As Australian governments at state, territory and federal levels grapple with dramatically escalating healthcare costs, a bow wave innovation opportunity has arisen to provide a solution that will save billions at the same time as actually improving the quality of care: eHealth.
The digitisation of health information in particular will enable the provision of medical records and other diagnostic and decision support data for health practitioners to point of patient care at any time, in any place with the right connectivity.
Financial savings from reduced duplication of tests and endless repetition of patient history, along with the reduction of adverse patient events due to increase in information accuracy and integrity will transform the cost effectiveness as well as the service efficiency of care delivery.
In addition, the integration of care across the primary~tertiary healthcare divide facilitated by the sharing of digitised information will radically amplify both cost savings and quality of care improvement.
But this digitised information will still need to be managed. Any electronic ‘decision’ about the quality of what an electronic informational device reads as ‘data’ can only be as good as the last ‘data entry’. Ontologically, artificial intelligence cannot understand ‘meaning’ better than the intelligence that generates it.
The health industry, the Health Information Management Association of Australia warns, ignores the need for a frontline health information workforce (HIW) at its peril.
On 6 April HIMAA joined a host of stakeholders in lodging feedback on the Framework for Action for the Australian Digital Health Agency’s National Digital Health Strategy. The ADHA is tasked with the implementation of the national electronic My Health Record for primary care in Australia.
The strategy, released last August, targets seven outcomes for Australia’s national electronic health record:
Health information that is available whenever and wherever it is needed
Health information that can be exchanged securely
High-quality data with a commonly understood meaning that can be used with confidence
Better availability and access to prescriptions and medicines information
Digitally enabled models of care that improve accessibility, quality, safety and efficiency
A workforce confidently using digital health technologies to deliver health and care
A thriving digital health industry delivering world-class innovation.
No-one would question the systemic succinctness and efficacy of these objectives. From HIMAA’s perspective, the digitisation of health information is a key to the strategy’s success, and the first two outcome areas acknowledge this.
HIMAA is highly supportive of the consultation process the ADHA has undertaken in engaging both the community and the health industry in its brief two year history. The Association fears, however, that the My Health Record risks missing the wave in its construction as a digital storage facility rather than an information management system. And that the framework becalms itself with a use of language that reveals conceptual creaking in the rigging.
Information vs Data
For a start, the terms “data” and “information” are at times used interchangeably. The third outcome area of the strategy seems to not even understand that when it’s referring to ‘high-quality data with a commonly understood meaning’ what it actually means is information.
And when “information” is used, the term is confined to “clinical information”. Other frontline health professionals don’t get a look in. Which seems short-sighted for a national electronic health record designed to serve primary care in a climate of increasing chronic and aged care requiring multidisciplinary coordination.
The conceptual conflation of “data” and “information” elides a logical link between experienced data (the raw stuff of practice), its conversion into a textual signification of meaning (information), and then the translation of meaningful information into meta-data (for instance through clinical classification). Data is all just data, whether a product of higher order signification through information management, or the often hastily scribbled notes that come out of a consultation between health care professional and patient.
For the latter, HIMAA provides an authoritative dictionary of some 11,000 clinical abbreviations, acronyms and symbols to aid their conversion into information for medical record. That is 11,000 sources of potential error if the generation of information is not expertly managed. Not even clinicians can carry that number of linguistic reductions in the one head, along with the actual wealth of operational clinical knowledge they subtend.
The conversion of the resulting health information into coded meta-data, based on an international clinical classification of disease adapted for Australian conditions (ICD-10-AM), reduces a lot of text and numerical data into smaller packages for ease of transmission and storage. The precision of the classification ensures that information out, once extracted from the codes, is identical to information in.
Clinical classification thus aids the integrity, security and accuracy of health information when electronically shared over time and distance. This coded health information is used in health care financing, research and planning.
But if the coding is to be useful in the integration of primary and tertiary care – an integration on which major benefits of the digitisation of health information depend – then interoperable classification is needed. At the moment most general practitioners do not code their medical records at all and the My Health Record itself uses another system of categorisation, SNOMED-CT. There is nothing in the strategy or its Framework for Action to cater for interoperability of health information classification.
Nor is any other management of health information proposed as a central operating principle in the future of digitised health information. Information will – presumably through the existential clash of informationally standards-free softwares and the sheer processing power of information technology – somehow take care of itself in perpetuity. Mere electronic warehousing is all that is required.
The essential workforce
The second area of conceptual absence in the framework is in its sixth outcome area. All of the actions framed for this outcome are laudable, except for the one that is missing: the health information workforce.
As established in Australia at two national health information workforce summits in 2015 and 2016, HIW is experiencing chronic workforce shortages in the face of increasing demand, as health informaticians and health information management professionals alike are called upon to develop and implement digital health solutions.
Unless the current health information workforce, including health information managers and clinical coders, is supported and developed, few of the other actions in outcome six will flow. Indeed, the existing HIW is the logical community of practice to be enhancing in order to act as a central change agency in this outcome area. But it doesn’t get a mention.
HIMAA has recommended the ADHA address these and other aspects of the Framework for Action before releasing the good ship from its moorings.
Richard Lawrance is Chief Executive Officer of the Health Information Management Association of Australia.
HIMAA is currently calling for abstracts for speakers to its 2018 HIMAA NCCH National Conference to be held in Hobart from 31 October-2 November.