The development and implementation of a national HI Service is a very significant achievement and a major contributing step towards the implementation of national e-Health programs. The difficulty of integrating national Healthcare Identifiers into extremely diverse clinical processes and clinical systems, all with their own identifiers, across public and private health services is a major undertaking and the scale of this challenge should not be underestimated. The significant effort made by DHS, NEHTA and AHPRA in implementing this Service and establishing the day to day operations is very evident, as is the level of expertise of the staff involved across all organisations.
The core functionality of the HI Service is in operation and working effectively. There have been a number of improvements made to the business processes that underpin it to support vendors and implementers and positive feedback about the role of both DHS and NEHTA.
Although the HI Service has been operational since 1 July 2010, the systems that have a high dependency on the Service such as the PCEHR system are only now being implemented. In addition the incremental release of compliant software by vendors since 2011 has also influenced the uptake. As a result the usage of the HI Service to date has been low. Consequently, some of the issues associated with the functionality that has been built, the policies and processes surrounding the HI Service, and implementation processes are only now starting to emerge. The scale of the change management and technical effort involved in this implementation will only become fully evident when there is a drive for the use of the HI Service to become more integrated with local business processes.
Now that clinical users are beginning to access the Service it is highlighting aspects of the operation that do not integrate well into clinical workflows and this creates a risk for adoption. These issues could be addressed by making some changes to the Act, or to Healthcare Identifier Service functionality, policy and processes that would facilitate easier access to both Healthcare Provider Identifiers and IHIs.
As new health systems and services begin to integrate with the HI Service it is inevitable that issues will be identified that were not anticipated at the time of development of the Service. As the HI Service supports clinical systems the ability to manage and resolve issues as they arise in a timely fashion is critical. The success of the implementation will largely be driven by the degree to which the HI Service is tightly integrated from a technical, process and policy perspective with the other clinical systems in daily use in healthcare services.
The governance structure must be able to manage change requests, incident resolution and drive the strategic direction of the Service through clear responsibilities and accountabilities, user engagement and agile decision making processes. Equally important is the capacity to support a steadily increasing user base through a robust policy framework that provides clear guidelines to support the implementation and use of the system. Effective communication and well defined and resourced pathways for implementation and operational support are also important.
The major issues identified in relation to the operation of the HI Service were in the areas of management of change requests, prioritisation and content of releases, the complexity experienced in establishing organisational seed and network structures, access to HPI-Is, and assignment of IHIs for individuals that do not return a result when a search is conducted. Concerns about the processes relating to identifiers for newborns were also reported, as well as the as yet unimplemented functionality relating to provisional and unverified IHIs.
As additional programs such as the PCEHR system are being implemented there are increasing issues arising from the parallel operation, support, policy frameworks and governance of these programs. This environment will become even more complex as additional programs come online. This is likely to exacerbate the challenges for all participating organisations that arise from maintaining the separation between these programs.
The primary issues identified in relation to governance were: determining a long term funding strategy for the Service, lack of clarity in responsibilities and accountability between organisations, parallel governance structures for programs of work with a high level of interdependency, and a need to revise the terms of reference and members of key governance groups to enhance stakeholder engagement.
There are overlaps in functions between organisations that result in duplication of infrastructure, cost and maintenance effort, and in the operational complexity of the Service. This is particularly evident in the functions relating to assignment and management of HPI-Is by AHPRA, and DHS and in provider directory infrastructure between DHS and the National Health Services Directory operated by Healthdirect Australia.