Clinical and non-clinical staff of today spend too much time on things that do not interoperate, according to Royal Australian College of General Practitioners (RACGP) President Dr Harry Nespolon. 
 
“Let me give you what a normal day in general practice is like without interoperability. I see a patient, who has been to the hospital the night before, first thing in the morning. The patient tells me that the hospital advised him to get some ‘stuff’ done. I check my inbox, but there isn’t a discharge summary,” he said, at a recent Australian Digital Health Agency (ADHA) event.  
 
“If I am lucky enough to have a discharge summary, there may be just some vague instructions to contact a particular department, which may not know of this patient’s needs. This wastes my non-clinical time, which sometimes even results in achieving nothing. 
 
“So much time is spent ringing up other departments, scanning, faxing, moving paper from one side of the room to the other, etc. It’s very inefficient and I rather have my clinical and non-clinical staff talking to patients instead of waiting on machines to do things. As a practice owner, I can’t wait for this to be right,” he said. 
 
Nespolon addressed the pressing need for interoperability, saying that it enables healthcare to spend more time on patients and producing better outcomes, rather than chasing things up. 
 
“If we were able to access the hospital’s pathology or appointments, for example, we can see what was written on the notes. That would save us so much time; one thing that you can’t compress in medicine is time.”
 
eHealth NSW CEO Dr Zoran Bolevich said there has been some skepticism around interoperability in healthcare, but mentioned that interoperability issues exist in the paper world as well. 
 
“Even in the paper world, there are issues with communication and how departments work with each other to communicate information,” he said. 
 
Bolevich said the current systems in many healthcare organisations are challenged in: 
  • Information flowing seamlessly between systems, resulting in new sources of patient safety risk
  • Continuity of care where various departments or organisations share information seamlessly for better patient-centric experiences
  • Enabling a learning system that uses data to improve patient safety, healthcare quality and outcomes. 
“A lot of systems have data hoarded in fragmented IT systems, so we need a system we can mobilise for analytics and research. But for that to happen, we need to develop our workforce. We need more data scientists, clinicians with digital health skills, technologists that understand health and clinicians that understand technology,” he said. 
 
A symbiotic relationship 
 
Queensland Aboriginal and Islander Health Council Independent Director and GP Dr Steve Hambleton, said while it is true that healthcare needs to evolve with changes in technology, the same should be said of technology. 
 
“Technology too, needs to evolve to support healthcare. Computerisation by itself is not the solution; software needs to be able to fit into the clinical workflow. Computers are good at doing routine things but healthcare isn’t routine – every patient is different and that’s why it’s challenging to build software that works for everyone,” he said. 
 
“We’ve got to think about the way our health system is set up, who it’s focused on and the data repositories that we have. A lot of them are still paper-based and data is locked up in paper. It’s very hard to get it out.
 
“The lack of connection and availability of data is reflective of the way we practice. With a patient ending up in hospital because of medication misadventure every two to three minutes, it’s worth reflecting on what we’re trying to solve.”
 
 
As a result, Hambleton called for a future-looking, interoperable system that moves today’s “average care” to one that is universal and personalised.  
 
ADHA Chief Executive Tim Kelsey said interoperability is the solution to making the future of health digital. 
 
“The momentum [of digital] is growing. My Health Record is just a part of the solution in Australia. The solution is interoperability – broadly, a modern, person-centered health service that has dealt with all the inequities introduced by paper-based health provision and no longer supported by fax machine in care delivery,”  he said. 
 
Core values
 
Kelsey addressed four core values required for a modern connected health service:
  1. Participation: Empowering the recipient of healthcare to be able to fully participate in health decisions by providing them with access to health information in a consumable way. 
  2. Collaboration: Having a broad consensus behind the delivery of digital tools.  
  3. Transparency: Creating meaningful, understandable information about the availability and quality of local care services and understanding the balance between the responsibilities of the recipient of care and opportunities in an information rich, modern service.
  4. Trust: Having the social license in place for digital services healthcare will provide in future. 
Kelsey said secure messaging would play a large role in the uptake of interoperability.  
 
“We can’t possibly imagine a world full of precision medicine when we’re communicating ubiquitously using fax machines. It will never happen and it calls out for the development of secure messaging. We need to start… building the necessary foundations in the standards we propose around interoperability for the future.”
 
But there is also a broader challenge of health literacy in Australia, according to Kelsey. 
 
“How do we ensure that people are not disadvantaged by the arrival of some digital services? We need to think about how we can support this agenda. The tipping point for that conversation is going to be the arrival of meaningful care facilitation through My Health Record and other infrastructures in Australia, which will hopefully take place in the next year,” he added. 
 
Getting the foundations right 
 
Software Industry Association Medical CEO Emma Hossack said technology isn’t the only aspect to come under review when it comes to interoperability. She mentioned that the industry needs to ensure that “foundational considerations” are set right. 
 
“We need to make sure that we don’t rush into it driven by a timeframe that’s unreasonable,” Hossack said. 
 
“For this, we need to have an environmental scan of all the projects that are currently working, or not; a test bed of areas where there is interoperability, where there’s patient benefits, where efficiencies or sustainabilities lie, etc. That’s absolutely key.” 
 
Hossack also addressed the issue of culture and cynicism, saying that those two areas need to be looked into. 
 
“We can work it out, but we can’t expect people to take on interoperability and be enthusiastic about it unless it’s going to be sustainable for their business. And let’s get our priorities right because we need to make sure that we’re getting what patients want right,” she said.  
 
“It’s also worth remembering that while we’re an industry, it’s not always all about the money. It’s about making a health system better, more accessible and enabling better outcomes for Australia. And none of that is possible without managing data.”
 
 
According to Health Intersections Principal Grahame Grieve, interoperability is about information management and people. 
 
“It’s not a technology problem; it’s a people problem and an information management problem. Technology comes and goes but information management is where the hard stuff is,” he said. 
 
“I talk about interoperability a lot, and about FHIR [Fast Healthcare Interoperability Resource]. But a lot of people misunderstand what FIHR is. It’s not so much about technology. It is two important things – a community of people and a set of technical agreements about information management and exchange.
 
“The FHIR standard and the FHIR community don’t deliver solutions to real-world problems; they exist to enable other people to do it. The challenge then, and the biggest challenge by far, is developing the right story, the right solutions and deploying it.” 
 
Grieve addressed three stages to deploying interoperability: 
  1. Getting basic capabilities into international standards: These consist of platform standards to build solutions on.
  2. Taking those standards and applying them to the Australian context: This involves industry collaborating to figure out what these local guidelines or rules should be, testing them and integrating that process into a sustainable standards cycle.
  3. Turning those local agreements into operating software. 
“FHIR is scoring goals in the first and second stages around the world, but it’s the third stage that’s the hardest stage, by a long shot. The challenge is that each of these stages means different people, different cultures, different processes and the handover between stages cause potential disconnect,” he said. 
 
“Getting continuity to run the process to the ground is the hard part, and it’s increasingly our focus. But in Australia, we’re starting at the back of the pack. 
 
“What we need is the belief that we can collectively get it properly moving and solved. Interoperability can be done, but we have to be realistic about the issues and roadblocks faced in Australia and start navigating our way around them.” 
 
To lead a productive conversation around interoperability, the ADHA has released a National Health Interoperability Roadmap Co-design paper, which is currently open for consultation. 
 

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