Thursday, July 19, 2012

The Lack Of Health Sector Wide Knowledge and Understanding Bites NEHTA Hard. Pretty Pathetic Really.

The following popped up today:

States not ready for e-Health system

GENERAL practitioners will have to wait up to three years to receive secure discharge summaries digitally signed by hospital doctors following more delays to the Gillard government's e-health system.
State and territory health departments say they are not ready to use healthcare providers' 16-digit unique identity numbers created for the national system to verify the identity of doctors or other medical staff creating a patient's discharge summary.
Healthcare providers individual identifiers - dubbed HPI-Is - were created and assigned to all registered doctors two years ago as part of the Healthcare Identifiers service launch, which also saw unique 16-digit identifiers allocated to every Australian enrolled on the Medicare database.
Use of local hospital or state health agency identity numbers instead of a uniform national identifier will impact their use for authentication and audit purposes within the personally controlled e-health record system.
The ability to accurately identify individual healthcare providers, health organisations and consumers using the PCEHR system is key to securely exchanging electronic information and reducing the potential for errors - either through assigning records to the wrong patient or sending documents to the wrong doctor.
User verification is supposed to be provided through the not-yet-available National Authentication Service for Health (NASH), which is also supposed to provide an audit trail of all access to a patient's electronic record.
Delivery of the NASH is subject to ongoing negotiations between the contracted supplier, IBM, and the Health department after the PCEHR system launched without it on July 1.
Health chief information officer Paul Madden yesterday called for comment from stakeholders on a proposal to abandon the mandatory requirement to include HPI-Is in discharge summaries in the near to medium term.
Lots more of the saga is found here:
Here is a slightly more technical summary of the issue from NEHTA:
-----

ISSUE

The current Nehta specification and proposed Australian Technical specification for discharge summaries includes a mandatory requirement for an HPI-I.
Jurisdictions and lead implementation sites have difficulty in obtaining HPI-I’s for their providers, and have been unable to secure funds to store HPI-I’s in their systems.
Jurisdictions have estimated a 1-3 year horizon for the implementation of HPI-I’s.
As a result, it will take a considerable time for discharge summaries to be available in the PCEHR if the HPI-I remains a mandatory requirement.

BACKGROUND

Nehta and the NCAP have been reviewing the opportunity for a number of quick wins for increasing the clinical utility of the PCEHR through the jurisdictions.  These opportunities have been presented by the NCAP to the Nehta Board.  A key opportunity in most jurisdictions is the implementation of an interface from the hospital discharge summary process into the PCEHR.  Queensland, South Australia, Victoria, NSW, the ACT and the NT have all expressed a desire to move forward with discharge summaries.
Jurisdictions raised the issue of the steps they would have to go through to implement the HPI-I’s into the discharge summary.  A series of workshops, facilitated by the NCAP and attended by jurisdictions, Doha and Nehta concluded that by relaxing the conformance requirement of a mandatory HPI-I on discharges, that jurisdictions would then be able to build the necessary infrastructure to send discharges to the PCEHR. 
It is noted that while the requirement of a HPI-I is relaxed, there remains a mandatory requirement for a Provider Identifier of some nature.  This identifier may be an identifier supplied by the healthcare facility associated with the individual provider.  It may be of any form (e.g. Numeric, Alpha-Numeric, etc).  The identifier must be unique to the facility, for example a concatenation of the local identifier linked with an OID derived from the facility’s HPI-O or ABN.
A clinical impact and safety assessment has concluded that there is no introduced clinical risk by relaxing this conformance point.
----- End Extract
So it seems that no-one at NEHTA has noticed that, as far as most of the States are concerned, use the Health Identifier Service is distinctly optional - and they will get round to it sometime in the rather ill-defined future.
It should be noted that without Individual as well as Provider Identifiers flows of information both to AND FROM the NEHRS / PCEHR are made more problematic. How can an internal hospital system use B2B to request PCEHR records if it does not handle the HI Service?
You can read my comments on feeder systems  being an issue from last year here:
What is not clear to me - reading this - is just how a particular discharge summary - with a local identifier - can be safely merged with a PCEHR record. It is not clear to me if the IHI remains mandatory (looking at the V1.3 specs it seems not) and if all the hospital systems are able to use this identifier.
An obvious question is, of course, if the IHI is not mandatory just why is that and how is that decision justified?
Despite the words from NEHTA Clinical Safety I think this needs some careful development of test cases to make sure any interactions between the Hospitals and the PCEHR occur exactly as expected with a high degree of reliability.
The failure to take a health system wide view - when working with a so called ‘nation system’ - just shows how far out of touch some are.
What exactly are NEHTA playing at with all this?
David.

15 comments:

Anonymous said...

"What exactly are NEHTA playing at with all this?"

What are you and Karen playing at, speculating in ignorance?

"So it seems that no-one at NEHTA has noticed that"

Your conclusion from a NEHTA document announcing it is that no one in NEHTA has noticed?

"What is not clear to me - reading this - is just how a particular discharge summary - with a local identifier - can be safely merged with a PCEHR record."

That should be quite clear: it can't be.

It is not clear to me if the IHI remains mandatory (looking at the V1.3 specs it seems not)

Which v1.3 spec?

Dr David More MB PhD FACHI said...

"What are you and Karen playing at, speculating in ignorance?"

Nope.

"Your conclusion from a NEHTA document announcing it is that no one in NEHTA has noticed?"

Two years too late.

"Which v1.3 spec?"

The current Discharge Summary spec which is not downloadable for some rubbish reason.

Get a life..this is a major planning failure and we all know it. Just hoping rather than making sure feeder systems and jurisdictions were organised is pathetic.

David.

Anonymous said...

NEHTA and the NCAP are looking for ‘quick wins’ to increase use of the PCEHR.

What a lot of boloney. There is no such thing as a quick win in e-Health – you either do it proper and right or you stuff it up big time. E-Health is a long, slow, slog not a quick there ya go – got a quick win. How stupid are these people.

They have a mess on their hands and they know it but they don’t know what to do about it. This talk of quick wins is just another version of the “TIGER TEAM” rubbish of a few months ago, albeit in another guise.

Has Minister Plibersek got any idea what is going down here?

Anonymous said...

Jurisdictions and lead implementation sites have been unable to secure funds to store HPI-I’s in their systems.

Hello, come in spinner.

More money please or we won’t be able to proceed. We are stuck. We‘ve used all the money you have given us and now we need some more or we won’t be able to do anything.

Yes Minister, it’s time to cough up again, and again, and again …..

Anonymous said...

"NEHTA and the NCAP are looking for ‘quick wins’ to increase use of the PCEHR."

Hang on. Wasn't the PCEHR mean to *be* the quick win while we slowly built up a national HIE? But now it is becoming clear that the PCEHR is a cul-de-sack to nowhere, rather than a staging post on the way to where we should be. Propping it up as its many failings become manifest is quickly consuming more and more resource, that should be going elsewhere. We need a quick win? Give me a break. Pull the plug. Start again. By all means spin it as a pause or whatever, but behind he scenes, stop, clear out the leadership, start again.

Decision and governance fiasco. Planning fiasco. Execution fiasco. For all those who worked so hard with good hear and noble intention because they believe in e-healht - sincerely thank you, I hope some good is to come of this. But you have been let down by those with the power to make big decisions. Those who made these decisions against impartial advice should be embarrassed and resign. What made you think you knew better? Hubris? How do you get up in the morning?

Keith said...

David,

I'm not sure why you had trouble accessing the eDischarge Summary documents - worked for me.

Under the heading "Background to this Release" there is a comment that this is a re-release of the eDischarge Summary Solution Bundle, originally published on 2 December 2011, issues having been found with the CDA Implementation Guide, as well as inconsistencies between Solution Bundles.

So the requirements in V1.3 are the same as previously, requiring both the author's HPI-I and the patient's IHI. Reading the article carefully the reference to the relaxed conformance requirement applies only to the provider's HPI-I; the IHI requirement stays. Surely?

But I agree with you that the people running this project should have seen this coming a long time before this. Perhaps the states thought that they had plenty of time, but have been caught out in a push to bring forward eDischarge Summaries because somebody thought it would be easy?

There is another side to this: the documentation makes it very plain that the PRIMARY purpose of the eDischarge Summary is to inform the patient's GP, specialist(s) where appropriate, and patient's nursing home if applicable. Sending a copy to the PCEHR is a SECONDARY consideration. It should also be remembered that this communication between hospitals and other health providers is a fundamental ehealth function. Getting Discharge Summaries onto GPs' desks should be the priority, not getting them into a PCEHR (for which the GP may not even be registered). IT IS ANOTHER EXAMPLE OF THE PCEHR AGENDA HIJACKING THE EHEALTH IMPERATIVE. I have a feeling we are going to see a lot more of them.

Dr David More MB PhD FACHI said...

"IT IS ANOTHER EXAMPLE OF THE PCEHR AGENDA HIJACKING THE EHEALTH IMPERATIVE."

I agree 100% and have been saying it loud and long!

I can access but - for some bizarre reason - not download the documents.

NEHTA must be embarrassed about the quality?

David.

B said...

"Doha and Nehta concluded that by relaxing the conformance requirement of a mandatory HPI-I on discharges, that jurisdictions would then be able to build the necessary infrastructure to send discharges to the PCEHR."

The single most reliable indicator of a failing project is unstable requirements.

The indicator light is getting brighter and brighter. It's a pity it is being ignored.

Anonymous said...

Upon navigating the numerous PCEHR specs available at http://vendors.nehta.gov.au (you need to register), it is a little confusing but it seems that we need to be careful to distinguish between a unique identifier for an individual provider (e.g. a HPI-I) which is an attribute (document author) of a clinical document (say a discharge summary), and a “digital signature” (which will likely contain a HPI-O) and which sits alongside a clinical document in a ‘CDA package’. The purpose of the digital signature seems to be to authenticate the organization or individual who prepared the clinical document at the point in time it was prepared, whereas the document author would be used in rendering the document on a screen, or to sort clinical documents on a screen, or in an audit trail.
However there is another level of identification and digital signatures required for posting/viewing/updating of clinical documents, and it seems from the specifications for these transactions (separate to the clinical documents - see the B2B gateway specifications on the http:/vendors.nehta.gov.au site) that only the organizational level (HPI-O) level is required. It is presumed that only transactions from organisations who have registered to participate in the PCHER system will be accepted.

From the Australian IT article and NEHTA information, it seems that the ‘document author’ field in the clinical document is currently specified as mandatory to be a ‘HPI-I’ value but that if that is not available (as we know it often is not in hospitals), that an alternative local identifier could be used. This is probably OK as an interim step, because this field (the author) will only be used for audit, and rendering and sorting – but not for accessing a record or a document, as the specs indicate that this is proposed to use the HPI-O level.
But I am just guessing, as it is very confusing navigating the myriad of specifications on the portal site.
I just think it could be worth relaxing the requirement for the HPI-I document author from hospitals if this helps with getting the discharge summaries into the system sooner, and GPs and consumers wanting to see them.
One step at a time, and discharge summaries would be a good first step.

Anonymous said...

It will be interesting to see what Mr Fleming has to say at HIC next week as a key note speaker/panelist. Also will he be "protected" as NEHTA is a major sponsor?

Anonymous said...

“Quick Wins” has a very dubious history and legacy within major ehealth programs. This includes Richard Granger’s use of it in the NHS. The language of quick wins, its dubious rationale and self-interested purpose has been adopted by nearly all state based ehealth programs in recent times. It’s the old fake it till you make it play!
Again!. Again and Again – It enables you to argue to your funder that you are indeed delivering. It’s a useful play to ensure you secure further funding.

Anonymous said...

Indeed, look at dear old Queensland Health – “the viewer”. QH are hoping this “quick win” is good enough to demonstrate they have done sufficient to ensure their ehealth program doesn’t go the way of the Vic Healthsmart Program.

Anonymous said...

But "The Viewer" won an award! It proves progress, Minister.
Please sir, may we have some more?

Anonymous said...

The irony of this as that the HPI_Is for all doctors and many other health professionals have already been allocated and stored in the HI Services.

The problem is that the processes and methods to make them discoverable are too complex to implement.

Dr David More MB PhD FACHI said...

Indeed,

Mine is printed out on a piece of paper I got with my registration 2 years ago...

David.