Sunday, October 23, 2011

E-Health Got Some Coverage At A Senate Estimates Committee. The Full Transcript is Worth A Browse.

I thought it would be worth putting the relevant e-health sections up on the blog. I feel this way it the post can act as a reference point by which to judge future claims by DoHA and NEHTA.
I have decided to change to italics those sections which need careful reading and which I feel may be subject to some later revision as time passes and we move close to various deadlines.

Community Affairs Legislation Committee - 19/10/2011 - Estimates - HEALTH AND AGEING PORTFOLIO - Health Workforce Australia

Health Workforce Australia

Non E-Health Material Deleted
CHAIR: We will start with Senator Furner.
Senator FURNER: Starting with the IHIs, the individual health identifiers, how many layers have been either downloaded or accepted as being sole identities in the e-health system?
Ms Granger : It is a million all together, or a little over a million—830,000 in GP practices and e-health sites and 430,000 in Tasmania and ACT administrative systems as part of their data cleansing projects.
Senator FURNER: As I understand it, that is administered by Medicare? Can you run through the process of how someone gets on the system?
Ms Granger : How they download into their system?
Senator FURNER: How they get onto the system, yes.
Ms Granger : To get IHI identifiers?
Ms Granger : They apply to Medicare and have to provide identity and their name. Do you want to add some more depth?
Ms McCarter : They ring Medicare and provide their name and date of birth by phone, and a form is sent out. They are able to receive an IHI identifier at that point.
Senator FURNER: Medicare has already got that material, hasn't it? They have all that data—it is just a case of being identified as IHI.
Ms McCarter : Correct—based on the date of birth and the name.
Senator FURNER: Is there any other information that is stored as an IHI, as opposed to being on the Medicare system, other than the typical identification of name, address, sex, date of birth and those sorts of things? Is there anything in addition to those?
Ms Halton : The question is not completely clear, Senator. If your question is: is that number stored separately and securely, yes.
Senator FURNER: Is it separate from the Medicare system?
Ms Halton : Yes.
Senator FURNER: Because there have in the past during estimates been some concerns about privacy and security, can you run through the protections that are available as an IHI?
Ms Halton : Is this in terms of the privacy legislation?
Ms Granger : Or the proposed PCEHR?
Senator FURNER: Maybe do both.
Ms Forman : There are quite strong controls in the Healthcare Identifiers Act to protect access to and use of identifiers. Those protections limit the use of individual health care identifiers to the delivery of health care and the use of health care information in the normal health care provider organisations.
Senator FURNER: Just going to the infrastructure partner arrangements, can you explain what the process was in respect to the choice of the national infrastructure partner, and whether that was a rigorous exercise in terms of identifying and achieving that?
Mr Madden : Their selection of the national infrastructure partner was based on a two-pass process, where we went to the market to select systems integrators and providers of particular services. The processes used there were the usual procurement processes we use for the Commonwealth for procurement of infrastructure of that kind. They certainly followed all of the procurement guidelines. We had probity advisers and independent representatives on the committee in both of those places.
Senator FURNER: How has industry as a whole embraced the eHealth system?
Mr Madden : Industry being the IT industry?
Mr Madden : There is certainly a groundswell of support there from the IT industry to be involved in eHealth. I think the expectations of reaching a set of specifications and standards that will allow interoperability is what they have been waiting for. We are certainly reaching that point now. But the level of interest is certainly high. Those who wish to participate in providing infrastructure support and those who are looking to provide services to GPs, consultant physicians, specialists in hospitals, are certainly there.
Senator McKENZIE: I would like to know what will have been achieved by 30 June 2012 with regard to eHealth and the PCEHR in Australia?
Ms Granger : By 30 June 2012 the infrastructure will be in place for all Australians to register for a personally controlled electronic health record. They will be able to set their access controls for the record and enter data that they choose to share with their clinicians. We will be able to approach a provider to create a shared health summary for them.
Senator McKENZIE: Can you provide the benchmarks for the PCEHR on notice?
Ms Halton : Certainly.
Senator McKENZIE: When the minister was first notified that the usual standard-setting process would have to be bypassed to meet the 1 July 2012 deadline—
Ms Halton : This would be a certain newspaper article.
Ms Halton : I think I have a copy of it.
Senator McKENZIE: I would appreciate clarification.
Mr Madden : The article depicts that we have changed the standard-setting process in order to meet a time frame, but we have not actually changed the standard-setting process at all. We are committed to using the Standards Australia process through the IT-14 committee. We have been working collaboratively with that committee to work out the time frames, program and plan to develop the standards.
The first step in the setting of standards is the development of specifications and guidance material on how to use these things. We are publishing those specifications in October and November such that software vendors who want to get involved and start providing those services to their users early—as in somewhere between February and July 2012—have the guidance, material and information to do so. But it is the complete expectation that those specifications will continue the normal track through the standard-setting process and they will emerge sometime around July 2012.
To make that possible for the software vendors, we have offered a change control process which will give them certainty and stability that building systems based on those specifications will be guaranteed to continue working and will continue to support those specifications for a two-year period. The expectation from the software vendors is that standards give you stability; they do not change very quickly over time. So we need to keep that same guarantee in relation to the specifications.
Senator McKENZIE: Thank you for that clarification. Is it the case that a patient may have registered for PCEHR by 1 July 2012 but their doctor, pharmacist or clinician may not yet be capable of entering the data onto the patient's electronic record? Essentially, what provisions are in place to encourage medical professionals to upgrade not only their own software but also their skill sets as well?
Mr Madden : The expectation is that the infrastructure and the registration process will be there for the patients. We are doing what we can around software vendors to provide them with the instruction material, guidance and testing facilities for them to get the products to the users, being GPs and hospitals. We also have a change in adoption partner who is working with the healthcare professional community to look at change in adoption and how it is we get them to a point where they want to demand those services and use them. We have software vendors in the wave sites. We also have software vendors who wish to get engaged in this. While they might put the products in the hands of the health professionals, getting them to use them is the next step. So we are doing all of those things at the same time to get the software in place, to get the demand and the ability and willingness to use that and also to get the understanding of the things they need to do to get their data quality lifted up to a standard where they can transact electronically to share their records with other clinicians.
Senator McKENZIE: Excellent. Is it also the case that the PCEHR audit trail will only be able to identify which organisation has accessed the PCEHR and not the individual within the organisation who has accessed it, unlike similar systems, for instance, in police forces et cetera?
Ms Granger : It will log access at the individual level.
Senator McKENZIE: It will log at the individual level?
Ms Granger : Yes. So there will be an audit trail.
Senator McKENZIE: Okay, thank you. I just wanted that clarified. The draft legislation says:
A nominated healthcare provider will be responsible for creating and managing a consumer’s shared health summary …
This is surely going to increase the time burden on the healthcare provider. Is there an estimate of how much extra time the nominated healthcare provider will spend maintaining a consumer's shared health summary? Will they be compensated financially for this extra time? And any comments you have around those sorts of issues would be good.
Ms Huxtable : Senator, we are sharing things a bit here—
Senator McKENZIE: Everyone is getting a go!
Ms Huxtable : Yes. Mr Madden spoke earlier about the wave sites, and we have not really discussed those, but there are 12 lead sites that have been funded as part of the measure and which are on foot already. Those lead sites are enabling us to better understand what the processes are around putting a PCEHR into the field, so they are a very important part of the learning. One of the things that we are interested in in that context is what the benefits of a PCEHR are, not just from a consumer perspective but also from a provider perspective. I think that we need to keep in mind, when talking about what this means for a general practitioner or a specialist, the amount of time that is already spent in practices basically searching for the right bit of paper—for example, trying to connect the pathology test that came in with the right patient. I think we are already developing some of this anecdotal evidence that there are many business benefits to PCEHR, and we are working with our change-and-adoption partner around explaining and broadcasting some of those benefits. It has to be a balanced proposition in this regard. We would anticipate that, in developing a shared health summary, a nominated provider will gather information that is readily available and accessible in their patient information systems. Certainly, we are looking on the wave sites at how some of that information can be streamlined and uploaded into the PCEHR.
As for what supports there might be going forward, no decisions have been taken in respect of how workflows might be managed. I think we still have a lot to learn about what is happening in the lead sites and how that gets translated into broader practice.
Senator McKENZIE: Yes. I guess, when you think about your normal general practice, that sort of paper-chasing is done as a back-office function, or a front-of-office function, really, and the GP is not doing that level of paper-trailing, whereas with this the onus is on the health professional themselves rather than on some of their support staff in terms of taking on that administrative task.
Ms Huxtable : I am not sure that is entirely correct. I think often practitioners do get involved in trying to marry up information. Certainly, that is some of the anecdotal advice that we have been provided with.
Senator McKENZIE: I want to follow up on something you just said about the wave sites—that you have got these happening and you are collecting danger about how this is going to work and, obviously, that is going to be feeding back into your processes over the coming months. I am just wondering about the relationship between the wave sites and the specs that Mr Madden was talking about being developed for the ICT software providers: how is that being fed back in, given that we want the specs sooner rather than later, to get it all tidied up?
Mr Madden : The wave sites were dealing with some of the early versions of those specifications and guidance materials. So the benefit of them having tried to implement some of those and going through the testing processes has been fed into the next level that are going to be produced. But, on the wave sites themselves, there are some specifications for the PCEHR which have been published already and they are already using those. Others that will be published on 31 October are being consumed and reviewed by those wave sites as well, with the background that we have seen the earlier versions of those and we understand some of the pitfalls. We are also bringing some of the software vendors who are not in those wave sites into that process as well, so it gets a broad review. But we fully expect that the wave sites will be the first adopters of those specifications that come out in October and then November—and, if there are things that change as a result of their implementation, then we will upgrade those as we go. But that would only be if they create system errors, as opposed to 'we thought of a better idea'.
Senator McKENZIE: Yes, because we want to give the ICT software providers security to develop.
Mr Madden : The specification process has matured quite well. The feedback and the loop to the software vendors has got us to the level where what we produce is at a high level of quality and meets their needs in comparison to where we were maybe two years ago. So I think, with the experience we have had in iterating and reviewing those, it has a level of maturity now.
Senator McKENZIE: Thank you. I have a few more questions that I will put on notice.
Senator ADAMS: Have allocations been made in this and the out years to support doctors, remote area nurses and allied health professionals in rural and remote areas to become involved in the priority rollout of the personally controlled electronic health records? Are there any plans to support allied health professionals and nurses in the use of electronic health records for clinical management so they are equipped to contribute to the PCEHR when it starts?
Ms Huxtable : There are probably two elements to that question. Included in the work that is being conducted now in respect of the investment that has been made leading up to 30 June 2012 is money around change and adoption. As part of that, there has been work done about the readiness of various sectors to pick up and run with PCEHR related material and money to support them in this period through change and adoption. So our change and adoption partner is out consulting with various groups, analysing their particular circumstances and advising us about how materials can be prepared to support them.
In respect of beyond 30 June 2012, there has basically been no decision by government on funding beyond that period, so I think the question you are asking is probably a little premature because it does relate to something that might happen in a period for which there has not yet been a funding decision.
Senator ADAMS: I was just trying to highlight the fact that often rural and remote get forgotten. Our allied health people out there and, once again, our nurse practitioners and remote area nurses sometimes do get forgotten.
Ms Huxtable : With regard to those wave sites, there are a few operating in rural and remote areas. There is one, for example, that is covering the whole of the Northern Territory, so we are learning about things from that. There is another on the Cradle Coast that is looking at advanced care directives. So quite a variety of activity is occurring around the country. The consumer population covered by those 12 sites is up around the 500,000 mark, so we have quite a lot of activity occurring across some quite diverse areas.
Senator ADAMS: That is good. It is just something I had not caught up with. What funding has been made available to allied health and nursing professional organisations to ensure that standards and practice guidelines are available for their members' involvement in various facets of e-health? Is any funding or are any grants available for them to apply for?
Ms Huxtable : We might have to take that on notice. There might be moneys that have been available over the period, but we are talking about quite a long development period here, so we should it take notice.
Senator ADAMS: Thank you very much.

Community Affairs Legislation Committee - 19/10/2011 - Estimates - HEALTH AND AGEING PORTFOLIO - National E-Health Transition Authority

National E-Health Transition Authority

CHAIR: Senator McKenzie, NEHTA are here. Can you do your questions in 10 minutes?
Senator McKENZIE: Thanks to Senator Boyce, we have oodles and oodles of questions for NEHTA.
CHAIR: The 'oodles' will be 10 minutes and the rest will be on notice.
Senator McKENZIE: Yes, absolutely, Chair. Mr Fleming, are you aware of the steady stream of criticism directed NEHTA and its parent DOHA by local industry of their handling of IT and software tendering and contracting?
Ms Halton : And I am pleased to know that I am his parent!
Senator McKENZIE: You are looking remarkably well!
Mr Fleming : The structure of NEHTA is that we are owned by the Council of Australian Governments, so all of the governments obviously contribute as per the COAG formula. Therefore, the Commonwealth contributes 50 per cent plus obviously also the PCEHR relationship. As part of that, Ms Halton sits on the NEHTA board.
In terms of the stream of criticism, there have been, obviously, a number of comments in terms of various aspects of the tendering process. As Mr Madden mentioned earlier on, for the tenders around the PCEHR, all have followed Commonwealth guidelines and all have had independent probity assessments as part of that process. So we have all the way through followed Commonwealth guidelines in that process.
Senator McKENZIE: Given there has been some issues around that—Oh, now I am asking you for opinion. Okay.
Mr Fleming : Sorry.
Senator McKENZIE: I have had another question tonight in the Defence portfolio, where there were issues. Yes, it is Senator McKenzie's first estimates! So you have outlined those issues in that regard—it is around the tendering.
Mr Fleming : The tendering process has absolutely followed Commonwealth guidelines all the way through and, as you are aware, there have been many tenders issued through that process.
Senator McKENZIE: Thank you.
Senator McKENZIE: The proposal by NEHTA to have 'tiger teams' develop key standards in less than one month and bypass the normal Standards Australia process could have enormous and negative consequences. Please respond.
Mr Fleming : The tiger teams is a process we have used for a number of years now, and certainly was part of the process for the individual health identifiers. This is not a process that has been underway for one month. In terms of specifications that have been developed, it has been happening for a long period of time and, as Mr Madden mentioned earlier on, it is absolutely not bypassing the Standards Australia process. The tiger teams consist of representatives from key stakeholder groups, including clinicians, technicians, vendor reps et cetera. Through that group we put together a series of specifications which are then, through the wave 1 and 2 sites, tested in the field and then followed through with the Standards Australia process thereafter. It is very much in line with what Mr Madden mentioned earlier on.
Senator McKENZIE: Thank you. I have some further questions from Senator Boyce. This goes to the work culture and staff morale at NEHTA. How would you describe that, Mr Fleming?
Mr Fleming : We are, as you would expect, as are all groups associated with this program, working long and hard. We have some of the most talented and intelligent people in the country working on this program. There is an absolute commitment towards delivering this for the benefit of all Australians.
Senator McKENZIE: The capacity of your staff is not the question. How are they feeling?
Mr Fleming : How are they feeling? It is hard to give an opinion on that. We have been doing some research in the area of morale. We have an external company looking at that. I have not got the final research back. However, the verbal update I have received is that morale is actually quite high in the context of everything we are working on.
Ms Halton : Senator McKenzie, I can tell you that from a board perspective—if I can put that hat on for a second—we have a conversation with management quite regularly about what is going on, reasons for exit et cetera. So in terms of board duties this is a matter which is discussed.
Senator McKENZIE: Thank you. Has the NEHTA headquarters in Sydney been subject to a New South Wales WorkCover investigation following bullying complaints?
Mr Fleming : There was just recently a very brief investigation. I believe a WorkCover officer came and had a talk to our head of personnel and I believe that that issue was dealt with to their satisfaction immediately.
Senator McKENZIE: Thank you. Could you please provide details of NEHTA's staff turnover over the past 12 months?
Mr Fleming : The annualised turnover is approximately 28 to 30 per cent over that period of time.
Senator McKENZIE: Is that high?
Mr Fleming : It is reasonably high, yes. The research we do is in relation to the type of organisation—a transitional authority—and how it compares to other consulting groups. In terms of consulting groups, it is actually on par with what we see in the industry. In terms of what we would expect if we compare with the IT industry, it is probably significantly higher than we would want to see. So we have commissioned research to talk to our staff and understand the drivers behind that and what we need to do.
Senator McKENZIE: That does me for NEHTA. There will be questions on notice.
CHAIR: There will be many questions on notice, Mr Fleming. That concludes outcome 10. Thank you to the officers.
[22: 24]
1. It is pretty clear Senator Furner’s efforts at ‘Dorothy Dix’ questions went a little awry because he really didn’t understand what he was talking about - let alone understand the implications.
2. Senator McKenzie suffered a little from the same problem - but was rather better briefed!
3. Mr Madden’s comments on the feelings of the IT Industry on the e-Health Initiatives fails to mention that, at present, the PCEHR is pretty much the only game in town and so, to keep their staff and keep working they have to play along.
4. It is clear that little more than a ‘log-on’ portal for the PCEHR will be available July 1, 2012.
5. It is obvious that we have entered a new and unproven approach to e-Health Standards setting with NEHTA - whose lead staff are hardly expert implementers - coming up with Specifications - having them briefly reviewed and cast out to the developer community in the hope that they are safe, workable and reliable.
6. Offering a 2 year warranty when you are not actually funding the development seems just a trifle cheeky to me. Most Australian Standards are much more long-lived and evolve carefully and safely with considerable vendor input and confidence in the overall directions - and certainty their investments will be protected in the medium to long term.
7. Mr Madden saying specifications that have never been implemented are ‘of the highest quality’ is pretty brave. The proof of the quality of a specification comes with successful and interoperable implementation not neat formatting of a document!
 8. It is interesting that Ms Huxtable has no idea about workflow impacts - which is clearly a major issue among the concerns people have regarding the overall PCEHR design.
9. Claims of individual user audit trails for consumers are possibly correct - but for providers they are not and that will become clear over time. Clever words to obfuscate the truth I believe.
10. It is amazing only 7 minutes were devoted to NEHTA!
All in all, the whole program feels to be rather rushed and in ‘making it up as we go along mode’ which we all know is not a great way to undertake a major national Health IT project.
It is amazing with less than 9 months to go live that detailed specifications for the overall system don’t apparently yet exist - or they do they are not public!
Amazing stuff!


Anonymous said...

A few points worth making here are:

1. In an R&D environment where people are attempting to solve challenging problems; their motivation is not money but rather the challenge of solving the problem which is sufficient motivation to stay in their job.

An imperative for achieving positive outcomes in ehealth is to have highly motivated, well focussed, cohesive, stable teams, with all members capable of communicating and working as one.

In an organisation like NEHTA it is to be expected that large numbers (that is what it is) of people coming and going from project teams increases the likelihood of failure many many times over.

The only conclusion one can come to is that the culture and management are rotten and that no useful outcomes can emerge from such an environment.

2. On the assumption that NEHTA employs approximately 250 people (probably more) at an average of $100,000 per person and with staff turnover costs normally ranging from 50 to 150 percent of salary (let’s use 100 percent) subject to an employee’s level, job role and responsibility we can see that at a minimum the cost of staff turnover at NEHTA is currently running at 80 x 100,000 dollar plus 100 percent = $16 million. !!!!!

3. Ms Huxtable said – “In respect of beyond 30 June 2012, there has basically been no decision by government on funding beyond that period.” Ad hocery is the modus operandi here.

4. Ms Huxtable said – “As for what supports there might be going forward, no decisions have been taken in respect of how workflows might be managed.” This is akin to the Collins Class Submarine of eHealth being designed on the fly.

In conclusion:
Intelligent people know that 1 plus 2 plus 3 plus 4 all add up to a total disaster of extreme proportion.

Anonymous said...

I very much doubt that anywhere close to 830,000 IHIs have yet been "downloaded" in GP practices. Maybe 830. The software to support this has not yet been released AFAIK and is not due for release for a few weeks yet.

I would guess that 830,000 is the target for the lead site projects that are currently under way.

Anonymous said...

"Ms Granger : It will log access at the individual level."

This is at best misleading and at worst an outright lie.

The proposed legislation will require that a practice records individual access from (I think) 1 July 2012.

The PCEHR will rely on the practice to pass the identity of the individual to the PCEHR. If everything in this chain of trust works then the user identity in the PCEHR audit log will be valid, though it may not be an HPI-I.

It will be an enormous undertaking to get individual logins in place by that date. With everything else that is happening in parallel I will believe this when I see it. Especially since there will be no encouragemen$.

Anonymous said...

Ms Granger's lack of grasp on the IHI workings and indeed misrepresentation of the audit trail are greatly concerning.

Even more is that Labor is letting Furner lead on e-health - the man's either a complete dill or completely uninterested