The importance of interoperability: a conversation with Dr Nathan Pinskier

Dr Nathan Pinskier discusses how interoperability across the sector will benefit greatly from the adoption of secure electronic messaging.

Dr Nathan Pinskier is a Melbourne-based GP, and a prominent figure in Australia’s digital health scene. He chairs the Royal Australian College of General Practitioners National Standing Committee for eHealth, and has long been an advocate for digital health in Australia.


Dr Nathan Pinskier

As part of this long-standing involvement, he recognises better than most the central importance of interoperability to any large-scale digital health implementation. In April, you’ll be able to see him in person at Wild Health 2018, participating in a panel discussion on interoperability, where he will undoubtedly have many insights to share with the audience and other panellists. But we thought we’d get in early, and ask him to share some of his thoughts on interoperability with us.

Dr Pinskier, welcome to #Share! We know that you’re a strong advocate of the value of secure electronic clinical messaging. In your experience, both as a practising GP and as the Chair of the RACGP Practitioners National Standing Committee for eHealth, we’d like to hear about your views on this matter.

What has been your personal experience with paper and fax-based communications versus secure clinical messaging? And how do you see the Australian market overall?

Overall the Australian market is incredibly fragmented. There are lots of different secure messaging vendors – some of them are standards based, some aren’t; some are starting to communicate with each other and some don’t. On the other hand we have the ubiquitous fax machine, which has been around for 30-odd years, it’s relatively reliable, it works using a recognised telephone number system. It’s interoperable! You dial a number, insert the paper, the fax gets transmitted. It’s reliable and generally works.

So what’s the problem? The problem in essence is that over the past 20 years the healthcare system has moved to an electronic environment for the recording and capture and storage of healthcare data. So when you’re operating essentially in an electronic world, the last thing you want is a paper-based transmission which you then have to scan and save in an image format. So it’s not searchable, it clogs up your database, it’s not interoperable, and it has very limited value beyond the initial data set. You can’t search the data, you can’t do much with it.

When you compare this to the rest of the economy, and the enormous changes that have occurred throughout, for example, banking, we’re doing things now electronically that years ago would have been paper-based. I mean, how many people go to a bank today and physically deposit money? Generally you move funds around, using apps and PIN numbers. And as of last week we’re seeing real-time funds transfer using telephone numbers.

So we’re seeing enormous digital transformation in other sectors, but in healthcare we’re still reliant on the fax machine – because it’s reliable and works and because we haven’t got secure messaging operating at a level that provides high-level availability, essentially.

Our readers know that interoperability across the sector will benefit greatly from the adoption of secure electronic messaging nationally. What are your perspectives here?

I’d describe this issue as a few things. First of all interconnectivity – the first thing is to get the interconnectivity working. We have to “standardise the rail gauge”. So a train travelling from Melbourne to Sydney can actually cross the border at Albury Wodonga without the need for a different train. So we get the interconnectivity between the vendors working.

Once we start moving the trains, then we can start focusing on the content of the messaging. We should be doing that simultaneously, but clearly you’ve got to get the trains rolling – standardise the stocks, standardise the gauge – and then focus on the messaging so we can start to actually understand the content of the message, which we talk about as semantic interoperability. That is, the computers can understand the information contained in the message, not just the humans. That’s moving from human readable to machine readable.

Right! And that’s when clinical terminologies become important.

That’s when clinical terminologies become critical! So that’s about having standardised clinical terminology, and obviously the one we’ve chosen for Australia is SNOMED CT-AU, which is also used internationally. It’s about linking the clinical terminology coding to recognised clinical vocabularies. So it doesn’t matter what vocabulary you use, so long as it links in to a back-end coding system.

I think this is a critical point that most people don’t quite get. They talk about getting clinicians to code. What I say is that they don’t need to code – the code’s in the background, it’s a machine number. What we need to focus on is to have clinicians use drop-down boxes to record critical information as opposed to merely recording free text.

Despite the complexity of these issues, we’re confident that they can be and will be resolved, and we trust that you have a similar outlook. So how do we get from here to there? What steps should the Australian digital health community be taking to resolve these issues?

In finance in Australia we have the big four banks as the pillars of the system. So if the government wants to do something, they develop a process which, if the big four banks adopt, all the smaller banks and financial institutions get on board. They just accept the situation and that’s the way it is.

In healthcare we have a really fragmented, disseminated marketplace, with lots and lots of vendors, some are small, some are large. But none of them are really market leaders. So it’s not a matter of converting one or two players and then the rest of the market will come on board. We also use a lot of best-of-breed technology. Within a general practice we might be using 5 to 10 different software products. In a hospital (and I’m on the board in a public hospital in Melbourne), it might be 20, 30, 40, 50 products. So there’s a huge number of best-of-breed products.

So one of the challenges is to convince people to come on a journey to improve healthcare delivery and healthcare outcomes, but at the same time not threaten their actual existence. If the change looks like it’s going to be costly or prohibitive or difficult to implement at the vendor end, understandably there’s going to be resistance. So it’s about supporting people through a process, supporting their existing businesses, but also allowing them to innovate and to recognise that there are opportunities moving forward.

Thanks for your time Dr Pinskier, this has been an illuminating discussion.