The wonders of modern digital connectivity are there for the taking, but there are elephants in the e-waiting room
This is one of those stories that as a GP you won’t, on spec, be interested in. But only because you’ve never been told “what lies beneath” the story: the unnecessary, and potentially significant, retardation of better communication between the various important hubs of health information in this country, and therefore the slowing of delivery of much more efficient healthcare, via GPs, to their patients.
Ask most GPs what they think of the big private pathology providers and your response will be usually be somewhere between indifferent to unusually positive. One GP we asked is literally thrilled with the new mobile results service that Sonic Healthcare now provides through its path labs. To GPs, path results arrive through their patient management system with relative ease. What is there to be bothered about?
If you ask a practice manager, or a practice IT contractor, you get a degree more of concern, but still nothing catastrophic. The issue for them is there are so many different systems talking to their patient management systems. That is a hassle, but once they are downloaded, they are usually robust and work. Some combinations still won’t work, however, no matter how hard you try to jam them together, and so, in some cases, the IT manager has to buy in another messaging solution, or develop a costly and frustrating workaround.
The problem is, unless you’re an immersed GP owner, or one of those GPs who are into their IT systems, you never see these issues, and generally won’t be aware of the additional cost. Over time, there is a lot of additional cost.
For the majority of GPs, these gateways are magically working, so never given a second thought. Which is normal behaviour. Does anyone know how their mobile phone works, or how Facebook targets those ads at you?
This article is largely about you giving everything that happens down the messaging and IT interoperability rabbit hole a second thought. Because our whole healthcare system is being slowed down currently by what is a mess of spaghetti-like communication protocols, that don’t talk easily to each other.
This situation has been created by a mix of poor planning, ineffective regulation, vested interests doing what they do best, and bad luck.
So what’s the fuss about?
Here are a few things:
• The messaging systems of the major private pathology providers are antiquated and proprietary. They aren’t up to the messaging standards being laid down by the government for a modern e-health messaging environment, and, in some instances, they aren’t even secure to the standards required. Also, there are lot of them, and they still change from time to time and remain proprietary and basic. In the case of Primary Health Care, the system can be dependent on which region you are in and the labs that are serving that area.
• Add to this a host of private, independent messaging systems, such as HealthLink and Argus. They are often a little more interoperable, secure and can provide better sources of data analysis if you want to tweak a system, but they, too, don’t talk to everything. Part of that is that the private pathology providers don’t want to talk to them, because if they do then these independent providers can move in on their referrers more easily and facilitate easier change of pathology providers. So long as they don’t talk to the private path systems, these independent systems aren’t that efficient either, so they never get to take hold of the system, like they have in NZ.
• The effect of this, and other techniques used by the big pathology providers, such as pre-printed branded and bar-coded pathology forms for doctors to use, and buying up all the real estate in large practices where pathology can be co-located, is that these big labs can stay more strongly attached to their referrer base – which essentially is you, the GP. They want to be very sticky to you because you are their reseller even if you don’t realise it.
• The result is you don’t have any hassles, so you don’t question anything and patients don’t know they can use alternative pathology providers. So the big pathology labs hold on strongly to their long term client base.
• But it’s what you don’t get that might be hurting you. Reverse the saying, “You don’t know what you’ve got till it’s gone” to “You don’t know what you’re missing until you’ve got it”, and you might start being a little more interested. No one is telling GPs what they might be missing.
Here’s what this situation can lead to
Last year, a new fully cloud-based patient-management system launched into the GP market called MediRecords. This group had spent two years, and millions of dollars, programming specifically for mobile patient management via a true cloud-architected system – something that is likely to make GP lives far more efficient, interesting and, even, better rewarded.
The MediRecords system provides practice management software, online appointments, waiting room check-ins and patient access to their health records.
Prior to launch, this group had checked in with the pathology providers to see how their systems would talk to it. The answer came back from Sonic that HealthLink, one of the private independent providers, would be OK. The group also programmed for Argus, and a few other private providers, which provide more modern, secure, interoperable solutions between GPs, specialists, pathology labs and other outside providers.
MediRecords was installed in a major new practice with multiple doctors, but within a week of installation it became clear that that there was a problem with messaging between Sonic and the practice. Sonic refused to accept HealthLink. There is a long history between Sonic and HealthLink. MediRecords perhaps should not have been surprised. The practice rang MediRecords, which talked to Sonic, and Sonic it is claimed simply said that it had changed its mind.
Interestingly, Sonic can accept HealthLink as a messaging system. But it has to pay a transaction fee for it. This is the likely reason it gave the new client of MediRecords short shrift. This isn’t a trend that is currently commercially sensible for Sonic to start. Effectively it makes Sonic “openly, interoperable”, between MediRecords, HealthLink and a GP practice, something we don’t think exists.
There is also a more tenuous possibility. Sonic owns 30% of Best Practice, which theoretically would be competing with MediRecords. But knowing how Sonic works, TMR doesn’t think this would have been in play.
The result of this was that this practice had to pull out of MediRecords as it couldn’t wait the four to six weeks that it would take to write a special interface to talk to “Fetch”, the bespoke Sonic messaging system. It also cost MediRecords a fair bit of money to turn around and write a specific routine of code to hook to Fetch, code which will, in all likelihood, be redundant within two years as the Fetch system is very old technology.
This is perhaps a small incident, but it’s a telling one. Fetch, and all the Primary messaging solutions, do not talk to anything but their own companies. So if you aren’t dealing with those companies, you aren’t in the picture because, between them, they own 74% of the market.
Interoperability is not just a problem involving Primary and Sonic. All the software vendors have refused over the years to talk to each other at one point or another. It wasn’t in the interests of MedicalDirector years ago to talk to its emerging competitor, Best Practice, so for many years, there was no simple way of getting the companies to share data.
Today, both of these systems have had years of sorting out how to talk to the various messaging systems. And it hasn’t been cheap for either vendor. But there are still instances where some things just don’t work when you have so many vested parties involved – pathology labs, software vendors, messaging vendors, and government, with all the dreams of a single electronic health record.
This isn’t unusual, or particularly awful, private-sector behaviour. Apple, Amazon, Google and Facebook, all leverage their hold on “distribution” and “communication” to make more money. Apple has never liked talking to Microsoft and vice versa. We can’t really expect big pathology providers and private-messaging providers to be any different.
Or can we? This is the health of the nation we’re talking about – and saving billions of dollars a year, and ultimately, lives.
The government has the ability to decide that, for the greater good, the law might need changing. For example, either all you guys play nice and talk to each other within three years or you don’t get any Medicare money any more.
Unfortunately, this sort of drastic solution has side-effects that can make things worse. Sonic is so big these days that it’s one of those things that almost “can’t fail”. Making groups such as Sonic or Primary unstable would create unacceptable instability in the health ecosystem. So a drastic regulatory resolution isn’t a likely option. Probably Sonic and Primary realise that, which makes change even trickier. There is going to have to be some sort of reward all round for this to change.
The prize of better, open, secure-messaging systems can be viewed over the ditch. In NZ, connectivity between GPs, pathology, radiology, government and other providers is significantly advanced compared with here. On one estimate, the Kiwi system is 650% better in terms of the interoperability, security and sophistication of data collection.
A key reason is that many years ago the NZ government put large chunks of pathology out to tender and decided on only a few providers, with just a couple of secure and standardised messaging systems between them. The result was a system that was a lot more efficient to operate, more secure, cheaper for government to rebate, and, most importantly, a system that delivered sophisticated real time data back to the government in order for it to continually fine-tune the mode of healthcare delivery and the mode of funding to incentivise better delivery.
A potentially ugly truth for all our software patient-management system and messaging providers is that one of the reasons NZ works so well is there are far fewer patient management system and messaging vendors. It’s simple, and partly as a result, they all talk to each other.
There is more to NZ’s advanced state of digital connectivity than just this one decision. For example, there are no state-federal boundaries and disputes in the healthcare system, so tertiary and primary care report to the same masters. As things stand, one patient management system owns about 85% of that market and one messaging system has 85% of that market.
At the time of the big change in NZ, Sonic was one of the major pathology suppliers which tendered, and lost. Sonic subsequently almost wholly pulled out of the country. At that time, the system could only survive the withdrawal of Sonic because the major secure messaging service was privately owned, not individually owned by each of the private pathology providers. So when Sonic left, it was just a matter of switching pathology suppliers, not “rewiring” the system. There was a neutral, sophisticated messaging service in place already used by nearly all of the vendors. In Australia, such rewiring would be horrendous.
The worst part of this set up is not so much that it’s harder for a new player to enter the market in pathology – because the wiring is complex and tied up – but that these messaging systems are not at all interoperable. This means they talk to nothing other than these pathology providers and the GP surgery. In a modern healthcare system, that, effectively, is a lock up on data. And the irony is that these systems are so old and not fit for purpose that not even these providers can extract good data from them to improve operational aspects of the system that would suit them.
MediRecords is a perhaps one small casualty of this resistance to being open and interoperable. But the whole healthcare system here is exposed to the problem. So anything innovative, such as mobility, might get stuck in the mud of the Sonic-Primary hold.
Pathology reporting, in one way or another, makes up more than 40% of all external, secure communications to doctors in Australia. If that communication is oblique and locked up, then the whole idea of efficiency from connectivity and interoperability is over before it starts.
Of course, Sonic and Primary will defend their staunch resistance to updating their messaging systems. For starters, the private providers of messaging, which generally offer more updated solutions, cost the pathology providers money. They require a transaction fee. It is well within the rights of Sonic and Primary to say, no thanks, we don’t need the additional cost. They could also correctly argue that initially, at least, they led the march into digital efficiency in this market. It was they who pioneered electronic messaging here.
There are other issues. Interoperability can have safety implications. But that doesn’t completely explain what is going on. Both companies are huge and multi-faceted, particularly Sonic.
Building an open messaging system that meets all the modern standards required by the Australian Digital Health Agency, that talks seamlessly to the My Health Record, that is properly secure and truly will operate across any number of modern and emerging healthcare system platforms, such as the cloud offering of MediRecords, is well within the reach of both companies.
Only last week, the ADHA announced that “patients in NSW will now be able to view their pathology results through the MyHR consumer portal”. That sounded epic when I first heard it. Then I looked at the fine print. It’s only public pathology labs that are loading results, and to start with just three. That data isn’t even going to register as a faint blip on the radar of your average patient or doctor, because nearly all their path results are coming out of the major private pathology labs.
How come Sonic, Primary and ACL aren’t loading their results to the MyHR? One very basic reason is that no one is paying them to do it.
If Sonic did start loading their results to the MyHR, then patients and doctors would start having another avenue to access pathology results other than a tightly controlled Sonic one – a very open and transparent pathway. And one where switching between pathology providers, by both doctors and patients, would likely become much easier.
So another reason for Sonic and Primary’s resistance is not only that there is no commercial upside in it, but there is, at the moment, very probably a commercial downside.
It is understood that when NEHTA first tried to negotiate more open and interoperable standards for messaging systems with the major patient management software vendors, the vendors arced up and said there wasn’t a commercial imperative. So NEHTA paid them.
From any commercial angle, it’s hard to argue against the idea that the government may need to pay Sonic and Primary to do the same thing. And even pay them something to load results, as they are doing to GPs through the ePiP program.
So the situation is a little more complex than your run-of-the-mill, “private company plays dirty and greedy” and the poor public suffer. The private companies are playing hard – but unfairly? In the circumstances, probably not.
How does this situation resolve itself so we can unclog the path to an interoperable environment where new technologies and communication protocols can thrive, with subsequent improvements to healthcare delivery?
The ADHA has made resolving secure messaging and interoperability one of its first priorities and they are a fair way down a path to some resolution. The problem is, the path is still very tortuous and long.
Dr Nathan Pinskier, who is chair of the RACGP Expert Committee on eHealth and Practice Systems and a lead on the ADHA secure messaging program, is the closest thing Australia has to an e-health journeyman.
He told TMR that recent progress on the problem was substantive and that there was now at least a clear path to resolution and programs underway to get there.
These programs involve developing interfaces between the various messaging and patient management system suppliers that will allow any messaging or software vendor combination to talk seamlessly to another.
If the ADHA can achieve this, it will remove the ability for proprietary blockage and make the system “open”. The spaghetti strands will all be able to talk to each other.
Dr Pinskier is also pragmatic when questioned about possible the role of Sonic and Primary in getting things sorted out more rapidly.
He points out that the private pathology providers were the leaders in e-messaging to start with and where they can, they do try to push technology to create efficiency, but they are businesses and they have their limits.
He acknowledges that their proprietary systems can create some blocks, but adds that the private messaging providers act in a relatively similar manner. One question that he couldn’t answer is why NEHTA (now the ADHA) paid the software vendors to write a link to the MyHR but so far has not agreed to pay the pathology providers. He does say that having the pathology information in the MyHR would be invaluable, however.
As things stand, there don’t appear to be any quick fixes.
The issues remaining
• The private pathology providers won’t move on open systems currently because they fear losing their grip on their referrer base. They also won’t write to the MyHR for the same reason and they see no commercial upside.
• The mix of patient-management software vendor compliance and messaging compliance is complex. There are up to 10 different messaging systems, and although Best Practice and MedicalDirector about 85% to 90% of the patient management system market, there are another five or so vendors dotted out there to confuse things.
• The ADHA path to a fix is difficult and slow, but at least there is one.
• For some reason the government is resisting paying the pathology providers to ease the situation a little.
In assessing this situation, Dr Pinskier makes a telling point.
“Although things do seem difficult still in this area, it is likely to get much better as the key stakeholders start to put more and more pressure on the pathology providers and vendors, as they come to realise what is at stake.”
Who are those key stakeholders? GPs, of course.
Which brings us back to the beginning of this article. For very obvious reasons, most GPs don’t concern themselves with this issue. They don’t even know it exists, and if they do hear of it, it’s hard to relate to it when they are just trying to get things done in the practice.
Possibly that’s where the ADHA needs to focus next. Getting the major stakeholders in changing our healthcare system for the better – GPs – bought into this problem in large numbers and changing the problem from the front.