Thursday, February 23, 2012

Now Here Is An Approach That Might Actually Make A Difference! Fascinating Stuff.

The following appeared a few days ago.

Scarborough first with TPP record viewer

9 February 2012   Rebecca Todd
Emergency physicians at Scarborough Hospital say introducing a GP clinical record viewer has been like “turning on a light."
Lead A&E consultant Dr Andy Volans says staff can barely remember how they coped before TPP’s new CRV went live on 25 January.
The viewer allows hospital clinicians to access a read-only view of the patient’s full electronic record held by a TPP practice. It is currently being used in A&E but will be rolled out to other departments.
Dr Volans said the viewer was especially useful when dealing with the area’s large nursing home population.
In the past, elderly patients would often arrive in A&E with no GP letter, nobody from the nursing home to explain why they were there, and unable to communicate their own medical conditions and medications.
“Consequently you’re working a bit blind, so we’re particularly targeting those patients so we know what the GP knows about them,” he explained.
Staff must use their role-based smartcards to access the viewer.
Admission, Discharge and Transfer (ADT) messaging is used to communicate between the CRV and the hospital's patient administration system, which, at Scarborough, is iSoft's iPM.
When a patient is registered on the PAS, a message is sent to the CRV, so the hospital can retrieve the patient's SystmOne record, subject on their giving consent.
A template pulls down relevant information, including most recent acute illnesses, any chronic illnesses, acute drugs, blood pressure readings, and the last three attendances or clinical interactions with a GP.
More here:
This is an astonishingly good story and makes a it makes great deal of intuitive sense that such a system could really make a difference in a local area. The concept of an access only view makes a great deal of sense as does the smartcard access control.
Of course there are always caveats - and here they come from across the Atlantic from the example above.

5 Considerations for Hospitals Releasing Medical Records to Patients Electronically

Written by Sabrina Rodak | February 13, 2012
In September the Office of the National Coordinator for Health Information Technology launched the Consumer e-Health Program to encourage individuals' engagement in their healthcare. One of the major goals of the program is to provide patients with easy access to their medical records. To accomplish this goal and others, ONC created the Healthy New Year Video Challenge and is developing an animated video to explain the value of health IT to consumers, among other initiatives.
Hospitals are also encouraging patients to take a more active role in their care by providing easy access to patients' lab reports and other medical information. Jan McDavid, general counsel and compliance officer, and Steve Emery, director of product management, at HealthPort share five considerations for hospitals when providing patients with electronic access to their medical records.
1. Compliance. Whenever dealing with patients' protected health information, hospitals need to ensure compliance with HIPAA and other applicable federal laws. HIPAA requires patients' records to be provided within 30 days of their request, barring certain exceptions. For instance, if a physician decides providing the full record is not in the best interest of the patient, the physician may withhold certain parts of the record.
Hospitals also need to be aware of laws of the state in which patients' medical records are located. Ms. McDavid says in general, that when federal and state laws differ, hospitals should follow whichever set of laws is stricter. She suggests hospitals' privacy and security officers constantly educate themselves on updates to the law and the specific facility's policies regarding patients' medical records. Policies may include requiring documents with confidential information to be shredded, prohibiting the sharing of passwords, and mandating training on HIPAA.
2. Security. Hospitals releasing medical records to patients need to consider both the physical and electronic security of the records. For example, Ms. McDavid says hospital officials should ensure restricted areas are enforced if a computer containing patient records is located there. In addition, computers with screens that can be seen by patients may need privacy screens. Hospitals may also need to develop policies on where to store patients' charts, which are typically placed outside the patients' doors and are easily accessible to unauthorized individuals.
Furthermore, computers and the hospital network need to be electronically secure to prevent viruses and people from accessing information. A best practice for securing medical records is encryption. While encryption is not required by law, it lessens the reporting requirements if breaches occur, Mr. Emery says. Another best practice for securely releasing medical records to patients is two-factor identification. For example, the hospital would send the patient an email with a link to a website that hosts medical records. The patient would then have to authenticate his or her identity with personal information and a password to access the records.
3. Content.
4. Format.
5. Portal.
Learn more about HealthPort.
More here:
Again this is a fascinating discussion of the issues you face when opening access up to the EMR for the patient. In the UK you are at least giving access to another clinician who will typically ‘get’ what is said! It might be just that much harder with patient access!
As I have said before we really do live in some exciting and interesting times and I have to point out that this sort of innovation rather makes the PCEHR so 1990’s!
David.

35 comments:

Anonymous said...

David, I don't quite get your last comment "this sort of innovation makes PCEHR seem so 90s". Seems to me this is exactly the sort of innovation that PCEHR enables. This is a good story about how sharing information across care settings makes a difference, which supports the concepts of EHRs in general. There's no particular reason for that to be a comment on PCEHR - other than the obvious comment that PCEHR is an EHR.

Dr David More MB PhD FACHI said...

It is the difference between a centralised shared record - and some other more innovative approaches. The PCEHR is just an unnecessary attachment to the working EHR.

David.

B said...

Section 2. Security is interesting. It covers quite a few non-IT issues that the Concept of Operations does not mention. Specifically access to computing devices in a hospital.

These are system use issues, but not IT issues.

In order to address these system issues will take time, effort and money. It might also mean that some hospitals cannot comply.

I wonder what thought, if any, has been given to non-IT issues such as these and who is going to bear the additional costs.

Anonymous said...

The PCEHR provides the ability for innovation - it provides a mechanism for sharing, but it doesn't dictate what can be shared over time.

The information listed here (illnesses, drugs and last three attendances) are very similar to data planned for the PCEHR.

What exactly is the innovation here that you think couldn't happen in PCEHR?

Dr David More MB PhD FACHI said...

Contact of the consumer with a live and trusted system and not a secondary copy is the key!

Also direct clinician contact etc to say nothing of real time DSS.

The PCEHR is an architectural dead end in my view.

David.

Anonymous said...

I think the TPP viewer as described is not an interaction between the consumer and their record - it's an interaction by a clinician in a hospital with a record held in a practice.

In terms of clinical outcome, it makes no difference whether that interaction is to a local practice or to a central datastore. From a technical perspective, it makes a big difference, because if you are connecting to a local practice you have a web of connections that the system must make and some sort of directory needed. If a consumer has records in multiple practices, you are putting the load on the emergency system to aggregate those records - which ultimately won't occur reliably. There is also a substantial risk of that system being offline when you want it (say, in the middle of the night when you present in emergency).

I'm not sure what clinical difference the solution you've pointed to has to the solution that PCEHR is offering. It certainly has technical differences, but I'd argue that the PCEHR solution is superior. What about the PCEHR architecture makes it a dead end?

Dr David More MB PhD FACHI said...

Difference is one is an actual in-use record - or a view thereof - and the other is a copy of unknown accuracy and currency.

The difference in the UK and what we plan to do here is have a nominated practitioner - but then we go an mess the purity of that idea up by allowing patients to edit and censor and others to add other material.

I do not like any shared records that are derived from anymore than a single source - that of the individual's GP. And I want a direct line - not intermediated and possibly compromised by patient and Government.

Doctors simply won't trust this spread trust sort of record.

Also the PCEHR specifically does not interact with provider systems to provide appointments, repeats and so on which are the main reason people like such attached PHR's in the US and elsewhere.

My view is you need to look closely at what KP gives their patients and docs and what the PCEHR offers - chalk and cheese.

David.

Anonymous said...

How do they know that it's an in-use record? If I visit one GP for a while, and that's established as my record, then I visit another GP....surely there is a chance the old record is displayed.

Both situations have the potential to be out of date, that's the nature of electronic records. But an out-of-date record is better than no record at all, which is the alternate situation.

I'm not sure why the focus on the GP, there are many other practitioners in the care ecosystem, and all of them have something to add. Yes, a nominated provider that summarises that record is ideal, but that doesn't mean that the other records shouldn't be available as well. And, as with anything in this space, there will be problems with completeness, usage, currency etc. Clinicians deal with that today with paper and local records.

I agree that PCEHR does not today offer bookings, the ETP spec does provide for repeats, but they aren't targeted at PCEHR.

I think the problem here is that this is a once in a decade opportunity to get something that works. If PCEHR fails then nobody will try again for a substantial period of time. Your objection seems to be that it isn't perfect. The UK have been at it for 7 years, and spent a lot more money. So yes, it's more advanced. But tearing down PCEHR because it's not perfect means that we'll end up with nothing.

Dr David More MB PhD FACHI said...

Sorry, If you are going to do something you try to do it at the 'state-of-the-art' level why bother. This is 1/2 a billion $$$ after all. The architecture of the PCEHR was driven by pathetic DoHA bureaucrats who don't get what is needed and were scared of the privacy lobby. So we are being given a camel.

I am not in the camp that says anything is better than nothing. Frankly what Argus, Healthlink and Medical Objects are doing (and the GP System Providers) is much more useful in the real world - and much cheaper than this nonsense national EHR.

Sorry. I think it is rubbish dreamt up by people who have no idea.

Show me the evidence supporting what they are doing. I keep asking but no one has any!

David.

Anonymous said...

Sure, the system was dreamed up by bureacrats, and any system with a bazillion architects hanging around it has compromises and things that people would do differently if they could do it again. Show me the system that isn't true in.

The question is whether we're better off finishing it then refining it, or better off giving up. Australia has a long history of failed projects of this nature. This one was funded to a level where it should be possible to actually work. But if we give up, there won't be another one for a long time.

What are the problems that you think will stop it from working? Are those problems correctable over time? Are those problems one of "cannot work" or one of opinion - "it'd be better another way"?

People have been agitating in Australia for proper investment in a national system for many years. Now that we have that, people seem to be unhappy that it isn't exactly their design. That's the nature of large projects (and, for that matter, standards processes) - they're compromises and everyone gets part of what they wanted. This project was never going to be designed and driven by one person and match that one person's personal vision (and even if it did, then everyone else in Australia would be unhappy that it didn't meet their vision).

Anonymous said...

> we go an mess the purity of that idea up by
> allowing patients to edit and censor and
> others to add other material

Where do you get the idea that patients can edit the material? It's digitally signed by the provider, and they can't do that. What is added is what is read, and the digital signature can always be verified.

They can censor, yes. Just like they can choose not to mention aspects of their care when they consult with a clinician - but at least there is an established audit trail on what was visible or not.

As for other people contributing, all information is clearly identified by the author and the role that they have. I don't see just why it's so bad that people can contribute to their own medical record. People actually do now, you know.

I understand why you don't like opt-in. That makes sense, and I'd rather have opt-out too. But allowing patients to censor their own record seems like a reasonable compromise. You might laugh at the bureaucrats being scared of the privacy lobby, but the politicians don't laugh. The people who spend the money live in the world of the possible, not the other fantasy one.

Anonymous said...

> possibly compromised by Government

uh? What do you have in mind here? What in the ConOps gives you ground for thinking that the government can compromise the record?

And the GP is only the GP. they can maintain a health summary, but there's loads of interesting data for chronically sick people (you know, the ones that actually consume the bulk of the money) that the GPs are only secondary or tertiary users of.

Dr David More MB PhD FACHI said...

Issues that will have it fail:

- No incentives for use.

- Doctor mistrust.

- Utterly wrong architecture.

- Lousy management of project overall.

- Health IT Vendor Community estrangement.

- Lack of Governance Framework that is even 1/2 reasonable.

- No working identification management.

- Lousy expectation management from NEHTA and DoHA.

- Last No assurance of clinical safety and data integrity.

That's for a start!

It is a joke if you bother to sort through what works and what does not!

David.

Dr David More MB PhD FACHI said...

"Where do you get the idea that patients can edit the material? It's digitally signed by the provider, and they can't do that. What is added is what is read, and the digital signature can always be verified."

They can delete records and do whatever they like with any data they enter.

Enough said.

David.

Anonymous said...

- No incentives for use.

Can be changed later - likely to reduce takeup but not cause failure.

- Doctor mistrust.

Can be a problem. But probably also something that many doctors are taking a "wait and see" approach to.

- Utterly wrong architecture.

Wrong in what sense? If this is true then it would be something that was hard to change later.

- Lousy management of project overall.

True, but once it's delivered that is no longer relevant - it's something that happened along the way.

- Health IT Vendor Community estrangement.

Mixed - different across different vendors. Remember these vendors have conflicting commercial interests, and also have seen many of these projects come and go. If this one starts working, they'll likely get on board. Again, something that could be corrected over time.

- Lack of Governance Framework that is even 1/2 reasonable.

Possibly true. But again, something that can be corrected over time - it's not inherent in the system, it's people and processes.

- No working identification management.

Meaning what? That the HI service isn't working? Potentially true, but I've heard that there are a reasonable number of locations that are now using it reasonably successfully. Again, this is something that could be corrected over time.

- Lousy expectation management from NEHTA and DoHA.

Possibly true, depending on who you listen to. But again, that's not inherent in the system, it's a failing of the process. Once it's there, then people's expectations will converge on what is delivered. Those things that are missing that are important will get put on some sort of enhancement list and sorted out over time.

- Last No assurance of clinical safety and data integrity.

This could be a real show stopper if true. What evidence do you think should be available at this point in a project of this nature? What do other similar projects have available?

Dr David More MB PhD FACHI said...

> possibly compromised by Government

uh? What do you have in mind here? What in the ConOps gives you ground for thinking that the government can compromise the record?

After the last week where we have learned what politicians are really like I am in "don't trust and extreme verification mode!"

You can be sure they will work out a way to 'data-mine' and possibly abuse PCEHR data.

Sad - but my trust is shot with ALL politicians.

David.

Dr David More MB PhD FACHI said...

Sorry,

I am tired of this.

The planned architecture is rubbish in my view and lots of the other points you admit are problems and there are 4 months to go. The thing is a mess and $500M has possibly been wasted.

The Clinical, Privacy and Vendor organisations think is it pretty awful. But you want to steam ahead. Just why is that I wonder?

David.

Anonymous said...

There's more than one person in the thread David, which isn't immediately evident as it's all posted as anonymous.

I disagree with your assessment. Nevertheless, you are entitled to your opinion.

Dr David More MB PhD FACHI said...

Funny how no one will use their name.

My view is this is a rubbish plan and when someone actually provides some actual evidence I am wrong I am happy to listen.

To date all the evidence (KP etc) supports my view and on one has amy evidence to support the PCEHR. If it exists - link to it!

David.

Anonymous said...

It's a classic political ploy to ask for more evidence. Prove it will work. Which cannot of course be done - it's delaying tactics, not an argument.

If you want commentary from those who are involved, however tangentially, you will need to accept that they don't come with names.

Dr David More MB PhD FACHI said...

Sorry.

Spending 1/2 a billion dollars should have an evidence base before you start. Why does that not exist?

The evidence for other approaches does exist.

Are we in an era of blind faith based policy or evidence based policy?

You can keep typing all you like - this is something I have been saying for at least 18 months - I did not just make it up to delay anyone!

Jinx even!

"If you want commentary from those who are involved, however tangentially, you will need to accept that they don't come with names."

Those who are involved are meant to know what they are doing - so link to the evidence that it is true!

David.

Anonymous said...

I asked..

"Where do you get the idea that patients can edit the material?"

You replied

"They can delete records and do whatever they like with any data they enter.

Enough said."

That's not enough. Patients cannot edit records added by other clinicians. They can only hide them. You casually say "doctors won't trust PCEHR because patients can edit the contents" but I don't think that's true, because what a patient can or cannot do is limited.

The I asked why you think it's already compromised by the government, and you say "You can be sure they will work out a way to 'data-mine' and possibly abuse PCEHR data."

So it might happen in the future?

It's hard to take you seriously when you twist things to make them look as bad as possible (and perform wanton terrorism upon exclamation marks too)

I too deplore Anonymous contributions too. But that's the rules of the game at the moment.

Anonymous said...

This a catch 22 scenario. You want evidence base to demonstrate it will work before going ahead to build it. Yes, you have said repeatedly that there is not such system anywhere in the world therefore, quid pro quo, there is no evidence base. So you cannot prove it will or will not work until you have build it and put it to the test. Either it will work or it will not work.

I think this is why a few very sensible people have been advocating a more incremental, modular, less ambitious approach.

Dr David More MB PhD FACHI said...

Look, first let me say I do love my exclamation marks - they make me heppy and stop me saying ruder things! Ignore them if you like.

Second, there was a workable practical plan for e-health developed in 2008 and instead we have wound up with a much riskier and less well thought out "shock and awe" approach - which I judge to be wrong.

Third my submission to the Senate Enquiry reviews all this and I believe lays out a better way forward. I don't expect everyone to agree, but I know a fair few who I would consider serious experts do. It is that simple. I think the Government has got this wrong and that the consequences for Australian e-health will be pretty awful. Time will tell who is right and wrong!

David.

Dr David More MB PhD FACHI said...

"I think this is why a few very sensible people have been advocating a more incremental, modular, less ambitious approach."

I have been advocating that since 2009.

David.

Dr David More MB PhD FACHI said...

"I too deplore Anonymous contributions too. But that's the rules of the game at the moment."

Pretty sad that - but I do understand. The sadness is that this reflects the corruption of our free and open market in e-Health towards an awful form of money driven domination by NEHTA and Government.

The number of smart people who talk to me off the record - in fear of their livelihoods - is quite dreadful.

David.

Keith Heale said...

This discussion started with "what are the differences between this (TPP) system and the PCEHR?", but then drifted to "what's wrong with the PCEHR?". A brief comment on each of these questions follows.

First, the Clinical Record Viewer in use at Scarborough Hospital, UK, works only with patients of GP practices using TPP's SystmOne software (which is about 50% of practices in the Scarborough area. SystmOne is a HOSTED software service: the information is held on central servers managed by TPP. So yes, it's live data. TPP's vision for SystmOne is "One patient, one record". There are modules for child health centres, community health, hospitals, aged care, pharmacies, even prisons. This is fundamentally different from the situation here, where nearly all patient primary care data is held in the GPs' own premises. This centrality of data makes possible the benefits described in the article, but it also limits participation to patients of TPP SystmOne practices.

In my view, the main thing wrong with the PCEHR is that it is simply the wrong project. There are many ehealth services which need to be progressed and which would make a difference. Universal secure messaging with supporting directory and authentication services would be a good start and should have been addressed at least a decade ago. Universal electronic prescription service is another. By universal I mean that all implementations conform to one standard and are interoperable. Having these services in place would have immediate benefits in better communications between GPs, specialists and hospitals, in savings to the PBS, catching "drug cheats" etc. There has never been a solid business case for the PCEHR, just a lot of "best case" dreaming.

Dr David More MB PhD FACHI said...

Keith, I posted this blog to point out there are alternative approaches to e-Health. The fixation on the PCEHR as the only way forward is a key part of my problem with what is happening at present.

David.

Anonymous said...

2/27/2012 09:51:00 AM said: “In my view, the main thing wrong with the PCEHR is that it is simply the wrong project. There are many ehealth services which need to be progressed and which would make a difference. Universal secure messaging …. Universal electronic prescription service …. having these services in place would have immediate benefits …. There has never been a solid business case for the PCEHR.

In summary – the eHealth Agenda has been hijacked.

Complicit in the highjacking have been the ego’s of many enthusiastic well intentioned individuals; representing the Peak Bodies which have allowed themselves to be seduced by technocrats empowered with buckets of government money and working in a politically turbulent, highly complex, rapidly changing environment riddled with conflicting cultures.

These technocrats have held and continue to hold an unfailing belief they can do what no-one else in the world has been able to do.

Keith Heale said...

Dr David More wrote: "Keith, I posted this blog to point out there are alternative approaches to e-Health."

David, I have no quibble with your post. Some of the comments failed to recognize the fundamental differences, and it was some of these that I was trying to clarify, and make explicit.

"The fixation on the PCEHR as the only way forward is a key part of my problem with what is happening at present."

AMEN!

David.

2/27/2012 12:04:00 PM
Anonymous Anonymous said...
"In summary – the eHealth Agenda has been hijacked."

Could not have said it better myself! And it is what David and a few others have been saying for the last 18 months. (see above)

Anonymous said...

"In summary – the eHealth Agenda has been hijacked." ..... is precisely what I warned on this blog was going to happen. If I looked back I think I'd find it was about 24 to 30 months ago. And if you don't mind me saying so I think it is now all too late to do much about it ... except let it happen until it withers and dies.

Anonymous said...

Today’s Australian details the extent of the highjack “Labor's Personally Controlled Electronic Health Record system blows out to $760m” when put in the context that nothing of note has yet been delivered.

Anonymous said...

With $760 million already spent according to Karen Dearne in The Australian today it is no longer possible for the PCEHR project to "whither and die."

Why not?

You may well ask. Because there are now so many senior bureaucrats too deeply involved in supporting this project in Federal, State and Territory jurisdictions that it now has a life of its own and no one individual or small group of individuals would be game enough to stand up and tell how badly out of control the project is and if they did no-one would listen or they would be ridiculed. Anyone who did so would be instantly moved aside and silenced. Therefore, in addition to what is already a gigantic waste of taxpayers money more money will be asked for and more money will be given in the forlorn hope all will be well one day.

Anonymous said...

According to Nicola Roxon last week the PCEHR was another Kevin Rudd whim made with no proper cabinet consideration.

It is apparent she is now trying to distance herself from the impending fallout she sees ahead and perhaps open the way for Tanya Plibersek to call a halt to the project.

Sensible Minister’s know that either way the PCEHR will be a painful carbuncle for Labor which sooner or later will have to be lanced.

Terminating the project now will be painful but it clears the way ahead for implementing more cautious approaches.

Maintaining the status quo or allocating more money will simply increase the likelihood this IT monstrosity will damage labor’s election chances big time.

Cancelling contracts with the big boys will inevitably incur onerous financial penalties, but there is no choice.

Increase the chances of losing the next election or bite the bullet now, clear the decks, move forward into calmer seas and increase the chances of winning the next election.

It’s Julia Gillard’s call and she cannot rely on self serving bureaucrats and DOHAs Departmental Head to give impartial advice.

DOHA created the problem and was most likely responsible for selling the PCEHR idea to gullible Kevin Rudd in the first place.

It’s a tough call for the Prime Minister but it has to be taken sooner not later.

Perhaps the Senators could help by making an unequivocal Recommendation to that end.

Anonymous said...

So, now the PCEHR is "to big to fail" - oh dear, what fills me with dread. It already has failed!!! It's currently nailed to the perch.