Emma Hossack is charged with trying to help our local health tech sector navigate what is likely the most disruptive time in the sector’s history.
Of all the questions I’ve ever asked Emma Hossack in her many years as CEO of the Medical Software Industry Association I’ve always forgotten to ask, “why do you stick with this job?”.
It’s a hard job with not a lot of kudos or reward attached to it.
For many years the Australian medical software sector has been made up of some smart but largely small, independent and eclectic business founders and owners, struggling to eke out a living in a highly fragmented and complex sector where the government has mostly favoured the major global players.
Over the years government has often failed to understand just how important some of the local vendors are in making vital components of the system connect and work.
The technology vendors should never have had much if any political clout, but Ms Hossack, who is nearly always charming and engaging, managed to muscle her way into the some of the higher echelons of influence and power in health in Canberra to give the sector a significant voice.
At one point she had the direct ear of the health minister, which is extraordinary given that if the government entirely ignored the sector there would be very little if any political blowback.
If you know a little of Ms Hossack’s personal background you get some hint as to how she managed to get the MSIA to start punching way above its weight.
She’s the mum of triplets, all girls, all grown up now and all successful in their own right, and she did all that during her career as a lawyer and a CEO. In her younger years in Brisbane she managed a series of indie bands. And she’s a marathon runner – she’s run the New York, Paris and Venice marathons and this year will run in Copenhagen.
Today as well as being CEO of the MSIA she sits on the National Aged Care Advisory Council, the Connected Care Council, the University of Melbourne Law School Foundation and the National Executive Cyber Council.
In the media you need to try to stay as neutral to the charismatic charmers as you possibly can. Ms Hossack is definitely one of the smarter operators in this respect.
Over the years we have written some pretty harsh pieces about some of the companies she represents, and about the MSIA itself, in particular how at times it seemed to be working to protect companies that were effectively operating monopolies of very old technology which was having the effect of holding the health system back.
When any of these stories were written, Ms Hossack would never not take a call and never not provide some sort of answer to the hard questions.
Healthcare, especially state-based healthcare, is notorious for being unresponsive and non-transparent with the media, even hostile at times. What Ms Hossack knows, that you see in how she operates across the board with government, is that no matter how critical or hostile the media is being, maintaining lines of communication is a must.
Today, a large proportion of her members are facing off the most disruptive and potentially dangerous transformation of the healthcare system in history.
The federal government is determined to transform provider and patient data sharing in the system so that meaningful data can be shared between providers and providers and patients in real time from any point of the system.
The problem in that for many of her members is that for decades they’ve lived off their server-bound platforms, each of which has a lot of complex and well developed IP.
Many of them are going to have to either re-architect their platforms from the ground up, for the cloud, or at the least embrace new cloud-based resources such as FHIR in a much bigger way and develop interfaces to their old platforms that will effectively make them be able to communicate with other platforms over the web, as the government is starting to demand.
None of this will or can happen overnight. Some of our established local server-bound health technology platforms are fundamental components in the overall system.
Ms Hossack’s role is to make sure the government understands exactly how difficult a task it is foisting on the local vendors to make changes like this.
Of all the vendors that are going to face business model disruption and capital constraints, Best Practice and Medical Director are some of the best placed.
Medical Director, now owned by Telstra, has access to capital to build out the new requirements that are going to be needed in the system, but Best Practice, although part owned by Sonic, doesn’t have a heap of capital lying around so their strategy is likely to be different.
Best Practice, founded by the same person that started Medical Director, is a good example of the sort of smart locally run vendor that Ms Hossack is trying to help in the journey. It’s a group that has proved very resilient and smart over the years, in part because it’s always been very close to its client base to understand needs – their founder is a GP.
Realising that change is coming, and without the huge amounts of capital available to the big overseas EMR vendors when they need to change, Best Practice is starting to build out creative interface solutions to meet the future requirements of communication the government is wanting.
Ms Hossack is the person in the middle of all this, trying to articulate to the government some important but subtle points like, if they crash certain vendors by going too fast, they could easily send the system backwards substantively.
But how much care and loving is too much and how much is the MSIA just extending the life of some vendors whose products should probably now be mothballed in the name of building out a much more modern and interoperable healthcare system?
Some of Ms Hossack’s vendors are now new generation cloud and AI companies who are frustrated with the MSIA for helping the old guard too much.
I sat down with Hossack a week ago to ask her some questions about where the local healthcare technology sector finds itself, and what she thinks about how the government should be managing their transformation goals in terms of shifting the system substantively more towards being properly interoperable.
Is this the most challenging period of your time as CEO of the MSIA, the most exciting time, or a mix of both? Why?
Purposeful reform is why this role keeps me interested.
Not many people get a chance at being a part of potentially positive change, so I love the role as challenges are exciting.
There is currently significant reform. But we have seen that before in 2010 and the National Health and Hospital reform Report, with less than positive outcomes.
The key is to keep the sequencing realistic, tighten up the disconnect between the policy and implementing teams in government, and ensure industry has a sustainable business model.
DSS Minister Bill Shorten recently called this a “caste” system – where policy areas of government treated implementers like second-class citizens. I think this has some truth.
Looking at MyMedicare for instance, the MSIA members endorse the policy and are keen to implement it. The Department of Health and Aged Care was charged with codesign but provided PowerPoints.
The Services Australia team, the ones who build the system, should have been given the running and it would be up and working right now. As it is, the process is a fraction as seamless as it could be with proper industry engagement. Which of course, we have called out and just last Thursday the Services Australia team leapt into action – or were allowed to.
Our job is to clarify the risks which abound in any ecosystem so the endgame can be achieved. So, the question is whether the current reform package is realistic and more than rhetoric and funding.
During covid, we witnessed a new partnership grow between industry and the government. Daniel McCabe (First Assistant Secretary Medicare Benefits and Digital Health at the DoHAC) asked for a meeting with our companies, and around 90 companies got on the line. To his enormous credit he said, “we don’t know what we don’t know – we need to work together”.
The work we did together and the success we all achieved changed the dynamic from one of friction to mutual respect and trust.
Previously reform was tossed over the fence, with industry told to get on with it (old style co-design). From March 2020 this changed.
We led discussions about imperatives and the best approach to achieve them effectively. Organisations which were developing from Adaptors to Web Services (a more streamlined technical solution to connect with Services Australia) needed to swiftly upgrade to enable uploads on the vaccinations to the Australian Immunisation Register.
Some companies shared code at no cost with the competition so they didn’t need to develop solutions twice – the Department trusted us to deliver and to keep information confidential. The result was that continuous dispensing, telehealth, online meetings and connection with HealthDirect were all rolled out – as was the first end-to-end electronic prescription.
Australians were at last able to see the concrete benefits of digital health which had until then been largely invisible despite the estimated $2 billion investment into the Accenture MyHR. Local industry succeeded swiftly and cost-efficiently where a huge behemoth had failed. Sometimes small is beautiful – especially when smaller entities work together.
Sadly as the PBS Data Distribution program is showing, things have gone backwards.
All our members want is co-design, to share issues and jointly resolve them, and to have a safe and reasonable time for parallel testing of the PBS data – a program that is bedrock of our health system. In this case, consultants are running the show, failing to contact or engage with the MSIA and are insisting on dangerous contracted timeframes – no way to ensure a successful project.
‘Sharing by Default’: what specific challenges do you see for your members in the government’s plans?
Sharing by default is a noble cause, assuming all the privacy and security safeguards are in place.
Tying reform to political timetables is risky, as Professor Trish Greenhalgh warned Australia in 2012 when describing the UK National Program for Health IT (the same type of one-size-fits-all architecture Australia adopted with MyHR). That cost the UK an estimated 16 billion pounds, with very little to show.
Without beating around the bush, decision makers on both sides kept funding our version of what was clearly inflexible and clunky technology. Australians didn’t find it useful as statistics attest.
What is different this time?
Enabling a new environment built on international standards, with an improved identification engine, open APIs and cloud-based architecture is not technically difficult. What is challenging is responding to this in addition to multiple requests for significant infrastructure changes without due engagement and safe timelines.
Naturally having a solid business case is key, as removing layers of technical debt isn’t cheap. So there need to be drivers both in demands from their client and business efficiencies.
Is that here?
It seems so. This is because maintaining libraries of adaptors is expensive and not sustainable.
Virtually all MSIA members are motivated to make healthcare more efficient and effective. What they struggle with is inadequate notice and no specifications. Resourcing would be good for development outside the business as usual – but that is secondary.
Between tenders and specifications for vendors for state and federal work the procurement process is hugely complex and not consistent. Should this be a much easier fix for governments?
Lots. And they are listening as we asked for reform in our budget submission last year
We have spoken to the Department of Finance which is responsible for the Commonwealth Procurement Guidelines. [Helping here] is a part of an election promise and should help with removing some of the inefficiencies federally, which then could be adopted by the jurisdictions.
In our recent submission to the Department of Home Affairs we referred to the punitive security clauses currently abounding in contracts which then affect the hefty cybersecurity premiums. This is a classic example of how certainty and consistency of standards could not only improve Australia’s cyber posture, but also limit repetitive and unrealistic expectations on industry from all levels of government which are often inconsistent.
Finally, one reason small companies fail, as found by the DTA in its procurement report years back when Paul Shetler was still here, is because their balance sheets don’t stack up compared to the multinationals and the procurers in government are rightly concerned about the ability for reparation if things don’t go well.
I have suggested that in lieu of some of the huge funds that go to startups – which of course we love – some of the funding could go to a guarantee or indemnity which would allow these smaller companies to actually compete on the basis of a government-backed guarantee. It would make them sustainable and give our industry a huge boost.
The reforms in privacy and security are shining a light on some very onerous contractual obligations. The MSIA called for reform, and it is happening. Never fast enough but positive signs.
What do you think the government means when it talks about a national health information exchange and what it will do?
The US has had the HIE architecture for a long time and the UK has the same approach through its work with the trusts. The Commonwealth blueprint is not crystal clear on the direction, but discussions indicate an acknowledgement that having a more nuanced approach where the standards are set to enable communities to form around useful records which can be connected.
Australians want a birth-to-death atomised record which can be read in any way that suits them. Specialists may like to flick through graphs, GPs current meds and the consumer or carer may just want to see the schedule of next appointments. All this is technically feasible right now.
The Government is setting the standards. Industry should be able to respond by providing an ecosystem of HIEs, not just one massive exchange. It’s time Professor Greenhalgh came out again to give us our second warning.
The Minister has shown great faith in a hefty budget allowance for what is essentially under the hood work – not hospitals and more obvious, easier projects to justify. I know from projects delivered that Australian health software is up to delivering, just as long as it is not stymied by a large procurement of a one-size solution which is underwritten by a multi-billion dollar company system.
Do you think governments have something to learn from the PWC debacle and big overseas vendors versus the local talent?
Absolutely.
We have noticed Senator David Pocock has taken a serious interest in this area, so together with the behaviour on record, the government appears to be looking at much more nuanced approach to using expert advisors to test their policies – rather than write them,
Australian expectations and payment systems are unique. Inserting large-scale solutions from other jurisdictions has not been successful in environments where many need to communicate to many (MyHR). Sure, the internal systems for use by departments alone, like Salesforce, have a place. It’s when they are shoe-horned into other environments that it ends in tears.
But to be honest, it’s not just the big internationals.
Services Australia could effectively revolutionise online prescription authorities within months thereby saving millions of dollars, the drone type work of support desks which could be far more valuable in humanising the face of SA, and using an industry ecosystem architecture.
To date they maintain that their system will get better but it is very clunky now and will not ever be as good as an industry-developed solution. There is still a big-is-best mindset, but there are pockets of excellence in SA – David Hazlehurst the new CEO appears to understand the issues and be on the road to serious improvement – with luck, genuine co-design and enough smarts to ensure that his department is not treated as a lower “caste” member by the policy makers – which was alluded to recently by Minister Shorten.
Building greater competence within departments is a great direction. The way consultancies have become default staff members, using departmental email addresses for instance, is not ultimately effective for government outcomes as a gravy train approach is taken rather than outcomes at the best price.
Is there a lesson in the fact that one of our most successful digital health initiatives, eScripts, was done all locally largely via contracts with private vendors.
One hundred percent.
It worked, was cheap for a national fit-for-purpose medication management system and was adopted with alacrity by consumers and providers. Users love it and didn’t need to be “incentivised’ to use it, like the past payment of $50 million to the PHNs to encourage doctors to use the MyHR.
People used it because it worked. It’s very disappointing that it could not remain as a multi-party system, where all our members had an opportunity to participate and innovate in a sustainable way, but it was a great exemplar.
I’m excited to see the Defence [healthcare system] project [JP2060] which involves a number of MSIA members including MediRecords, Alcidion and Coviu – a smart move which should be watched carefully as a model for how information can be exchanged purposefully in a very specific environment. It could well be the model for the national HIEs.
Given how well locals did eScripts is there any reason some can’t do some of the outlined eRequesting work?
The health software industry in Australia has massive capability. Some companies however, like ProMedicus, which is a multi-billion dollar business, find our regulatory environment difficult so carry on the majority of their business in the US.
This does not need to be the case. From 2019-2021 we co-designed a world-class software as a medical device regulatory regime with Tracey Duffy and her team at the TGA. Similar industry capability was demonstrated in the delivery of ePrescribing.