Tuesday, July 7, 2015

Call me naive but an eHealth record shouldn't be hard

The Federal Government is about to attempt to revive the originally dubbed the personally controlled electronic health record (PCEHR) now rebadged myHealth Record.

The bottom line is that clinicians are reluctant to use the system - they don't see enough benefit compared to the cost. They also have very real concerns about putting too much of their own diagnostic and consultation detail on line as they see that as their "intellectual property" - and a reason why the patient will come back to them.

And that is quite valid, the health system would be better off if everyone had a good relationship with a GP. The problem is that is easier to do as you get older. The solution to it may lie in differential Medicare rebate rates - if the patient declares a practice as their primary GP then they get a higher rebate for that GP visit.

But the Government does control the purse strings for a lot of health care, and once the system becomes opt-out there is Government data that can and should be entered. The obvious ones are:

1. The fact of any visit to a doctor and the attendant item number included in the Medicare claim.
2. The details of any script filled. This can be captured by pharmacies and almost certainly is already captured.
3. The details of any pathology tests ordered.
4. Focus on the providers of practice management software to build the appropriate APIs for interfacing between the myHealth Record and the practitioner system.
5. The date and purpose of any hospitalisation in a public hospital.
5. The fact of any imaging from the medicare claim. Build APIs for the myHealth Record to access images held in practice records (subject to data limits).

The issue isn't about training, it is about forcing some of the data onto the system. This won't capture historic data (though the Medicare records might) - and I can't see GPs ever loading historic data. But as time goes on it becomes increasingly rich.

The really good value will come from capturing the referral letters and replies relating to specialist consultations. The easiest way to capture those is by myHealth Record being a convenient and secure means of communicating between practitioners.

The data set obtained is not only useful for the purposes of accurate history taking, but also as data sets in big data studies on health issues.  Two contributors reporting on a workshop convened by Australia's Chief Scientist Ian Chubb identified this "big data" analysis as a critical pathway to making the health system more efficient and equitable.

Sally Redman wrote "Australia’s excellent and world-leading big health data sets – including large, long-term research cohorts and routinely collected information such as hospital and Medicare data records – will be central to this effort."

James McCluskey wrote "There is an agreed need for electronic medical records across the nation to simplify patient interactions with the health system and drive new research. Indeed, 'Big Data' in health needs to be better harnessed to inform public health policy and practice"

Jane Gunn wrote "Clinical data should be used to inform efforts to improve the system. Currently we have no standardised system for recording diagnoses and management across separate health care settings. This makes it extremely difficult to keep track of what is happening to people as they interact with the health care system."

The benefits of these health records are so great we need to stop pussy-footing around on "permission" and wherever possible make data capture the default.

Monday, July 6, 2015

Where is the NBN Co Corporate Plan?

In my AFR column that appeared in print today I noted that it is 34 months since a full NBN Co Corporate Plan was released.

I just thought I might touch on a bit of history here on why it has been so long.

Prior to the 2013 election NBN Co had submitted a 2013-16 plan, but the Government asked that the plan be reviewed in the light of some current issues. One in particular was the construction delay caused by the halt to Telstra remediation while working with asbestos training and work practices were revised and implemented.

In the 'NBN Debate' conducted on Lateline on 12 August 2013 between Malcolm Turnbull and Anthony Albanese the now Minister asserted the then Deputy Prime Minister was sitting on the plan and wouldn't release it to the public.

Later in the same program a very agitated Mr Turnbull was far more direct saying that the company had been told to keep the "draft" stamp on it because there was a "time bomb ticking away."

Unfortunately Labor wasn't re-elected and so no 2013-16 Corporate Plan was ever published.

However, both the plan that had been originally submitted as referred to by Mr Turnbull and the plan submitted to the Minister subsequently have since been leaked. Most importantly Mr Turnbull chose not only not to release either version of this plan, but instructed his strategic review to work off the 2012-15 Corporate Plan. (An archive on the history of the NBN including Corporate Plans is being developed here.)

Mr Turnbull was particularly aggrieved by the idea that Corporate Plans might be received in "draft" and took to Twitter two days later to record his "outrage".

Mr Turnbull released neither version of the 2013-16 Corporate Plan. The 2014-17 Corporate Plan was released in November 2014. In doing so NBN Co heavily qualified the plan saying:

NBN Co's officers do not give any guarantee ... that the results, performance or achievements expressed or implied by the FY2015 estimates will actually occur. NBN Co is not yet in a position to generate projections with a reasonable level of confidence for FY2016 and FY2017,

The shareholder Ministers also noted the limitations of the 2014-17 Plan, saying:

Given the transitional nature of the 2014-17 Corporate Plan and various ongoing activities (such as negotiation of amendments to the NBN Co/Telstra Definitive Agreements) which will be material inputs to future planning, the forecasts, analysis and risk assessments in the 2015-18 Corporate Plan will be crucial.

As the company advises, it is not in a position to generate forecasts with a reasonable level of confidence beyond the current 12 month business cycle and as such anything beyond that are heavily premised on long-range assumptions.

The Corporate Plan is important. The now Minister thought so when he demanded the original Corporate Plan be published in full. He thought so in the NBN Debate on Lateline.

He also thought so four months after that debate when on 7:30 on 12 December 2013 he said:

We have got to stop the spin. We've got to start telling the truth and have some numbers and forecasts.

The 2015-18 Corporate Plan is the first time NBN Co will make firm commitments about anything to do with the Multi-Technology Mix. Almost everything delivered in FY2015 has been the continuation of the original NBN model.

The plan is already with the Minister. The Minister previously vigorously objected to the idea that a plan other than the final plan might be received by Government. The Minister previously failed to release either version of the 2013-16 Corporate Plan despite insisting on its publication during the election campaign (see Note).

The SSCNBN in its Second Interim Report called for the release of the full plan when finalised. The Government Response is that Government supports the recommendation and notes the Statement of Expectations from the Australian Government to NBN Co requires the preparation
of annual corporate plans for the purpose of “consideration by Government and subsequent public

More recently the Senate passed a resolution (known as a return to order) on 17 June requiring the tabling of:

A complete and unredacted copy of the NBN Corporate Plan 2015 18, prepared by NBN under the Public Governance, Performance and Accountability Act 2013 and applicable rules and guidelines, and containing each and every financial and deployment forecast identified by NBN and the Department of Communications during the 2015 Budget Estimates hearings as being contained in the NBN 2015-18 Corporate Plan.

The response from the Minister for Finance was:

One observer noted "Fine sentiments, but there's just one small problem: the 2015-2018 Corporate Plan doesn't exist." The writer referred us to the Hansard from Budget Estimates.

There Deputy Secretary in the Department of Communications, Mr Robinson,  noted "The corporate plan is still being settled. All the processes get a draft at the end of May and the government considers it and talks to the company. There may be changes in timing of debt associated with that, but it has not been settled."

The language, however, becomes fun in itself as this exchange showed:

Senator CONROY: When do you expect to receive the final draft? Today is 28 May so it does not leave a lot of days.
Mr Robinson: GBE guidelines call for a draft corporate plan by the end of May, and we expect one.
Senator CONROY: A final one?
Mr Robinson: A final draft, yes.
Senator CONROY: Not another iteration? It will be their final one.
Mr Robinson: It is a draft in discussion with the government, but yes.

On the basis of the Minister's earlier comments about drafts it wasn't perhaps that unreasonable to ask for the Corporate Plan. The motion also asked for an un-redacted version of the Strategic Review, but that was also denied.

The questions that Senator Conroy was asking about the Corporate Plan indicate that this plan will be like the 2010 Corporate Plan in that it will still be premised on detail of Government policy.

NBN watchers will wait in anticipation of the Corporate Plan. As a marker the only real Corporate Plan released so far was on 8 August 2012. It was 12 August 2013 when Minister Turnbull aggressively demanded the next one. That should be when we get to see it.

Note: In his outburst on the Corporate Plan in the Lateline Debate Malcolm Turnbull said "You've got a time bomb ticking away. You've got a confession from the company that they're failing and you don't want to let the public know." Mr Albanese had previously repeated that the project was on time and on budget, and under questioning that it would be delivered by FY2021 for $37.4 Billion in Capex.  The Corporate Plan that Mr Albanese was supposedly "sitting on" did exactly what Mr Albanese claimed. It did show a $1.6B increase in peak funding due to delays at the start of the roll-out.

That the Government was justified in not relying on that plan is revealed in the next version of the plan that was only considered by the NBN Co Board after the election. It may never have been formally submitted to the Minister but comments about targets indicates the Minister was aware of at least some of its contents. That next version moved the completion date 6 months because of the suspension due to asbestos, it maintained Capex but reduced peak funding by $0.8 billion.

Of course, Mr Turnbull maintains that these weren't achievable.

But in the Lateline interview he also said of his $94 billion estimate:

Now, those four assumptions about revenues, cost of construction, wireless-only households and time are very reasonable ones. We put them out more than four months ago and nobody has been able to say that our assumptions are unreasonable, or, that given those assumptions, you would not end up with a $94 billion figure. And you'd think if they were wrong, in more than four months, the Government or NBN Co or somebody would've said, "No, Malcolm, you've got that number wrong." No-one has said that.

He is right, in large part because Labor didn't use the company management to do political work. But the company did eventually tell him he got it wrong - in the Strategic Review. And as the First Interim Report of the Senate select Committee on the NBN said the most accurate forecast was the cost of the Radically Redesigned model without assuming lower revenues and without assuming limited numbers of simultaneous work fronts. In brief, the Strategic Review largely confirmed the NBN Co Corporate Plans.