What happened to our dysfunctional innovation-killing health bureaucracies?

12 minute read

As far as I can remember, if you were trying to innovate in health, digital or otherwise, it was once a safe assumption to make that you needed to steer well clear of government if possible

As far as I can remember, if you were trying to innovate in  health, digital or otherwise, it was once a safe assumption to make that you needed to steer well clear of government if possible.

Unfortunately for health innovators, this was virtually impossible because health has to have more governance and oversight of risk, and in health, the government holds the cheque book for nearly everything that goes on.  If you add to this starting point the vendor induced problems on the digital side of health where much of the innovation is gong on – that many run on old models of closed systems with gated data and breaking out of that too quickly can kill their businesses – then you’re some way to understanding why digital health has progressed mostly at the pace of a poorly snail in Australia for the last couple of decades.

Disturbingly, this no longer is a safe assumption. During COVID-19 we can’t at all rely on government to be ineffective, slow and political any more.  They’ve stopped taking queues from Ron Swanson in  Parks and Recreation.

WHAT happened here? And is there anyway we might be able to somehow bottle what is going on for future generations of health innovators to tap into?

Of course, there are still stuff ups. But what is telling, and annoying if you think about it, is that the ratio of stuff ups, to significant success, is much lower now than when they weren’t getting anywhere. Low failure rate and outrageous progress and success is the current trend. WHAT is going on?

COVID-19 has outed a lot of people working for government in health and digital health, as highly motivated  and talented under the right circumstances. The  phenomenon has to be all the way to top if you think about it, as a lot of the successes we are seeing in digital health problem solving involve the breaking of normally sacred rules of risk aversion, politics and bureaucratic ass protecting. People at and near the top have cleared their troops to simply “get shit done effectively and quickly”.

And wow, there must have been a lot of pent up frustration in some of those departments because they’ve delivered in spades. Digital health has moved forward more than a decade in a few weeks, and is threatening to move even further as COVID-19 persists.

A couple of years back the founder of the revolutionary digital health web sharing standard FHIR, and international health interoperability guru, Grahame Grieve, predicted that something like this could happen. Frustrated with how much potential and talent obviously existed in Australia but how little anyone was doing to realise that potential in digital health, he told me that Australia might stay stuck in time and the only thing that would likely change things was if the system is hit by some major crisis . He didn’t actually say it would be a pandemic. That might have been truly impressive.

At the time he told me, I thought it’s never going to happen because Australia, for all its faults, still had a relatively good healthcare system compared to any other country in the world so such a crisis just wasn’t likely. No one would ever be that motivated to act. We were surely doomed to be that frog in the slowly boiling water.

Grieve said something else I remember clearly which also predicted quite accurately what seems to have happened in Australia. It surprised me for someone so often outspoken and critical about the dysfunction of government here and some of the big global vendors. He said that should such a crisis ever happen, most of the ground work has been done by a bevvy of good people working hard in the background, including those in government, that we would be ready to do a lot, and, that there is a lot of talent in Australia in government and industry that can get stuff done if they get pushed the right way. Our “easy as she goes” ecosystem just needed a big fat push.

And then along comes COVID-19.

Following are just some examples of the government achieving amazing things in no time. Ironically I can’t provide full details on all  of them because of confidentiality issues. Oh yeah, the government actually does something amazing and when you want to write about it, they still somehow manage to make things weird by saying, “Oh, we don’t want that public, not yet, and maybe never”…as if it won’t eventually get out anyway. That’s the old government I still recognise – phew, they are still in there somewhere.

The most glaring example of rapid and effective change is telehealth. After a decade of experts pushing the government with very reasonable arguments as to why introducing it properly at the general practice and allied health level would lead to major efficiencies not uncontrollable MBS blowouts, it took just two weeks for us to go from some 63 telehealth items to the near full gamut for GPs over 360 items, and growing.

That this rapid introduction led to a bit of a mess, and GPs losing more money than they were previously making with face to face consults is possibly a great example of ‘known and unknown variables’ when dealing with transformational change. The government boldly set aside $600 million to deal with what they fully expected would be the telehealth fuelled MBS blowout. But so far it hasn’t come. In fact, so far, if we can believe multiple surveys, up to 50% of GP practices have lost more than 30% of their revenue and some are facing near term bankruptcy if things don’t change soon.

I don’t think anyone called that.

The jury is out still on where telehealth can take us as there are lot of variables that are not settled and won’t be for some time. GPs are suffering a lot from the fact that patients were told to go home and stay there and they did. And most of those patients had no idea that they could call their GP. Others simply couldn’t manage it. The result is the drop in overall consults, telehealth or otherwise, and subsequently, revenue.

But moving forward, as GPs get used to the idea of telehealth, and get properly educated, it seems almost impossible that the government will be able put the telehealth genie back in the bottle. Not fully anyway. The data is showing the government how obviously smart it is for the system to have a certain amount of telehealth capacity. Overseas, in some Scandinavian countries, and in some HMOs in the US that are very well vertically integrated, telehealth comprises up to 60% of all primary care consults. These other systems are systems that have efficiency signals in them.

We have a long way to go to get telehealth here efficient and without the many loopholes it currently has.  One huge problem that is already emerging is the harvesting of low hanging consults by aggregated service providers, some of them tech companies, not healthcare companies, and some centralised corporates. If, like in the UK, groups were allowed to keep doing this on the government dollar then they would likely harvest some 20-30% of the easy revenue from community based and connected general practice.

If this occurs we are in a lot of trouble. Community connected general practice is our secret for managing the coming chronic care tsunami. If you disconnect a patient enough from their community GP, continuity in care is lost, and a big cohort of the patient population, pursuing convenience rather than good health, will start costing the system a lot more in the end.

Perhaps it is challenges like this that are going to be the test of these until now secret government heroes who are taking advantage of a crisis to make things work much better than they have in the past.

In terms of telehealth can we just say to them and their bosses: “OK, you started this efficiency thing with some pretty brave and drastic decisions, which you knew would initially be hugely messy. Start iterating and finish the job please – at least to the point where when we leave COVID-19, we’ve made a two decade leap, not just one”

How the government ends up treating telehealth will be perhaps the biggest marker of their success when we look back at COVID-19. The opportunity is there for huge transformational change in the system for the better, for both GPs and patients.

Another interesting example of either very informed or brave decision making has been the government’s embracing of cloud based technology to rapidly create systems which provide widespread organised access to many patients but are centrally co-ordinated in the things that matter like common systems for clinical notes, and the like.

AWS is in the news a lot at the moment for its involvement in the COVIDSafe app, which is effectively a cloud based patient side service, but below the waterline there has been a near revolution in the uptake of specialised healthcare cloud-enabled middleware.

The government has until now been over cautious about using the cloud, to the point where developing apps and having them integrate with key systems was becoming mired in the need for  most cloud based applications to be architected to talk and integrate to old server bound systems, many of them government based. This was holding everything back. Two ecosystems were building, one cloud based, the other legacy server based, and increasingly this was stymying the progress of health innovators.

Now we have examples where the government has thrown that policy out the window for obvious practicality reasons and embraced technology that they know will get the job done for them in a very short space of time. This tends to be what cloud can do.

In one example, a cloud based clinical system was regeared within four working days to provide to  3,000 healthcare workers across the country working in in all regions with a system that directed phone calls on a priority algorithm, started their cloud app on a call being answered, and allowed each operator record common clinical notes which were available to the government organisation for live analysis of the unfolding situation.

The utility of this, and the speed with which it was implemented, is not likely to go unnoticed by government as they move onwards and upwards in their new and exciting decision making phase of ‘don’t-waste-a-crisis’.

The major patient management systems – Best Practice, MedicalDirector, Genie, and perhaps ZedMed – are hopefully watching with some trepidation. Such demonstrated cloud utility is likely to expedite the highly conservative general practice sector into thinking more carefully about their next installation or iteration of this vital practice software. And corporates will be, or should be, be taking notes.

Expect COVID-19 to mark a significant discontinuity event (progress) in the use of cloud services in healthcare in Australia.

It is interesting to think that all along the government must have been watching and understanding the utility of this and other cloud based services so that when the crisis called, they were ready and confident enough to act.  They negotiated with the vendors with a very solid knowledge base of what is possible, then broke all their usual rules to set up and execute contracts for operation and services with a variety of vendors, sometimes in less than one week.

Other examples of working being expedited include in the areas of patient management, triage, online education of healthcare professionals to man our ICUs should COVID-19 really take hold, and of course electronic prescribing. If you’re in the tech vendor sector you’ll have heard many  of the stories, or even more likely, be involved in one of them. Just try to keep up with the COVID-19 new technology implementation stories in PULSE IT each day. It’s an amazing new paradigm we find ourselves in.

The Australian Digital Health Agency (ADHA), which has come in for so much flack over the years for its dysfunction was already doing a a good job pre COVID-19 on the electronic script writing project. It was one of the few projects that was making good progress against the many goals the agency had set itself. But when COVID-19 hit, it wasn’t actually near ready. While the pharmacy vendors had a system they could roll out, and the script exchanges were ready to play ball, the GP PMS system vendors had other priorities and issues. The timeline expected to a reasonable implementation was estimated by one expert in the know in February at the HL-7 Congress in Sydney at 6-12 months at least.

We aren’t saying it’s done and dusted, but late last week the ADHA announced that they had successfully achieved electronic script transfer No 1. So maybe 8 months is going to become something like 8-10 weeks in the face of need? That’s an impressive job.

We won’t make mention of what happened to the My Health Record (MHR) during COVID-19 though, as that’s possibly a little less impressive. It does feel like it went seriously MIA during our biggest health crisis in a generation and  if so we might do well to to think about what that means for the utility of this whole idea moving forward.

All of this amazing activity on the part of the government proffers something even more disturbing than the realisation that there was so much latent potential lying near dormant for years.

Will the government decision makers involved in all this change shapeshift back to their prior form once COVID-19 moves on?

Is anyone putting any research or thought into how they changed shape, and how we might be able to turn the shape shifting on outside of a crisis, moving forward?

I hope so. It’s been a pretty amazing show so far. I’d hate it to end.

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