Sunday, February 20, 2011

As Usual It’s Friday That Brings Another Interesting NEHTA Publication. A Plan For HI Service Implementation Asking for More Planning!

This time we have the:

Healthcare Identifiers in Primary and Ambulatory Care Proposed Implementation Plan

The document can be downloaded from this link:

The document is at Version 0.6 and was completed in this form, apparently, on January 9, 2011.

According to the document properties the author is as follows

"David Rowlands, Direkt Consulting Pty Ltd"

In the last version the final sign off was NEHTA so they clearly approved it. Oddly it is still marked ‘Confidential’ - despite being released on the web site.

A few highlights from the Executive Summary provide a good flavour for the overall document.

Amazingly in the first couple of paragraphs we read: (Page 5)

“On 1 July 2010, the Healthcare Identifiers (HI) Service commenced operations with three different types of identifiers:

- Individual Healthcare Identifiers (IHI)—for individuals receiving healthcare services.

- Healthcare Provider Identifiers—Individual (HPI-I)—for healthcare providers and other health personnel involved in providing patient care.

- Healthcare Provider Identifiers—Organisation (HPI-O)—for organisations that deliver healthcare (such as hospitals or medical practices).

Activity has now commenced to plan and manage the implementation of these identifiers across the health sector.”

So we are told operations have commenced and now we are planning implementation. Cart before the horse in the extreme I would suggest.

On Page 6 we see:

“There is considerable stakeholder variation in views about the accuracy of record matching and potential match rates and thereby a significant degree of uncertainty about practice level workflow and workload implications. Early adopters of Healthcare Identifiers will need to test data matching accuracy and address issues as part of the implementation process and this will yield substantially more information upon which to refine roll out planning.”

So it seems others share my concerns about just how well - in a quality and workflow sense - this is all going to be delivered.

A few lines on we see a quick summary of the approach being planned: (Page 6)

“Implementation Plan

In summary, three parallel streams of activity are planned – a set of activities to enable the enhancement of relevant software; activities to build implementation program capacity; and another set of activities to build implementation readiness in the early adopters and subsequently the fast followers. This will produce a state of readiness for early adoption, the outputs of which will initially be uptake of the identifiers – allocation of the identifiers to the in-scope practices, providers and their patients – and better identity management within practices. As the number of identifier enabled parties grows, better identity management in communications between parties will produce safer, higher quality care. These outcomes can be reinforced and sustained by a range of policy and program measures, practice standards and accreditation, social marketing etc that further encourage the use of the identifiers.”

This seems to me to be clearly recognising there are a fair few things that need to happen before any Identifier is actually going to get used in real action. While this plan is directed at ambulatory care clearly all relevant software (GP, Hospital and Labs etc) are going to need to be modified in any geographical area before implementation can actually happen.

These paragraphs make it clear there are a few critical steps still not addressed: (Page 7)

“Well functioning software that enables business-to-business level access to and management of the identifiers and minimises the workflow implications for practices is essential to the success of the Healthcare Identifiers Service (HIS). “Threshold” activities critical to the enhancement of the relevant software and which require urgent action include:

  • Finalisation of Medicare Australia’s Licence Agreements and delivery of NEHTA’s compliance, conformance and accreditation (CCA) scheme, a clear understanding of which will heavily influence software redesign.
  • NEHTA’s ‘Healthcare Identifiers Implementation Collateral Project’ will provide guidelines on key procedural issues such as the handling of unverified identifiers – which have the potential to “pollute” the identifier system; and the allocation of identifiers as and when patients present, rather than via batching, which was strongly preferred by stakeholders on matching accuracy and workflow management grounds.
  • Agreement on the levels of ongoing technical support to be provided by Medicare Australia and any transitional support to be provided to software developers.

It will be critical to the successful implementation of HIs that information, guidance and support are available at the practice level. A number of implementation support systems are currently either in place or expected to be available prior to HI take-up. It will be important to continue to review the success and suitability of these systems over the implementation cycle to ensure they are fit for purpose or to identify any additional support requirements.”

The summary then moves on to make some sensible comments about the need for proper governance and finishes up with the following section: (Page 9)

“Critical success factors and risks

Factors critical to the success of implementation in primary and ambulatory care can be expected to include:

- The ability to secure adoption of the identifiers in high volume electronic communications – i.e. in diagnostic service communications, ETP, communications with deputising services, e-referrals and hospital discharge communications.

- Commitment and involvement of all key stakeholders, including strong leadership in particular from clinicians and practice managers.

- Software enhancements that make it easy.

- Effective and responsive support, when and where it is needed.

- Relentless pursuit of the final outcomes, and willingness to “make the changes stick” via policy and program congruence and upgrading systems such as standards and accreditation.

- Strong, decisive and inclusive governance.

Accordingly, each of these factors should be regularly monitored.

Major risks to the implementation of the identifiers in primary and ambulatory care include:

- Patient and provider indifference or antipathy – i.e. the risk that practices will not implement the identifiers even if well informed, for example because they see the benefits as being sound in concept but not relevant enough to them specifically, because they are not willing to bear any associated risks or because they fear work flow slowdowns.

Mitigation strategies that could be considered include peer leadership, well targeted communication, positive feedback and financial assistance.

- Governance “disconnections” – i.e. the risks that key messages are not supported by visible actions, efforts in one domain are conflicted by visible actions in another, or supporting actions are framed to meet multiple needs and do not in fact support implementation particularly well.

Mitigation strategies include inclusive governance structures, transparent governance mechanisms and strong leadership empowered to raise perceived issues.

- Resource shortages – i.e. the risk that the overall resources available are not sufficient for smooth implementation. For example, it will take time to build effective practice support capability – it cannot simply be switched on.

Mitigation strategies include an early start to implementation capacity building to ensure it is ready for the fast follower stage, and consideration of multi-pronged strategies to access available expertise.

- Risk of disconnection with the 3 lead PCEHR sites, to the extent that they may fall under different governance arrangements and to different time frames, etc.

Mitigation strategies include effective project dependency and liaison arrangements.”

Other than the points already made there are a few observations I would add.

First this is a very high level document which needs a much deeper layer of planning of the individual aspects raised before anything can actually happen.

Second this plan has a time window until June 2012.

Third we need to know what this document contains ASAP:

“NEHTA’s ‘Healthcare Identifiers Implementation Collateral Project’ will provide guidelines for managing transcription and identity matching risks.”

Fourth on Page 15 we read:

“Stakeholders tended to agree that there are substantial benefits that can be delivered to the primary and ambulatory care sector through the implementation of Healthcare Identifiers, but that there are significant challenges in “personalising” or localising these – i.e. demonstrating that they will provide substantial enough benefits at the level of individual practices and providers to prompt action.”

Fifth it seems pretty clear that the author of the report sees a complex range of issues arising at the intersection of manual and electronic are processes.

Sixth it is surprising to see this footnote after a couple of pages of real risks. (Page 42):

“Only risks perceived to be high are articulated at this stage. More comprehensive risk analysis will be necessary when overall planning is further developed”.

Seventh - where the document really slips off into unreality is to suggest that by Mid 2011 we will have:

1.Tested Enabled Software

2.Program Readiness

3.Impelmentation Readiness.

Bit game that to say the least!

Last there are two areas in this report that are just not really made anywhere as explicit as they need to be. Those are the issues of proper project resourcing and governance and the issues around genuine incentives to achieve adoption. These areas cannot be circled around in the context of either software providers or providers.

The detailed plans are going to need to be more direct and explicit handling these issues (to say nothing of the increasingly murky authentication issues) if any success is actually to flow.

Success in Ambulatory Care will make or break the HI Service and NEHTA I suspect. The need to invest much more than is currently planned in incentives and support is pretty clear as far as I am concerned - Medicare Australia's application implementation history supports that view.

Right now this is a plan to do more planning and the emphasis needs to fully address these issues. It is interesting that the actual document contents is a good deal firmer on both these issues than the executive summary - as it is in identifying risks and their mitigation approaches.

(Just as an aside the Table on Page 55 makes very interesting reading on the place of identification issues in the overall error rates in care.)



Anonymous said...

The best advice for any self respecting software developer who is determined to remain viable is to get on with what you are already doing and don't allow yourself to be distracted by NEHTA for a very long time.

Anonymous said...

Thats very good advice, Imagine if you had tried to actually implement any of the Nehta specs to date, none of that work would have been of any use what so ever...

Someone has to pull the pin on this failed organisation before they take everyone else down with them. This scandal has to surface at some point. They obviously have a very good PR team.

Anonymous said...

It looks as though the Victorian health Minister David Davis has had the courage to "pull the pin on" HealthSmart. Perhaps he needs to take Minister Roxon aside and tell her what this pin-pulling means for NEHTA.

Anonymous said...

I have been following this and most HealthSMART related commentary with interest as I, unlike most of you from what I can garner, actually work with TrakCare as a user - the community health "dumbed down" version of the wider application. Buried in these comments are insignificant references to a major health infrastructure delivering multiple services to the community post exposure ton the Victorian public hospital system - their backbone - the 23 community health centres around Victoria. Do not under estimate the impact that the expenditure has on these DHS funded agencies who must magically make the costly maintenance fees appear out of thin air - we are not-for-profit organisations that rely on government funding and some income from our client fees. Do not sweep us under the carpet when considering the impact of the dissolution of this project - one we have invested hundreds and thousands of dollars in - not only in a fiscal sense but in human resources - there are of course some major areas of functionality that we desperately need to provide patient-centric care (a basic fundamental principle).

Where are the original business requirements specifications? Which industry representatives were part of the vendor selection process? Why did community health get a souped-up statistical reporting system vs a patient-centric client management system?

When you think of HealthSMART don't just limit your views to the acute sector. Cast a thought to the thousands of clinicians who work in the community health sector - working in self-management techniques, early intervention into chronic disease, diabetes management, mental health and well-being, crisis support - far too many services to mention - working to reduce the ER presentations in the acute sector.

And this was a MANDATED system with very little evidence of community health consultation. The larger percentage of development resouces are dedicated to the acute applications leaving very little left to develop key requirements of community health.

Next time you see a disadvantaged member of our community consider that they are probably being supported by the very services we provide.

Anonymous said...

I am trying to interpret what message "Monday, February 21, 2011 8:56:00 PM " is trying to give us. Are you saying HealthSmart should continue in its present form? or TrakCare is the only part of the HealthSmart program that works successfully and should be expanded? or TrakCare has been a failure? or Community Health has been neglected in the whole HealthSmart program? What exactly are you trying to say? Can you be a little more precise please.

Anonymous said...

Intersystem's Trakcare position within Healthsmart is interesting.

Trakcare, as the poster above points out, has a much larger application capability, in fact it is somewhat of a competitor for Cerner.

But in Healthsmart it was setup with a NON-clinical, statistics collecting focus, and its deployment was restricted to metropolitan community health services.

One wonders what the actual strategy there was.