State and territory governments are embarking on major projects to implement state-wide electronic medical records and to achieve integration across the range of clinical information systems in hospitals and health services managed by a state or territory government. While each state and territory is working within its own investment cycle, with its own software and integration partners, and is at a different point in achieving this goal, there is a common pursuit to make health (and, for some jurisdictions, human services) information available in a more timely and usable way.
Similarly, private hospitals, aged care service providers and community health services are investing in information systems and technology to improve quality and service delivery. Innovation in data analytics and increased expectations from consumers and funders to improve the experience and reduce avoidable errors and re-admissions to hospitals are among the drivers of investment in the non-government sector.
Given the progress that is being made within geographic areas, individual health services or within a health sector, there is a risk that uncoordinated investment in technology that does not meet a common set of standards will exacerbate siloing in the health system, with each service or sector using a different system. A national strategy that articulates agreed priority areas and is underpinned by standards will send a signal to the market of areas of interest to governments and can encourage investment in both the public and private health systems in a common direction. Coupled with standards where stronger direction is required, this will lead to an environment where healthcare providers will be able to access more complete information about a person under their care, irrespective of whether that person received health services in the public, private or community setting.
The ability of different healthcare providers to use shared information with commonly understood meaning is a pre-condition for team-based, coordinated care, continuity of care, efficiency, data analytics, and positive patient experiences.[64-67] Exchanging high-quality data between multiple health systems, trusting that the meaning will be interpreted in the same way, requires “interoperability”., , 
What is Interoperability?
Interoperability is a complex concept. At its simplest, it is the ability to move information easily between people, organisations and systems.
“The importance of getting a co-ordinated approach between industry and government is critical. The government has a clear role in providing key infrastructure and allowing industry to meet the market. It is the role of the government to capitalise on existing projects as well as to foster new solutions.”
- Medical Software Industry Association (MSIA) submission
It is imperative that when information is shared between people and systems, its meaning is preserved from one context to another so that information is interpreted in the same way. That is, what was meant is the same as what is understood. This is the concept of “semantic” interoperability, which can be defined as: “The capability of two or more systems to communicate and exchange information, and for each system to be able to interpret the meaning of received information and to use it seamlessly with other data held by that system”.
Australia was recently ranked number one in the world for its open data policies that create an environment for interoperability, and use of our data assets as a national resource. In Australia, meaningful progress has been made in establishing foundations for interoperability, including clinical terminologies and standards. However, adoption has been limited, and a lack of interoperability remains a significant issue.
" Although there have been some vendor-based improvements in recent years, the lack of vendor interconnectivity and interoperability remains a major issue."
- Royal Australian College of General Practitioners submission
" Standards exist in some areas, such as diagnostic imaging, however we are far from having genuinely interoperable informatics in health."
- Royal Australian and New Zealand College of Radiologists submission
The lack of interoperability between systems means healthcare providers often cannot exchange information effectively, which contributes to disjointed care, adverse events, inefficiencies and poor quality data.[72-74]
Both healthcare providers and health organisations called for interoperability – they want their systems to communicate more easily with other systems outside their organisation’s boundaries.
" Interoperability of digital health systems is fundamental to sharing information.
- Royal College of Pathologists of Australasia submission
" There is a clear need to establish standards across the industry to guide developers and ensure everyone is working towards a common purpose of interoperability.
- Australian College of Nursing submission
There is strong demand for clear guidance and certainty regarding interoperability standards:
" The strategy should clearly identify what standards are required to support digital health, including connectivity and interoperability, and by who and how such standards should be developed."
- Australian Medical Association submission
" BUPA believes the private sector will play a critical role, equally critical will be the role of government in supporting the development of necessary frameworks and standards to ensure the interoperability of any privately developed products."
- BUPA submission
Achieving interoperability is a complex and substantial undertaking.[75-78] Internationally, there have been concerted, nationally led efforts to achieve interoperability, from which Australia can learn and leverage. Key components of international programs have been:
- Close collaboration,  in developing interoperability strategies and roadmaps.[80-84]
- Adherence to a principle of open systems and transparency by default.
- Nationally endorsed standards., ,  A number of countries have taken the additional step of mandating the adoption of standards in a specific timeframe.[87-89]
- Conformity assessment schemes., 
- Measures of digital maturity and toolkits to support health services to improve their digital maturity,  and assist local organisations in procuring and implementing local interoperable solutions. Digital maturity is the extent to which health services are supported by the effective use of digital technologies.
Interoperability is core to state and territory health department work programs. State and territory health departments are facilitating and capitalising on interoperability through programs of work to update clinical information systems, , [13-15], data governance and management, , and through better utilisation of clinical data., [15-17] For example, Queensland Health is implementing an Integrated Electronic Medical Record across its hospitals to allow clinicians and supporting staff to securely access a single view of a patient's medical record irrespective of the hospital in which treatment was provided, making it easier to share information about a patient's history. Six hospitals have already been upgraded, with progressive implementation of other hospitals across the state. Interoperable systems are also being leveraged in Queensland Health’s Digital Hospitals program, where new digital bedside patient monitoring devices automatically upload vital signs and observations, such as blood pressure, temperature and heart rate, directly to the secure electronic medical record.
These types of programs form an important part of each jurisdiction’s digital health strategy. Combined with the national program to make pathology results and discharge summaries available from hospitals to the My Health Record system, and to view this information through conformant software in general practice, key information about a person’s experience in the public health system is being shared with authorised healthcare providers in other hospitals and in the community to support more co-ordinated and informed care for individuals.
The strategic aim is to enable the exchange of clinical information between healthcare providers, the systems they use, and the people they care for through interoperability. The standards and health informatics communities, technology industry, and health services expect collaboration and co-production, with national coordination where appropriate. Acceptance and adoption of standards that support interoperability by the health technology industry will be critical to our success in moving information easily between people, organisations and systems.
The Australian Digital Health Agency will take a national leadership role in achieving interoperability, through the development, monitoring and management of specifications and standards, and the development and implementation of compliance approaches in relation to the adoption of agreed digital health specifications and standards.
The strategic approach we are proposing calls for a national interoperability strategy, and agreed interoperability standards, an implementation roadmap, a conformance scheme and digital maturity measures to be developed using a consultation and co-production process. In addition, there is a need to provide a more seamless experience across government services, enabled by common national foundations, to ensure that there is no duplication of digital infrastructure services across governments.
A co-production approach recognises that interoperability will be supported through a mix of pull and push adoption mechanisms that require careful design, including policy, procurement, compliance and accreditation frameworks, and quality measurement.
There are also regional and commercial realities – the effort involved in upgrading systems to become conformant and priority and demand from the health sector, the need for backwards compatibility, the need for alignment with international standards (sometimes at the expense of local standards) to offer economies of scale, and the need to support regional approaches to interoperability where adoption of national standards is not optimal. Digital maturity support services will be required to support state and territory health departments and health services to increase their digital health maturity, leveraging national and international experience.
Delivery of this strategy will not provide a fully integrated set of implemented systems across Australia by 2022 or completely seamless service delivery. Such an outcome will require adoption of all agreed standards by software systems, procurement of those systems across all health and hospital services, comprehensive service redesign and workforce capability, and confidence to deliver digitally enabled services.
However, this strategy will deliver an agreed view of base level digital maturity, articulation of required standards, conformity assessment, and clear guidelines for jurisdictional and local health providers to inform procurement decisions.
It will provide a focal point for health service design to address one of the greatest challenges to our health system – delivering high-quality and timely health services to people living in rural and remote areas. Digital technology opens up new possibilities for people in our regions to access health services currently available in our cities – without the need to travel out of their communities.
Services will be designed for a regional area to capitalise on the excellent – but stretched – healthcare providers working in regional and remote areas to connect with a wider support team in both the community and public health sectors in other locations. Making better use of telehealth, integrating with services such as Hospital in the Home, and ensuring visiting specialists use a shared health record will help overcome the tyranny of distance when delivering health services across all parts of the country.
A focus on improving data quality is also required, reflecting the underlying need for efficient use of high-quality data, which will enable future developments including precision medicine and genomics and the tracking of the efficacy of medical devices via linkages with the national product catalogue. Evidence suggests that high-quality data requires both strong data governance and agreement on standards for terminology., 
Aboriginal and Torres Straight Islander Health
The Closing the Gap Prime Minister’s Report 2017 highlighted that the health of Aboriginal and Torres Strait Islander people is slowly improving but the current rate of progress is not sufficient to close the life expectancy gap between Indigenous Australians and non-Indigenous Australians by 2031.
The National Digital Health Strategy contributes to national objectives to ensure that Australians have a health system that promotes social inclusion and reduces disadvantage, especially for Indigenous Australians. Enhancing the My Health Record system, and establishing national infrastructure and interoperability standards will enable better access to information and resources to improve data collection, availability, quality and analysis that will help ensure that policies and programs aimed at improving health outcomes for Indigenous Australians are evidence-based and informed by robust health research and data systems.
Recognising that for many Aboriginal and Torres Strait Islander people, language or lack of transport may be an additional barrier to accessing health services, accelerated take up of My Health Record will achieve registration with vulnerable and hard to reach groups that may not otherwise have been engaged in the My Health Record system under opt-in arrangements. The telehealth test bed will focus on Aboriginal and Torres Strait Islander communities, with the aim of providing timely access to healthcare services to ensure early diagnosis and early interventions.
“We wanted to establish programs and support infrastructure that strengthens Indigenous participation, practice and entrepreneurship in the digital economy.”
- Kirstie Parker, CEO National Centre of Indigenous Excellence
Actions to address digital literacy, and collaboratively developing inclusive design principles and guidelines for digital health services and content will provide more Indigenous Australians greater opportunity to access technology and use it effectively.
Case study - Ramsay Health Care
Ramsay wanted to improve the efficiency of its supply chain processes, while leveraging Australian national eProcurement recommendations. To address this need, Ramsay has deployed a full suite of standards for identifying, capturing and sharing information to support interactions with its suppliers. As a result, Ramsay has increased both the speed and efficiency of its purchasing processes, strengthened the efficient operation of its hospitals and helped ensure the continuous delivery of quality healthcare. The cost of automated processing of purchase orders and invoices has reduced from $35 to approximately $2. Document volumes were estimated to have been in excess of a quarter of a million in 2016, and the associated savings were significant.
How will Australia benefit?
- There will be improved coordination of care, leading to reduced medical errors and avoided hospitalisations.
- There will be reduced demand for services through improved self-care.
- Duplication and operating costs will be reduced through alignment of government health gateways and infrastructure.
- Patient and healthcare provider experiences will improve through a better connected health system.
Framework for Action - How Australia will deliver the benefits of digitally enabled health and care
Critical Success Factors of Australia's National Digital Health Strategy