The document discusses strategies for building a national health IT system in Australia. It argues that a "middle out" approach, where the government sets standards and incentives while allowing local flexibility, may be most effective compared to purely top-down or bottom-up approaches. Under this model, the government defines the policy framework and funds public sector participation, while providers upgrade local systems to national standards. This preserves what works locally while facilitating information sharing nationally over time. Clinicians also have an important role to engage with patients and lead the implementation of easy win e-health services.

1. Building a national health IT system
from the middle out
Enrico Coiera
e.coiera@unsw.edu.au

2. The Sustainabilty Funnel: when demand
for resources and supply diverge

3. E-health can help improve system sustainabilty
and patient safety
• Gartner (2009) report provides many examples
where E-health:
– Improves patient safety (eg reduce
prescription, medication errors, avoid ADEs)
– Improve clinical efficiency (eg reduce duplicate
tests, or admissions via home monitoring)
– Help clinicians care for more patients (e.g.
EMR, CPOE reduce length of stay)
– Helps burden of care shift to the consumer (e.g.
electronic messaging reduces GP visits by 10%)

4. The Personally-controlled electronic
health record (PCEHR)
• Mid 2012 launch; > $500 million cost
• Every citizen will control a PCEHR and able to elect
who sees it and what goes in.
• PCEHR may contain:
– GP summaries, discharge summaries, referrals, specialist
letters,
– MBS funded “healthcare events”
– PBS dispensed medicines
– Childhood immunisation register
– Organ Donation Register
– No pathology results in first release
– Consumer entered information

5. But health system inertia appears to limit
change
• 1999 IOM „„To Err is Human‟‟: reduce medical
error by 50% in 5 years.12 years on, no
where near target
• Evidence-based recommendations,
standards pile up, unheeded or poorly
enacted. Only 50% adults get recommended
care.
• Restructuring health services appears to
achieve little.
• Inertia to change appears to be a
fundamental property of the health system.
BMJ 2011; 342:d3693

6. Clinical Inertia
• “failure to initiate or intensify therapy when
indicated”
• documented for many conditions e.g.
diabetes, hypertension and dyslipedaemia
• As number of patient problems increase,
decision to change therapy more likely to be
put off until next visit
• Explanation - Clinicians make best decision
possible in face of multiple competing
demands

7. Competing demands

8. Is similar complexity the main cause of
health system inertia?
• Competing demands grow with increasing
– Number of stakeholders
– Sunk costs and entrenched practices
– Competing standards and technologies
– Problems, processes, tasks to manage
– External pressures e.g. climate change, economy

10. Is nation-scale E-health a victim to
complexity and inertia?
• No agreed international model. Varying
success, few generalizable lessons. Local
context is all.
• In Australia, Federal Government has spent
~$1 billion /10 years with little tangible front
line change [$230m DSS review (2002) +
$241m NEHTA + $475 PCEHR]

11. Strategy: How do we find our way across
the E-health fitness landscape?
Some natural experiments to study ….

12. Case study 1: English NHS NPfIT
• World‟s largest civil IT project, £13 billion over 10
years to improve services and quality of patient care
• NHS a nation-scale, single-payer system
• Adopted a top-down strategy for system
architecture, standards compliance, and procurement
• Some wins but clinical unrest, delays, cost
overruns, paring back promised functionality.
• Political demands to shut it down : “Conservatives
pledged to cancel programme … Liberal Democrats
"a disaster … from the start.” BMJ 28 Jan 2009
• 2011 - New government, major cuts, move to
decentralise decisions, non-preforming contracts
(e.g. CSC) to be scrapped.

13. Problems with top-down strategies
• One size doesn‟t fit all.
• No easy migration plan. Non compliant systems shut
down and replaced even better fit local needs.
• Imposed redesign is expensive, wasteful, generates
disaffection. Staff retraining/workflow adjustment can
introducing errors.
• Long delay until ROI means „stuck‟ with ageing
systems and technology despite significant
changes, i.e. more brittle to change.
• To meet emerging needs service providers will build
work-arounds, adding “unwanted” local variation to
singular national design.

14. Case study 2: US Health Information
Exchanges
• Pre American Recovery and Reinvestment Act (ARRA), US
embarked on a bottom-up strategy to NHIS development.
• Service providers form coalitions to interconnect existing
systems into regional health information exchanges (HIEs).
• Preserves existing systems. New technologies, system designs
can be adopted locally where is need and capacity
• Standards not mandated but adopted on a business needs
basis. Little central intervention.
• Does not create a single central record, but allows remote view
of local records, perhaps abstracted or aggregated regionally.
• Expected that Regional HIEs would eventually aggregate into a
nation-scale system.

15. Problems with bottom-up strategies
• Business model unclear – some HIEs went bust
• Cannot predict how expensive or feasible it is for a
local system to interface with an HIE.
• Cannot predict how much information is available to
other providers.
• Incompatible data models may make reconciling
information across different systems arbitrarily
complex.
• Unlikely to be aligned with national policy goals.
• The price for preservation of local systems is a
weaker national system, which may have data holes,
and data quality problems.

16. Which regulatory model?
Free Guided Centrally
Market Market Controlled
“Bottom up” “Top down”
Local investment in safety Nationally developed
driven by cost/benefits legislation, infrastructure
including patient National clinical standards
expectation, insurance, legal
“Middle out”
Locally driven investments and solutions
Nationally investment in legislation, infrastructure & standards

17. Middle-out: A third way
• Modelling says managing your “patch” of control and
expertise is most effective way to find fitness peaks
• Acknowledges government, providers have different
starting points, goals and resources.
• Allows government to pursue policy goals.
• It is a co-production (no need for
„consultation‟, partners are not on the payroll).
• All come together to agree on common NHIT
strategy, functions, standards,.
• Providers bring systems to national standards e.g.
customized interfaces or make new purchases.
• End product has rich capability for information
sharing, resilient over time, preserves what works.
J Am Med Inform Assoc. 2009;16:271-273.

18. Middle-out: Government‟s role
• Define policy framework to converge public and
private, local and central systems into a functionally
national system.
• Fund public sector to join the NHIS.
• Incentives for private sector where the business case
is weak but national interest is strong.
• Develop public goods e.g. standards, core building
blocks, broadband, health informatics
workforce, evaluation of progress.
• Legislation to protect privacy and interests of citizens.
• Avoid as far as possible what it is not good at, like
designing, buying or running IT.

20. Middle-out: Clinican‟s role (1)
• HIT safety – a clinical not a technical issue:
– Emerging data about risks associated with rushed
implementation, poor training, software performance.
– We are yet to experience our first HIT ‘air crash’
– Safety is a systems issue and software is just one
component of the socio-technical system
– Standards needed not just for technology (e.g. HL7) , but at
services level (system functions), implementation quality
(certification of process quality) and for the hands of users
(certification of competence)
– Routine monitoring of IT related safety incidents should be
mandatory as should rapid response to incidents

21. Clinical role (2)
• Having realistic expectations
• “Past performance (in one setting) does not predict
future performance (in another):
– HIT Centers of excellence often used as benchmarks for
outcomes, but often have home-grown solutions, developed
incrementally over decades, with large resource including
academic informaticians and IT staff (e.g. >1000 at Partners)
– Industry solutions are usually implemented entirely
differently, from generic packages, with little local expertise
available, and ongoing monitoring and modification.
– Need to base expectations upon robust outcomes at the
middle, not the top!

22. Clinical role (3)
• Chase the benefits, avoid solving the wrong problem:
– An "EHR first" strategy can quickly become and
“EHR only” strategy.
– Will miss easy wins to demonstrate success, keep
political momentum, preserve end-user buy-
in, build public confidence.
– Easy wins? Online booking, share discharge
summaries, advance care directives, electronic
prescribing, home monitoring, decision support, e-
psychiatry.
– Clinicians need to lead in the development and
adoption of these e-health services.

23. Clinical role (4)
• Engaging with patients in the transformation
– Consumer e-health applications rapidly maturing
eg HCF MyHealthGuardian PCeHR used by
25,000 Australians
– Will soon dwarf the professional e-health market
(think Google, Microsoft)
– Will create new ways of interacting with patients
(think Skype, email, facebook, twitter, iphone)
– Will require a willingness amongst clinical
providers to creatively engage in service
transformation with consumers

24. Over the next 10 years …
• We will build and deploy more ICT in the health system
than ever before.
• Systems will be larger, more complex, and shift from
local/regional to national/supranational scale.
• The demands for health system modernization are so
compelling that we have no choice.
• The costs and benefits of such systems have major
implications for national GDP and government.
• Yet we are probably at the same place in industry maturity
as aviation in the 1950s. Risks of failed or delayed
implementation, cost over-runs, and accidents are real.
• Middle out strategies most likely to help us find a way
through

25. Thank you
e.coiera@unsw.edu.au