports national E-Health outcomes|
What do we need to do to establish effective governance of the E-Health agenda?Establishing effective governance requires focused activity in three key areas:
• National E-Health governing board – Establish a national governing board for EHealth that reports to the Australian Health Ministers’ Conference, has an independent chair and a breadth of cross sectoral stakeholder representation. The EHealth governing board should have accountability for setting overall national EHealth direction and priorities, for reviewing and approving E-Health strategy and funding decisions and for the monitoring of progress against national E-Health strategy deliverables and outcomes
• National E-Health entity – Establish a national E-Health entity to coordinate and oversee the E-Health strategy, investment and the execution of the national components of the E-Health work program. The E-Health entity’s operating model should support discrete functions focused on strategy, investment management, work program execution, standards development and E-Health solutions compliance. The national E-Health entity should be overseen and governed by the national E-Health governing board
• National E-Health regulation function – Establish a national E-Health regulatory function to implement and enforce national E-Health regulatory frameworks. Regulatory frameworks should cover areas such as the establishment and implementation of unique health care identifiers for individuals, care providers and care provider organisations, the integrity, privacy and security of personal health care information, and the licensing conditions and compliance arrangements for electronic health record operators. The E-Health regulatory function will need to coexist with existing regulatory and privacy bodies and should have an independent reporting relationship to Commonwealth, State and Territory Ministers.
The New ‘National E-Health Entity'The national E-Health Entity should have the following set of responsibilities.
Strategy – the review and monitoring of E-Health strategy outcomes and the development of strategic recommendations and priorities for consideration by the E-Health Governing Board.
Investment – the development of E-Health investment submissions and business cases for consideration by the E-Health Governing Board, and the budgeting and tracking of national E-Health investment funds.
Execution – the coordination of specific project initiatives across the foundations, adoption and change and E-Health solutions work streams, focusing on the delivery of on time and on budget projects, the reporting of project progress, and the management of project dependencies, risks and issues.
Standards Development – the definition, maintenance and enhancement of national E-Health standards and the implementation of a consistent process for undertaking this work.
Solutions Compliance – the testing of whether E-Health software products and solutions satisfy nationally agreed certification criteria and standards.
These functions should initially reside within the one E-Health entity to allow them to be established in a coordinated manner. Once the functions have matured, consideration can be given to separating those functions that may best operate as distinct entities in the long term.
The Way ForwardGiven the strong national consensus for action and the amount of E-Health activity occurring at a national, State and Territory, regional and local level, there is a need to move quickly to establish an appropriate long term E-Health governance regime. A pragmatic option is to leverage the existing NEHTA organisation and legal structure as the basis for creating the new E-Health Entity. In NEHTA, Australia has created and invested in a vehicle for the progression of the national E-Health agenda and, whilst the journey to date has at times been problematic, it represents the best foundation upon which to build momentum behind a national E-Health work program.
In order to ensure there is a clear distinction between the new E-Health Entity and NEHTA, there should be a formal six to nine month transition process to implement required changes to NEHTA’s constitution, board and operating model.
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