There is a wide spectrum of opinion in Australia regarding how e-health should be progressed. At one end of this spectrum we have the proponents of national-scale, top-down architected and developed infrastructure, such as exemplified by HealthConnect and by the NEHTA work program. At the other end, we have those who believe that such national-scale, government-run projects are doomed to fail, have been shown to fail around the world, take forever, and cost an order (or several orders) of magnitude more than organically evolving, bottom-up, industry-led alternatives. Where does the truth lie?
Many cite “the internet”, as an example of a successful, complex, evolving ecosystem that was not designed top-down by a government. However, some parts of it were. What is clear, is that the internet’s success is based on many soundly engineered components. These components are based on standards, modularity, clear separation of concerns, ease of implementability, relatively simple conformance requirements, and well tested implementations. This notion of soundly engineered components is one that is poorly understood or acknowledged in e-health, but one that needs to be if substantial progress is to be made.
Beyond sound engineering, there is another interesting facet to development of internet components – that of cost/benefit. With the evolution of the internet, it was the people who put in the investment who tended to reap the benefits. This is far from the case in e-health. Why would a pathology laboratory bother to improve the way information is electronically dispatched, if there is a substantial cost and little benefit? Once they have reaped the efficiency gains from getting their results out the metaphorical electronic door, why spend more? Why would a vendor of GP software invest in incorporating an elaborate, incomplete, complex SNOMED terminology into its product? Who benefits? Why would a hospital pay even more for a new Patient Administration System or Clinical Information System, than they currently have to pay, in order to have a raft of complex, bespoke interfaces to exchange data with external systems? Why would the Board pay for such extravagances at the expense of hospital beds? In all of these cases, the primary, and often sole beneficiary is the patient.
The internet grew remarkably slowly until reaching a critical mass of connectivity and information flow, where each individual or organisation participating in the information flow reaped a direct and usually immediate benefit. This is true whether we are looking up an on-line bus timetable, downloading a video, sending an email, or buying a new book. But with e-health, we are a long, long way from that. We may never have such an equivalent paradigm. So, if we are to herald in a new e-health world in the timeframe most people are hoping or (worse still) expecting(!), then an organic, industry-led, bottom-up approach will not be sufficient. Intervention will be required. Innovative investment approaches will be needed. Leadership will be required. And good engineering will be required. Wither NEHTA?!