The document discusses the challenges facing builders of national health information systems over the next decade. It identifies sustainability and safety/quality as the two core problems. A top-down approach like the UK's NPfIT program faced challenges like cost overruns and delays, while US bottom-up health information exchanges saw variable success. The document proposes a "middle-out" strategy where governments, providers, and others work together to agree on standards and each contributes their expertise. It also identifies strategic risks around health IT safety, managing expectations, and solving the right problems in order to successfully build integrated yet resilient national health information systems.

1. The Dangerous decade:
Challenges for builders of national health
information systems
Enrico Coiera
e.coiera@unsw.edu.au

2. Setting the scene - a dangerous decade
• Over the next 10 years we will build and deploy more ICT
in the health system than ever before in history.
• These systems will be larger, more complex, and see a
shift from local/regional to national/supranational scale.
• The costs and benefits of such systems have major
implications for national GDP and accounts.
• The demands for health system modernization are so
compelling that we have no choice but implement nation-
scale health IT (NHIT).
• Yet we are at the same place in industry maturity as
aviation in the 1950s.
• The risks of failed or delayed implementation, cost over-
runs, and safety risks are still too real.

4. The two core problems we are trying to
solve
1. Sustainability
2. Safety and Quality

5. The Sustainabilty Funnel: when demand
for resources and supply diverge

6. Australian Population Growth and Aging
•In 2007, 13.4% +65,
and 2047, >25%
[87% increase]
•Very old (+85) rises
from 1.7% to 5.6 % 85+
[329%]
65-84
Budget Papers 2002/03: Intergenerational Report

7. Projected Australian Commonwealth
Health Spending
•In 2007, 3.8% GDP
•In 2047 7.3%
[92% increase]
Ageing -> 25%
growth, rest is new
technology and drugs
Budget Papers 2002/03: Intergenerational Report

8. A shortage of health workers today
Source: Dean, D; AHA Conference 2001

9. Dependents as % working age population
In 2007 5 people of working age support every person aged >65.
By 2047, will only be 2.4 people.
Combined
Aged
Child
Budget Papers 2002/03: Intergenerational Report

10. Average Annual Income Tax Paid, by Age Group
WORKERS

11. Safety and quality
• 10% of admissions to acute care hospitals are
associated with an adverse event (ACSQHC 2001).
• About 2% of separations associated with serious
adverse events causing major disability (1.7%) or
death (0.3%) (Runciman et al. 2000).
• 1 million general practice encounters each year in
Australia involve an adverse event (AIHW 2008)
• Adults receive recommended care just over half the
time (55%) and children just under half the time
(46%) (McGlynn et al., 2003)

12. Adherence to quality indicators according to condition
(McGlynn et al. 2003)

14. In 2020 the health system will have to
• … treat proportionately more people
• … with proportionately more illness
• … to a higher standard of safety and quality
• … in a more evidence-based way
• ... with relatively fewer tax dollars
• … and proportionately fewer workers
MAKING THIS HAPPEN IS THE PROBLEM WE NEED
TO SOLVE

15. How will we do this?
• In 2020, each clinician cares for more
patients than today, more effectively,
because:
– Some burden of care shifts to the consumer (new
tools, new skills, new norms)
– Some burden of care shifts to new clinical roles
– Some burden of care shifts to smart machines
– Our services and systems are safer and more
effective because they are purpose „designed‟, not
inherited and patched up
– Many of the innovations are unimagined today
(remember Gaudi!)

17. E-health can help improve system sustainabilty
and patient safety
• Gartner (2009) report provides many examples
where E-health:
– Improves patient safety (eg reduce prescription,
medication errors, avoid ADEs)
– Improve clinical efficiency (eg reduce duplicate
tests, or admissions via home monitoring)
– Help clinicians care for more patients (e.g. EMR,
CPOE reduce length of stay)
– Helps burden of care shift to the consumer (e.g.
electronic messaging reduces GP visits by 10%)

18. Strategy: How do we make it happen?

19. Case study 1: English NHS NPfIT
• World‟s largest civil IT project, £13 billion over 10
years to improve services and quality of patient care
• NHS is a nation-scale, single-payer health system
• Adopted a top-down strategy for system architecture,
standards compliance, and procurement
• Many notable wins but also plenty of setbacks,
clinical unrest, delays, cost overruns, paring back of
promised functionality. Hospitals a problem.
• Demands from political quarters to shut it down :
“Conservatives pledged to cancel the programme …
Liberal Democrats described it as "a disaster … from
the start.” BMJ 28 Jan 2009

20. Problems with top-down strategies
• One size doesn‟t fit all.
• No easy migration plan. Non compliant systems shut
down and replaced even better fit local needs.
• Imposed redesign is expensive, wasteful, generates
disaffection. Staff retraining/workflow adjustment can
introducing errors.
• Long delay until ROI means „stuck‟ with ageing
systems and technology despite significant changes,
i.e. more brittle to change.
• To meet emerging needs service providers will build
work-arounds, adding “unwanted” local variation to
singular national design.

21. Case study 2: US HIEs
• Pre American Recovery and Reinvestment Act (ARRA), US
embarked on a bottom-up strategy to NHIS development.
• Service providers form coalitions to interconnect existing
systems into regional health information exchanges (HIEs).
• Preserves existing systems. New technologies, system designs
can be adopted locally where is need and capacity
• Standards not mandated but adopted on a business needs
basis. Little central intervention.
• Does not create a single central record, but allows remote view
of local records, perhaps abstracted or aggregated regionally.
• Expectation that Regional HIEs eventually aggregate into a
nation-scale system.

22. Variable HIE success
• Indiana HIE - www.ihie.org
– Based on Regenstrief Institute EHR
– Connects 39 hospitals, 10,000 physicians and
> 6 million patients
– 85 primary care providers, 20 locations
– securely aggregates and delivers lab > 5
million results, reports, medication histories,
and treatment histories regardless of system
or location
• Other successes e.g. Massachusetts (maehc.org),
Spokane (inhs.org).
• Less e.g Santa Barbara County: combination of
technical, leadership, and funding (Miller,2007;
Brailer, 2007), NE Pennsylvania (Robinson, 2007),
Oregon (Conn, 2007).

23. Problems with bottom-up strategies
• Cannot predict how expensive or feasible it is for a
local system to interface with an HIE.
• Cannot predict how much information is available to
other providers.
• Incompatible data models may make reconciling
information across different systems arbitrarily
complex.
• Unlikely to be aligned with national policy goals.
• The price for preservation of local systems is a
weaker national system, which may have data holes,
and data quality problems.
• Business model unclear

24. Middle-out: A third way
• Need to acknowledge government, providers have
different starting points, goals and resources.
• All come together to agree on common NHIT
functions, standards, strategy.
• Providers then bring existing systems up to national
standards e.g. customized interfaces or make new
purchases standard compliant.
• End product has rich capability for information
sharing, resilient over time, preserves what works.
• Allows government to pursue policy goals.
J Am Med Inform Assoc. 2009;16:271-273.

25. Middle-out: Government‟s role
• Define policy framework to converge public and
private, local and central systems into a functionally
national system.
• Fund public sector to join the NHIS.
• Incentives for private sector where the business case
is weak but national interest is strong.
• Develop public goods e.g. standards, broadband,
health informatics workforce, evaluation of progress.
• Legislation to protect privacy and interests of citizens.
• Avoid as far as possible what it is not good at, like
designing, buying or running IT.

26. The Dangerous Decade

27. Strategic Risks (1)
• HIT safety:
– Emerging data about risks associated with rushed
implementation, poor training, software performance.
– We are yet to experience our first HIT ‘air crash’
– Safety is a systems issue and software is just one
component of the socio-technical system
– Standards needed not just for technology (e.g. HL7) , but at
services level (system functions), implementation quality
(certification of process quality) and for the hands of users
(certification of competence)
– Routine monitoring of IT related safety incidents should be
mandatory as should rapid response to incidents

28. Strategic Risks (2)
• Expectations: “Past performance (in one setting)
does not predict future performance (in another):
– HIT Centers of excellence often used as benchmarks for
outcomes, but often have home-grown solutions, developed
incrementally over decades, with large resource including
academic informaticians and IT staff (e.g. >200 at Partners)
– Industry solutions are usually implemented entirely
differently, from generic packages, with little local expertise
available, and ongoing monitoring and modification.
– Need to base expectations upon robust outcomes at the
bottom, not the top!

29. Strategic risks (3)
• Solving the wrong problem:
– An "EHR first" strategy will miss easy wins to
demonstrate success, keep political momentum,
preserve end-user buy-in, build public confidence.
– What is ROI for a fully shareable national record
vs regional systems, viewable nationally?
– Easy wins? Web-based knowledge services,
decision support (e-psychiatry), electronic
prescribing, home monitoring, online bookings,
discharge summaries, personal health records.

30. Summary
• We are in the exciting, but not risk free, decade of
heath IT
• The two core problems we are trying to solve are
health system sustainability, and safety and quality
• Top down and bottom up strategies for building
national health information systems have had mixed
success
• There is a third way, middle out, bringing together
jurisdictions, consumers, health service providers and
clinicians, to agree on „meaningful use‟ and each
contributes what they are most expert at.

31. Thank you
e.coiera@unsw.edu.au