Tuesday, August 21, 2012

New Zealand Seems To Be Really Moving On Health Information Exchange. And It Is Costing Peanuts Compared With the NEHRS.

I had the following e-mail during the week from Tom Bowden the CEO of HealthLink.

122 successful CareInsight lookups in a single week, in one region!

Dear Colleague,
When a patient arrives at a hospital emergency department it is probably one of the most distressing experiences they will ever have.  So it is essential that we do everything to ensure that each and every emergency department visit goes as well as possible.  By having information about a patient’s existing medical conditions, current treatment plan and medication history ED staff get a “running start” in terms of getting their emergency care underway.  CareInsight is the system that makes that possible. 
The CareInsight system is a world first in its field.  It is an online system that hospital and after-hours clinicians use to obtain important information about ED patients, directly from their general practices and pharmacies’ medical records systems.  CareInsight provides an instant window into the patient’s relevant medical details and provides hospital ED staff with the totally reliable and up-to-date information that they need to make the right interventions and get urgent treatments underway swiftly and confidently.
Last week in the Hawkes Bay District Health Board region, ED staff performed 122 successful CareInsight lookups.  Usage has been growing steadily over the past year but this is a new record.
Now in day-to-day use for over a year, CareInsight is really proving its worth and has become an essential ED tool.  Five regions have now implemented CareInsight or are in the process of rolling out CareInsight.  It is interesting to dwell on the proposition that if the results gained in the Hawkes Bay were extrapolated across New Zealand*, more than  6,000 Lookups would have occurred last week
To learn more about CareInsight please connect to this link to a video we have produced about the service and refer to the attached Privacy Impact Assessment to learn more about how it works.
Note:  *Hawkes Bay is home to 2% of New Zealand’s population.
Once looking at this video you can see the other things with e-referrals and so on that are also now being progressively rolled out.
I am happy to send the report to people on e-mail request  (it does not seem to be online) but it is probably easier to read about what is being done from this link:
The great thing about this system is that it is being implemented in a ground up, incremental way learning as people go to minimise the problems and maximise clinical benefits.
Just saying this is so much more like what we should be doing - and costing ourselves so much, much less in the process. Here is a working system delivering what the NEHRS hoped to do and it is all working, and being used, here and now!
This is the promise of e-Health that sadly NEHTA and DoHA just don’t get or if they do they are just going about things the wrong way. Better to travel slowly and learn along the way than what we have seen in the last two years.
As confirmation of that see here:

Sharing your health information

The way information about our health care is shared is improving. By the end of 2014 the Government’s aim is for all New Zealanders and the health professionals caring for them to have electronic access to their health information.
It is really good to see how calmly and carefully the NZ team are going about all this. The chances of success are looking more reasonable than what we are presently doing I reckon.
Great stuff.
Late Alert: Here is the link you need to all the material.
The document then has a link to the privacy assessment and video.


Anonymous said...

Hmm. 122 lookups. Not a lot. And coming directly from the GP systems. I presume those GPs have 24x7 systems with data centres, UPS, redundant internet connections? Or sometimes the data just isn't available?

Certainly that's a budget way to do an EHR. But it's definitely not the same thing that's being done in Australia.

Anonymous said...

yes, but it actually works, unlike the complete cluster f**k we have here to date!

Dr David More MB PhD FACHI said...

Exactly. Do ER's in Australia have anything usable yet and will they any time soon. I doubt it.

It is a pragmatic and reasonable way to make ER information available.

BTW @8/21/2012 08:21:00 PM

Which OZ GPs will have all this to contribute to the NEHRS and when will all that be ready - given you can be sure they won't pay for it!

Anyway having logged on and waited 2 mins to even get close to some information the NEHRS is hardly an emergency system!

Assuming, of course, it is working.


Anonymous said...

Let's face the facts - they have gone much too far to change direction now so all they can do is hope that in time they will find a way to extract themselves but their dilemma is that in doing so the bureaucracy still wants to retain control. Work that one out. Maybe they are hoping to bluff ahead until there is a change of government and dump the pooh pile on the Liberals.

Anonymous said...

I'm not sure that we're at a point where a decision to change direction would make sense. Complaining about a system a few days after it's delivered, and declaring we need a change of direction, isn't reasonable nor rational - given the spend it makes sense to give it some time, as changing direction would clearly set us all back many years.

I accept that many on this blog disagree with the direction and detail of this project, but nonetheless most people here seem supportive of eHealth in general. Given that, it would be a pity to stop our best current chance for success. If, in time, it proves that you were right, then we can spend the 3 years+ to create a new project. But if we can get value from what we have, then surely it makes sense to do so.

Dr David More MB PhD FACHI said...

"Given that, it would be a pity to stop our best current chance for success. If, in time, it proves that you were right, then we can spend the 3 years+ to create a new project. But if we can get value from what we have, then surely it makes sense to do so."

This can only be the right approach if you think there is say a >20% chance of a good outcome in the end. For mine, as all who read here know, the number is less than 1%.

Surely it would be better to take a checkpoint now - decide consciously if success is realistically possible - and then act accordingly.

As you say most who read here think, done right, e-Health is a really good thing - but most seem to think we are not doing it right.

We can't wait ages for the benefits in terms of patient care and safety.


Bernard Robertson-Dunn said...

Anon said:

"Complaining about a system a few days after it's delivered ...."

Some of us "complained" in submissions re the first draft ConOp.

and "... if we can get value from what we have, then surely it makes sense to do so."

What if we can't get value and instead destroy community trust in eHealth?

For those with long memories, the fiascoes that were the Australia Card and the Access Card projects resulted in long delays in solving the problem of identifying Australian citizens in the digital age.

Getting the PCEHR wrong could have the consequence of delaying the introduction of eHealth in Australia for years.

In many failed projects, it is not the goal that is in question, just the way the goal is (or is not) achieved.

Anonymous said...

All those who travel here should take a moment to read Bernard Robertson-Dunn's parables. Although, in NEHTAs case, I don't think he has the right conclusion in the Parable of the Project. You be the judge.

Parables found here.


The parable of the Business Case
The parable of the Project

NK said...

"I don't think he has the right conclusion in the Parable of the Project". And the conclusion is:
"don't let a Project Manager anywhere near requirements. Get an architect, that’s what they do"

rofl. I can only think that he's not talking about the kind of architects I've ever worked with

Anonymous said...

I agree that many on here have objected to the approach to PCEHR from the start, and that many things about it aren't perfect. As is true of any large project in what is a very complex industry.

I'd be interested in what process people think would happen if this was shut down. A number of people here seem keen not only to criticise, which I sort of understand, but actively to wish the project to fail. I'd be interested as to what the road map looks like at that stage - whether any government would be likely to put money into eHealth again in the next 5 years.

I would have thought it more logical to focus on how to improve what we have, than to tear it down with the ambition of starting again from scratch, unless there is some viable plan to actually start again from scratch.

Dr David More MB PhD FACHI said...

@8/22/2012 12:32:00 PM

Can I say I think the perspective here is wrong. We have lots of e-Health initiatives that are working (GP Computing, Messaging, much Hospital Computing and so on). What we don't have is a Shared EHR System with a sensible scope and design that would be useful and trusted by clinicians.

We can easily keep what we have, look what is happening with some Australian and other initiatives and work out a way to do what is needed and which will also be used.

It is not rocket science but going on the way we are, without review, seems to be folly given all the issues we are now aware of in terms of utility, usability, benefit and actual adoption.

I am sure it would also turn out to be a good deal cheaper.

The bottom line is that there are real and sensible ways forward that are simply not being considered for reasons that for me, at least, are very unclear.


Anonymous said...

Why give the poeple that gave us this failure another $100m, the best indication of future performance is past performance.

We are not solving the problem and we are eroding confidence in ehealth.

I say we need to take a pause and re-evaluate, with a Project Implementation Review being front and centre for this.

Lets not make the same mistake twice!

Anonymous said...

I nominate David More to lead the project review with membership on the committee fro MSIA and NEHTA. That should be balanced and collegial

Tom Bowden said...

For those people with some earlier questions... I thought I’d chip in with a few comments for clarification.

The Care Insight system is implemented by District Health Board (DHB) region (we have 19 of those; average population served 230,000 people) and this is a good size to work with.

Hawkes Bay is a small DHB, serving only 2% of the population. It had 122 queries last week. If this system had national coverage (which I think it will before too long) then there would have been over 6,000 queries last week. That is a serious number, especially if you consider that each query is of immense benefit to a patient who is in very difficult circumstances.

The system operates from a browser-based system at the ED or after hours clinic and scans each practice and pharmacy system to find where the patient identifier shows up (this takes 3-5 seconds). It then presents a pick list of sites and invites the clinician to choose which ones he/she wants to see, the patient already having given consent to access this.
Because we have a widely used health identifier and a very large volume of direct messaging between providers, the infrastructure is there to create this kind of service.

It has been very successful and we are now installing it in all parts of the country. The cost of the service is low, with no install costs and a cost per GP site off NZ$80 and NZ$14 per pharmacy.

I think the key benefit of this approach over the PCEHR is that it goes to the authoritative source of information not an intermediate system. You know that the information is robust because the patient’s GP or pharmacy provides it – in real time so that nothing slips between the cracks.

The challenge to doing this in Australia is that the individual GP systems are not robust enough, nor available 24 hours. But these issues can be overcome and at very modest cost. I believe that this approach will prevail as the key record sharing method over the next two decades. This is a Google approach (RIP Big Iron)

Bernard Robertson-Dunn said...

NK said...

"rofl. I can only think that he's not talking about the kind of architects I've ever worked with."

Without knowing what kind of architects you've ever worked with, they sound like the sort I've had to deal with over many years especially vendor architects.

In which case I totally agree.

Designers and technology specialists who have been mislabeled as architects are not architects.

IMHO, if you are not able to challenge the problem you are not an architect. If all you do is implement a solution, you are a designer.

And as I say on my website, it's all just my opinion.

And as I've said here, show me the evidence and I'll change my mind.

Anonymous said...

Strange how perspectives differ - I've always looked upon Software Architect as a role that people migrate to when they no longer wish to implement solutions. Then the technology changes so quickly that they lose that capability.

Anonymous said...

WRT to Tom Bowden's comments - it would be interesting to know what makes the Kiwi GP and Pharmacy system more robust than the Aussie ones. My understanding is that Medtech owns the lion's share of the GP market over there - is their NZ product superior to the one sold in Australia? It must be the best designed piece of (non-trivial) software in history if it can be made robust at a 'modest cost'!

Anonymous said...

Yeah, I find the architect thing amusing. The health industry seems to have more architects per project than any other I've ever seen.

To me architects are like lawyers - if you have 3 architects in a room you've got 4 opinions. You need a good one to get anything done and keep on the straight and narrow, but I'd argue that this particular project suffers from too many architects, not too few. Sooner or later someone has to get on and actually do some work instead of just talking about it.

Tom Bowden said...

My comment about robustness is an overall observation that because New Zealand practices use their electronic medical records (EMR) ystems for communications far more than their Aussie counterparts, the NZ systems tend to be better resourced, maintained, secured, connected etc, etc. The average NZ General Practice has electronic communications with 58 other healthcare organisations in any given month. The Average in Australia is about 4. There is a big difference and it is not shrinking.

Yes we have four GP EMR sstems, yes Medtech has the largest footprint, yes it is a pretty good product by and large, it certainly does the job we ask it to.


Bernard Robertson-Dunn said...

Re Architects

IMHO, the term "architect" has been overloaded so much that it is virtually meaningless.

To give a not entirely irrelevant example, the Chief Technology Architect on the Human Service Access Card project had a Bachelor of Arts in International Relations and Politics.

The Access Card project was happening at the same time as the 70th anniversary of the opening of the Sydney Harbour Bridge.

The Chief Engineer was J.J.C Bradfield, an engineer (BEng, MEng) who also had a D.Sc. This is a higher level of qualification than a PhD.

The comparison, at least in my mind, was telling.

Someone on a major development initiative like the Access Card, the Sydney Harbour Bridge or the PCEHR should be responsible for the technical part of the project.

In the case of the Access Card it was someone with no technical qualifications at all. The Sydney Harbour Bridge was led by a highly qualified engineer. I assume everyone knows which project was successful and which wasn't.

I'd be interested to know who is responsible for the technical aspect of the PCEHR, what their qualifications and experience are and what authority do they have, wrt project managers and politicians.

It doesn't matter if they are called architect or not, it is a question of ability, experience, responsibility, and capability.

At the moment, the PCEHR looks to me like a system designed by committee.

Anonymous said...

I agree with Andy Hunt and Venkat Subramaniam, in 'Practices of an Agile Developer', Software Architects who can't, or don't, write code are of little use. Real insight comes from active coding. Similarly, developers must do design work; coders who refuse to design are effectively refusing to think.

This is one of the many key differences between software engineering (a bad term anyway, some aspects of application software development & maintenance actually has more in common with gardening!) and civil engineering where bridge designers clearly don't require physical construction skills.

As a pure design shop, populated with architects, NHETA will always struggle because it is unable to validate its own work. Applications are made of compiled source code, not design specifications and models!

NK said...

NEHTA does write code to validate some parts of the systems. But you are still all thinking of the pcEHR as a technical system, not a social/political construct