Australia's Digital Health Agency and the World's Most Advanced National Health IT System

How Australia's intentional efforts in health care digitization is a model for the United States

The United States Department of Health and Human Services recently elevated the Office of the National Coordinator for Health IT to the Assistant Secretary of Technology Policy. This is a recognition that health information technology is a critical function for a modern health system.

Despite this, the United States is realistically hamstrung by the consolidated market control of health information technology by major electronic medical record companies. This begs the question: how have other countries developed their digital health technology ecosystem for the purpose of societal benefit rather than government subsidized and monopolistic control of the entire nation’s health data? ¹

Given the number of subscribers to Health Tech Happy Hour from the Australian government (especially the Australian Digital Health Agency), I wanted to highlight the great work being accomplished by our friends down under. I am typically very focused on American domestic health issues and innovation, but, thanks to the power of the internet, I have recently learned that Australia has a *literal* government agency called the Digital Health Agency and they have solved some of the biggest problems we face in American health services with respect to health information technology. To my American readers, Australia’s health information technology strategy is clear and concise and they are living about 15 years ahead of us.

As a policy board member of Washington D.C.’s health information exchange, I am quite impressed by the last decade of innovation and implementation by the Australians and I can see the significant population health improvement opportunities available to them because of their intentionality in digitizing health records for societal benefit.

It is this kind of intentional policymaking that has landed the Australian Health System as #1 in performance according to the Commonwealth Fund’s recent report. The U.S. continues to spend more and perform the worst². Australia spends the least per capita and performs the best according to this report.

There are many factors that affect the outcomes in the report and health system performance, but lets dive into how the Australians have invested in digital health infrastructure in this article. To my Australian readers, please do let me know if I missed something here!

Australia’s Centralized Health Record Strategy: The My Health Record Evolution (2012-Present)

In 2012, the launch of the Personally Controlled Electronic Health Record (PCEHR) represented an ambitious attempt to create a national electronic health record system. The Australian government's Personally Controlled Electronic Health Record (PCEHR) system, launched in July 2012, represents a significant national initiative in digital healthcare with funding of A$467 million for its initial release. The system was designed as a distributed network that allows healthcare providers to share patient information while giving consumers control over their health records. Unlike many other health record systems that act as central repositories, the PCEHR uses an indexing service to locate and collate patient information from various sources, including shared health summaries from general practitioners, discharge summaries from hospitals, event summaries, and Medicare data. This concept is very similar to the health information exchanges (HIEs) that have grown in the United States, but a primary difference is the lack of emphasis on the consumer access component in the US HIE systems (i.e., the US has not solved the problem of consumer access and control over their own records).

A key feature of the PCEHR is its emphasis on personal control, first implemented through an opt-in model where consumers must actively register to participate. The system provides multiple levels of access control, allowing consumers to restrict access to their entire record or specific documents, manage which healthcare providers can view their information, and receive notifications about record access.

While this level of consumer control was a clear requirement during the design phase of Australia’s PCEHR strategy, it created some challenges that are akin to issues experienced in the US by health systems and HIEs, including concerns about workflow disruption for health care providers, medical-legal issues regarding information completeness and verification, and questions about the balance between accessibility and privacy. Despite these challenges, by 2014, the system had achieved significant adoption with 1.5 million consumers (6% of the population) and over 6,000 healthcare organizations registered. Today, the system reports over 24 million health records in the system, or over 99% of all records.

A pivotal 2014 review of the system led to significant changes for the Australian program in 2015, including:

• Rebranding to My Health Record

• Transition to an opt-out model (taking a play out of the Nudge playbook)

• Establishment of the Australian Digital Health Agency in 2016

• Enhanced focus on meaningful clinical content (imagine the opportunities for precision health education and public health intervention with all this data)

• Improved security and transparency measures (trust matters for consumer adoption and given the numbers, it seems Australia has figured this one out)

Electronic Prescriptions

A review of the Australian Digital Health Agency website suggests that the agency has purview over electronic prescriptions. Electronic prescriptions are digital alternatives to paper prescriptions that can be accessed through SMS or email tokens sent to patients' mobile devices. When a doctor prescribes medication, they can either send a digital token directly to the patient or add it to the patient's Active Script List. Patients can then present these tokens at any pharmacy that supports electronic prescriptions, forward them to a pharmacy for preparation in advance, or share them with others who may collect medicines on their behalf. For prescriptions with repeats, pharmacies will send new tokens when it's time for the next supply.

The Australian Active Script List (ASL) is a comprehensive digital system that manages all of a patient's electronic and computer-generated paper prescriptions in one place. After registering at a pharmacy with proper identification, patients no longer need to track individual prescription tokens, as all new prescriptions are automatically added to their list. This system is particularly beneficial for people managing multiple medications, as it allows participating pharmacies to access the full list of prescriptions with patient consent, streamlines the dispensing process, and helps both doctors and pharmacists manage medications more effectively. The ASL also facilitates home delivery services where available and can be managed through various conformant mobile apps.

This is a big deal. In the United States, the siloed nature of health data and lack of true interoperability in many geographic areas means that a patient may have several separate medication lists which creates the prerequisite conditions for medication errors, adverse events, and a lack of coordinated treatment. A gastroenterologist may prescribe a drug to solve a particular problem, but may be unaware of that drug’s dangerous effects on another one taken by the patient for their cancer (this really happened to my Mom in 2017 and I caught it because I knew to look, but this scenario happens every single day and goes unchecked).

Australia’s National Digital Health Strategy

Australia's National Digital Health Strategy 2023-2028 outlines a vision for transforming health care through digital technology, aiming to create an inclusive, sustainable and healthier future through a connected and digitally enabled health system.

The strategy builds on previous digital health foundations and acknowledges the rapid acceleration of digital health adoption during recent challenges like the COVID-19 pandemic. It focuses on four key outcomes:

• Creating digitally enabled services that are connected, safe and sustainable

• Empowering Australians to manage their health with the right information and tools

• Ensuring equitable access to health services

• Using readily available data to inform decision-making at individual, community and national levels

The strategy identifies four critical "change enablers" needed to achieve these outcomes: policy and regulatory settings that support digital health adoption and innovation; secure, fit-for-purpose connected digital solutions; a digitally ready and enabled health workforce; and informed consumers with strong digital health literacy.

A key focus is modernizing Australia's digital health infrastructure to support emerging technologies like artificial intelligence, genomics and sensor technologies while maintaining robust privacy, security and clinical safety standards. The strategy aims to reduce health care inequities by improving access through digital means, particularly for underserved populations including Aboriginal and Torres Strait Islander peoples, rural communities, and people with disabilities.

I like to say in my writing that we can have awesome health information technology, but if that information is not translated into meaningful clinical care models and interactions that meet the patient, then the value is not realized. To steal a line from the management consultants; the people, process and technology components of HIT are equally critical.

The Australian strategic plan recognizes this in that they suggest that success will require sustained investment in digital infrastructure, workforce training, and consumer education to ensure all Australians can benefit from digital health advances while maintaining choice in how they access care.

Australia's journey toward digital health transformation represents one of the most comprehensive national efforts to modernize health care delivery through technology. From its early beginnings in the 1990s to today's sophisticated digital health ecosystem, this evolution reflects a deliberate strategy to improve healthcare quality, accessibility, and efficiency across the continent.

A Few Key Initiatives of Note in the Digital Health Strategy

1. Enhance and expand advance care planning documents to support end-of-life decisions, ongoing care and treatment preferences. The centralization of health data access allows for the accessibility of advanced care planning and end-of-life decision-making. A universal health record enables all providers to be aware of end-of-life wishes for patients. It is commonplace in the U.S. for end-of-life documents to be unavailable in emergency situations where they are most needed.

2. Evaluate virtual care models, policy tools and mechanisms that support team-based, multidisciplinary primary and specialist care and identify opportunities for further investment. Because health records are accessible and interoperable, it allows for more flexible virtual care models to be built nationally. Australia appears to be all-in on telehealth care delivery to reach both remote populations and for virtual primary care. The Commonwealth Fund does rank Australia ninth out of ten countries for access to care. The U.S. is tenth, by the way.

3. Develop and design capabilities that support the sharing of health information from personal devices. Australia appears to have a national strategy in place to incorporate patient generated health data from connected medical devices into their electronic health record. Essentially, this will allow real-time, remote patient monitoring-based care models to support the proactive capabilities of their care models. (I have a lot to say on this in the next section).

4. Uplift national and jurisdictional digital health infrastructure to flexibly accommodate AI, machine learning, deep learning technologies and genomics. The Australians are preparing to leverage their vast amounts of data to incorporate emerging technologies to advance health.

Cool Things the Australians Might be Able to Do Now

I am certain the Australians are already considering what I am about to say given the highlighted initiatives above, but I want to call out a few key things they can do if given the appropriate statutory approvals and funding:

1. Remote Patient Monitoring: By incorporating remote patient monitoring into their centralized health record utility, presumably via cellular network infrastructure or Bluetooth (into their mobile application), this data can be incorporated into medical records, nationally. By creating provider-interfaces that can handle real-time data inputs, proactive care management programs can proactively identify patients in need of support and intervene. This is particularly useful for collecting vitals from rural areas (which is a big deal in Australia). This data can be incorporated into emerging virtual primary care models.

2. Algorithmic Innovation: Using the vast amounts of data available, can the Australians create a public data innovation utility to facilitate the development of useful machine learning and artificial intelligence technologies? Through the existing EHR data and via the incorporation of RPM data into patient records, the ability to create algorithms to predict patient health events, hospitalizations, and deterioration may allow for significant clinical and public health value. Imagine mobile-app-based notifications to patients about potential rising risk of a certain future health event—there are ethical, privacy, and integrity issues here, but the opportunity exists.

3. Research Opportunities: The research opportunities from a data set incorporating EHR data, laboratory tests, RPM data, and genomics information can provide the opportunity to ask and answer research questions to better understand human health, to develop new treatments, to recruit for clinical trials, and to search for opportunities to repurpose current medications for new use cases.

4. Public Health Surveillance: A unified source of health data can allow epidemiologists and public health agencies to carefully monitor trends in both infectious and chronic disease to identify opportunities for intervention quickly.

Through careful governance frameworks to protect individuals and their privacy, the vast amount of data access can help the Australian health care and public health systems improve the health of the population in a cost-effective manner.

Looking Forward

Australia's digital health future appears promising, with continued government support and increasing adoption of digital technologies across the health care sector. The focus on remote health delivery, particularly beneficial for rural and remote areas, suggests that digital health will play an increasingly crucial role in ensuring equitable health care access for all Australians.

Australia's digital health journey represents a carefully orchestrated transformation of health care delivery through technology. While challenges remain, the establishment of robust infrastructure, clear strategy, and dedicated institutions like the Australian Digital Health Agency positions the country well for continued progress in digital health implementation. As technology evolves and adoption increases, the benefits of this long-term investment in digital health infrastructure are likely to become increasingly apparent.

This comprehensive approach to digital health transformation serves as a model for other nations, demonstrating both the challenges and opportunities in modernizing healthcare delivery through technology.

To my Australian readers, leave a comment below or send me an email if I got something wrong in my review!

1. Yes, that is cynicism you hear in my tone, but America appears to be in a period of complete detachment from policymaking for the sole purpose of societal good.

2. In our defense, we have a much more complicated situation with 340 million Americans to their ~26 million.