Tuesday, October 18, 2011

The Part NEHTA Is Going To Struggle With Are The Systems Which Feed The PCEHR! There Is A Very Long Way To Go!

The following slides from a NEHTA webinar yesterday afternoon somehow turned up in my inbox.
You can have a browse of them here:
What becomes really clear from all this is that NEHTA and the Infrastructure Partner (Accenture) are going to deliver a PCEHR system and that, based on the functionality provided by the various Oracle Components, there will be a portal established and some form or repository behind that portal gateway.
The title of the webinar was “Initiating Collaboration on PCEHR Specifications Development”. It seems just astonishing we are in mid-October, 2011 and that we are apparently just now asking the industry to start collaborating on PCEHR Specifications Development for a major national project that is planned to go live in July, 2012 (Some 8 months hence!).
What is also revealed is that the technical approach being adopted is based on a range on International ISO, IETF and Australian Technical Standards which will be mashed together to fit pretty much what Oracle presently does (as already suggested in the blog previously - they don’t have time to do much else - if that!).
Of course where the wheels will come off will be getting a coherent set of feeder systems flowing from the range of potential provider users of the PCEHR. All their system will need fundamental modifications to provide information to the planned repositories that is useable.
Additionally, while internally the PCEHR system will have the appropriate security and audit trails once all the feeder systems are linked pretty much none of this will flow down. I note there is no mention of NASH but rather the IHE Audit Trail and Node Authentication (ATNA) Profile being used.
All in all this webinar has made it much clearer that the PCEHR System will be essentially an out of the box product based on international Standards and IHE profiles - but with the external systems probably having a good (and long) way to go to link in an make anything useful happen.
One suspects what is going on here is NEHTA recognising an existential threat - i.e. the funding for both the PCEHR and NEHTA ending June 30 2012 - and pushing to get just enough to have the whole juggernaut roll on! It is now utterly clear this is a multiyear project and that very little will actually be delivered - other than a log-in portal - by the due date.
If ever there was a need for a review and audit before proceeding this has to be it. Otherwise you can get into a very had cycle!
On a related topic this appeared very recently.

Implementation and adoption of nationwide electronic health records in secondary care in England:  qualitative analysis of interim results from a prospective national evaluation

Ann Robertson1 Kathrin Cresswell1 Amirhossein Takian2 Dimitra Petrakaki3 Sarah Crowe4 Tony Cornford3 Nicholas Barber2 Anthony Avery4 Bernard Fernando1 Ann Jacklin5 Robin Prescott1 Ela Klecun3 James Paton6 Valentina Lichtner3 Casey Quinn4 Maryam Ali3 Zoe Morrison1 Yogini Jani2 Justin Waring4 Kate Marsden4 Aziz Sheikh1


Objectives To describe and evaluate the implementation and adoption of detailed electronic health records in secondary care in England and thereby provide early feedback for the ongoing local and national rollout of the NHS Care Records Service.
Design A mixed methods, longitudinal, multisite, sociotechnical case study.
Setting Five NHS acute hospital and mental health trusts that have been the focus of early implementation efforts and at which interim data collection and analysis are complete.
Data sources and analysis Dataset for the evaluation consists of semi-structured interviews, documents and field notes, observations, and quantitative data. Qualitative data were analysed thematically with a sociotechnical coding matrix, combined with additional themes that emerged from the data.
Main results Hospital electronic health record applications are being developed and implemented far more slowly than was originally envisioned; the top-down, standardised approach has needed to evolve to admit more variation and greater local choice, which hospital trusts want in order to support local activity.
Despite considerable delays and frustrations, support for electronic health records remains strong, including from NHS clinicians. Political and financial factors are now perceived to threaten nationwide implementation of electronic health records. Interviewees identified a range of consequences of long term, centrally negotiated contracts to deliver the NHS Care Records Service in secondary care, particularly as NHS trusts themselves are not party to these contracts. These include convoluted communication channels between different stakeholders, unrealistic deployment timelines, delays, and applications that could not quickly respond to changing national and local NHS priorities. Our data suggest support for a “middle-out” approach to implementing hospital electronic health records, combining government direction with increased local autonomy, and for restricting detailed electronic health record sharing to local health communities.
Conclusions Experiences from the early implementation sites, which have received considerable attention, financial investment and support, indicate that delivering improved healthcare through nationwide electronic health records will be a long, complex, and iterative process requiring flexibility and local adaptability both with respect to the systems and the implementation strategy. The more tailored, responsive approach that is emerging is becoming better aligned with NHS organisations’ perceived needs and is, if pursued, likely to deliver clinically useful electronic health record systems.
The full paper is downloadable here:
To be cited thus:
BMJ 2010;341:c4564 doi:10.1136/bmj.c4564  (Published 17 October 2011)
Again we see just how badly the top down Government applied approach is likely to go. There are lessons here for both State and Commonwealth Governments I believe.
There is sadly a great deal of lack of governance and short-term thinking happening right now in response nonsense political deadlines and we will all suffer in the end!
Also, all this on the various services just ignores all the fundamental issues that are wrong with the PCEHR proposal which both NEHTA and DoHA resolutely refuse to address.
This is the ultimate top-down proposal - but worse those at the bottom are not being seriously helped to be involved.
Just doomed I reckon!



Anonymous said...

The last slide in the webinar shows a PCEHR provider portal view, which seems to be a complex and potentially confusing user interface. The use model seems structured around information types rather than clinical tasks, which is not how it is meant to be done. Does anyone know if this is just a concept slide and the real interface is still to be released, or is this really meant to be 'it'?

Dr David More MB PhD FACHI said...

It is a mockup, and they been using the same one for a good while. It is 'foilware' at this stage.


Another Anonymous Coward said...

It's true that it's a mock up, but it is a guide to what *should* be done in the eyes of the clinical leads. Presumably they disagree with Mr Anonymous about how things should be done.

Anonymous said...

I don't see the issue. Everything else is a mock up so they consistent at least. Something real would look out of place.

Dr David More MB PhD FACHI said...

The real problem with the mockup is the assumption that there will be information sources that will populate what is proposed - in the next few years - and that all the data integrity etc issues can be addressed. I don't see it happening!


Anonymous said...

There won't be, but they will mock them up. Eventually the layers of mock up will become so deep and require so much processing power that it will all unravel. ETA mid 2012.... I wonder how many other government agencies are a mock up. We know the navy has mock up landing craft that required the intervention of the Kiwi Navy in the cyclone. The real question has there been anything of real value come out of NEHTA. I think not, its all a mock up.

B said...

Are there any standards for exceptions and error handling?

It is one thing to define how a system is to work normally, it is far more difficult and time consuming to define what happens when the system goes wrong.

e.g. what happens if someone's test results turn up on the wrong person's Health Record.

Or are they assuming this sort or error can never happen?

Anonymous said...