Wednesday, October 24, 2012

Transcript Of Senate Estimates Hearing - 17 October 2012 - Community Affairs Committee.

Here is the Hansard Transcript.
The Departmental Contributors are:
Ms Jane Halton - Secretary - DoHA.
Ms Huxtable - Deputy Secretary - DoHA
Mr Hallett - Role Not Listed That I Could Find
Mr Peter Fleming - CEO NEHTA
Mr Paul Madden - CIO DoHA
Senator FIERRAVANTI-WELLS: Let's do 10.2—e-Health Implementation.
Senator FIERRAVANTI-WELLS: I will start with the PCEHR, the electronic health records. Could you tell me how many people have signed up to date since 1 July?
Mr Morris : As of midnight last night, 13,340 people had signed up.
Senator FIERRAVANTI-WELLS: Does the department stand by the figure in the 2012-13 budget papers of 500,000 as the number of consumers who will register for a PCEHR? That was at page 192 of the portfolio budget statement.
Ms Huxtable : The 500,000 figure referred to the expectation that we had on the basis of international evidence and the like around the rate of consumer take-up that has been seen in other countries. A number of scenarios sit around that. The 500,000 relates to the first full year of operation. As I think we discussed at the last estimates, the PCEHR is being rolled out in a staged way. The first stage of the rollout was consumer registration, which took effect from 1 July. Then there was the staging of a provider portal, which took effect from mid-August—I think 19 August was the date. And we are gradually having software providers coming on board. A number of software providers have incorporated the PCEHR into what is called a companion tool, and there are other software providers that are well advanced in enabling connectivity. So we will see a gradual upgrading of software into GP practices. That will happen over a period of time. The first tranche of that will start from around the end of this month. The 500,000 figure was used for operational planning purposes to get a sense of where we would be heading in the first full year of operation. It needs to be read in that context.
Senator FIERRAVANTI-WELLS: Does that mean that 1.5 million, then 2.2 million and then 2.6 million in the forward years is really achievable given where we are at the moment?
Ms Huxtable : There are a number of processes that will be and have already been put in place that accompany the staging of the rollout. You would be aware that there has been clarification provided for GPs in respect of use of MBS items for their participation in the electronic health record. There have also been announcements made around the Practice Incentives Program and the expectations of practices in terms of their engagement with electronic health. These will all be drivers for adoption. As you would know, this is an opt-in system for both consumers and providers, but the expectation that we have, based on international evidence and our own experience, is that providers will be an important part of driving consumer take-up. We are very focused on the value of the participation in the PCEHR. Overall numbers is one metric but equally important is the metric around the types of people who are participating in the electronic health record. The focus of the development work has been very much around those cohorts who will benefit the most—people with chronic disease, mothers and newborns, Indigenous people, older Australians et cetera. That has been the focus and we are driving toward that.
Senator FIERRAVANTI-WELLS: So the telephone number that you call for assistance—
Ms Huxtable : To register?
Ms Huxtable : Yes, it is actually in the Department of Human Services. So there are three registration channels, one of which is a phone channel, but there is also the Medicare shopfront and the online channel.
Ms Halton : And I have to say: I am delighted that we have got 13,000. We are not even at the point of having the GP software available and yet, despite that, literally, day on day—we get the numbers everyday of how many people have registered—I open it and think, 'Goodness me'. People really want this. It is amazing. Most of those registrations are coming online.
Senator FIERRAVANTI-WELLS: Ms Halton, let me share with you my experience on 4 July.
Mr Hallett : You have tried, yes.
Senator FIERRAVANTI-WELLS: Let me tell you about my experience on 4 July. So I ring up and I spell my surname—three times. There was a problem with the hyphen—lots of problems with hyphens. So, after 20 minutes the person at the other end of the phone says, 'Can you go to a Medicare office?' I said, 'Great, terrific—I'll go off to a Medicare office to register for something online.' Ms Halton, not good enough.
Ms Huxtable : Senator, the online registration capability came into effect from 6 July, so the online channel has been opened from 6 July—
Senator FIERRAVANTI-WELLS: Does it take hyphens?
Ms Huxtable : It does.
Ms Huxtable : Yes, all of the above. And 90 per cent of registrations are coming through the online channel.
Ms Halton : Senator, I think it is important to understand here: this is a huge piece of software—softwares, lots of it. This is a huge change. This capability was stood up in the time that was actually requested of us to stand it up. Yes, there are all sorts of things that we are learning as part of this process. In fact, as we move to roll out the GP software—and my colleagues down this end of the table can talk to you about the early software we now have available to the profession. But the main bits of GP software will become available later this year. The last bit is available early next year. Essentially we are in the early phases of this. So you actually constitute an attempted early adopter. This is my point about the 13,000—we have not gone out and promoted registration to anybody.
Senator FIERRAVANTI-WELLS: Ms Halton, you qualified it by saying, 'as far as the department is concerned'. Doesn't it smack of an implementation that was rushed without properly—
Ms Halton : No.
Senator FIERRAVANTI-WELLS: Why didn't you do it properly? You wouldn't have had so many problems.
Ms Halton : No. Senator, I actually have to strongly disagree with you.
Senator FIERRAVANTI-WELLS: It has been done properly?
Ms Halton : It has been done properly.
Senator FIERRAVANTI-WELLS: How many people do you think may have tried and had a problem and may be put off—
Ms Halton : The thing we know—and it is definitely the case and we are working on this—is that there are some difficulties for people with online registration. There are some barriers in terms of what is referred to in the trade as 'useability'. My colleagues can all talk to you about that issue. My point is exactly this. Early adopters are giving us a lot of feedback about the registration process—some of the barriers, some of the issues, some of the challenges. When the GP software becomes available this is when we actually expect to see, and when we indeed expect to drive, registration. What we are doing is working through some of those issues in this early phase. And, yes, it is freely acknowledged that there are some challenges in people actually registering, and we tried to deal with some of these issues early on, with information provided on the website about what you might need to verify your identity. If you ask people along this table, they can all give you a variety of experiences about registration. Rosemary registered in about three minutes flat because she had—
Ms Huxtable : An account.
Ms Halton : an account. I did not. Everyone has got different experiences. The truth is that this is a long-term change. It was delivered, as we promised registration would be available, from1 July, and the electronic registration from the 6th. That is exactly what we promised.
Senator FIERRAVANTI-WELLS: Can I ask NEHTA: do you think this target is achievable?
Mr Fleming : Yes, it is achievable and yes, it was achieved—absolutely. As Ms Halton said, registration was available on those dates.
In terms of the software vendors that Ms Halton mentioned, we are working with four groups of software vendors at the moment. In terms of GP desktop vendors, there are nine of them; two of them are in the category of the companion tools, and the others are the traditional desktop providers. The companion tools have been built out and are operational in beta sites at the moment, and they will roll out before the end of the month to other sites. So that is a normal process.
In terms of the GP desktop vendors, who represent 98 per cent of the market, they have all built the HI system into there. They have an objective: by the 31st of this month to have the functionality of the PCEHR finalised, and they will do that. Then they have another objective for February.
In conjunction with that group, we are working with the aged-care vendors. Once again, the major vendors in that market are approximately 90 per cent of the market, and they have a series of objectives that they are working to. We will make announcements very soon about the community pharmacy vendors who are also signed up and working. The fourth group of vendors are ones that are not part of our vendor panel but are working with us for various reasons and, once again, progressing quite strongly down that path. So, yes, it is absolutely achievable.
Senator FIERRAVANTI-WELLS: How many shared health summaries have been created and uploaded to the PCEHR?
Ms Huxtable : I do not know that I know the exact number. With the companion software, there has been a shared health summary uploaded—that is correct, isn't it, someone? But it is in the very early stages, so, as Mr Fleming said, the companion tools are in use. I think there are two practices that have used those companion tools. It must have been at least a month or six weeks ago.
Mr Madden : Mid-September.
Ms Huxtable : The really important next step is when those software vendors are rolling out their desktop software, which will be starting later this month.
Senator FIERRAVANTI-WELLS: How many have been created? Do you need to take that on notice? I would have thought that that would be information Mr Fleming or somebody would have.
Ms Halton : Mr Fleming is not the operator so he will not have that information. We can get that information for you, but I just need to remind you that what we have here is actually ahead of what we were anticipating. It was not our expectation that there would be any summaries available until the GP software actually became available. The fact that we have had two software providers come out early because they are trying to get into the market is actually a bonus. We were not expecting summaries to be provided until the GP software started to roll out.
Ms Huxtable : I can tell you that 791,764 Medicare documents have been uploaded to Personally Controlled Electronic Health Records, however, as at the end of September 2012.
Senator FIERRAVANTI-WELLS: Medicare documents?
Ms Huxtable : Yes: information about MBS claims, PBS claims, organ donation registry records and immunisation records.
Senator FIERRAVANTI-WELLS: But the summaries number would be less than that?
Ms Huxtable : Yes, definitely, because, as Ms Halton and I both tried to say, we are not really at the stage—
Senator FIERRAVANTI-WELLS: I was just asking for the summaries.
Ms Huxtable : where we are getting the roll-out of software to enable the summaries to be uploaded.
Senator FIERRAVANTI-WELLS: Can you take on notice the summaries?
Ms Huxtable : Yes. Certainly the national infrastructure has the capacity to upload shared health summaries, event summaries and discharge summaries. So that functionality has been delivered.
Senator FIERRAVANTI-WELLS: Mr Fleming, now that the PCEHR has gone live, what is your focus over the next 24 months going to be?
Mr Fleming : NEHTA, as you know, is funded through two sources: the Council of Australian Governments—and within that context there was significant work to do around infrastructure-type services, the HI service, discharge referral et cetera—and, through PCEHR, the Commonwealth. We are still completing some of the COAG activities, and indeed our focus is now very much on supporting implementation. So we are working very closely with all vendors. One of the things we have built out within NEHTA is: every time we write a specification, we write sample code, build it ourselves and then make that available to vendors and help them implement. So our focus is very much now on helping the implementation of this throughout the country, whether that be with vendors or others. On the clinical side we have a group of people who are working with clinicians and those services on process re-engineering and so on, so it is very much around implementation. We are also finalising certain aspects.
We are working on medication management will flow through in the near future, for example.
Senator FIERRAVANTI-WELLS: What is the status of the National Authentication Service for Health?
Mr Fleming : As you are probably aware, we did terminate the contract with IBM. We have been working with DOHA and DHS. We have implemented a NASH solution with DHS, which is in operation and rolling out. That is progressing.
Senator FIERRAVANTI-WELLS: When will this be complete?
Mr Fleming : NASH is doing what we need now. For PCEHRS there is a second component which will support secure messaging. DHS is working with some final phases there, and they will make some announcements in the very near future. Certainly everything we need NASH to do it is capable of and it is doing.
Senator FIERRAVANTI-WELLS: Could I just give you a copy of this article. It is 'Experts brand e-health audit trail as "gobbledygook"'. Did you see that article?
Mr Fleming : I am aware of it from a little while ago.
Ms Halton : This is the infamous David More, the well-known blogger. 'E-health consultant and medico Dr David More', otherwise known as the well-known blogger.
Senator FIERRAVANTI-WELLS: You have not actually heard what my question was going to be.
Ms Halton : No. I have not seen before.
Senator FIERRAVANTI-WELLS: It is about the audit trail. Are you questioning Dr More just because he is a serial blogger?
Ms Halton : I was just reading the second paragraph, so I know can what this is about.
Senator FIERRAVANTI-WELLS: Are you saying his comments should be dismissed?
Ms Halton : I have not even got to the next part of the comment.
Senator FIERRAVANTI-WELLS: I will let you read it. That would be good.
Ms Halton : We might let the chief information and knowledge officer start talking while I read.
Mr Madden : I did see that blog some time ago. I cannot remember the exact date. Ms Halton mentioned earlier there were a range of issues around usability. We had delivered an audit log. We had expected that there would be low numbers of registrations, and the intention was to reformat and provide that information in what I will call a more user-friendly style, which has been done since. Back at that point what we had set out to do was to make sure that we were capturing all of the auditable records and the changes and the creation of things in the PCEHRS. All of the audit logs and all of those activities that have been undertaken have been recorded. How we format that and put it on a screen to make it usable has been updated to make more user-friendly.
Senator FIERRAVANTI-WELLS: If you are dismissive of Dr More's comments—he styles himself as an e-health consultant and medico, and I think he makes some pretty valid points there—over the page there are some other comments. One is by Carol Bennett. She makes the comment on page 2 of that article:
… the ability of consumers to track who had accessed their e-Health record was a "critical component" …
"For the audit to work it has to be user friendly and it currently isn't," she said.
What is your response? She also makes some other comments:
… have to make it a high priority to make the audit user friendly so it can generate confidence that consumers have the ability to have control over who accesses their record ...
What is your response to Ms Bennett?
Mr Madden : The response to Ms Bennett is that the usability and the ability for users to navigate the audit records is a priority, and we will continue to work on those usability aspects. I guess the critical aspect is that we have kept a record of every creation of record, access of record, change to record. So all of those elements of information are there. How we present them into the future to make them more useful and usable to the user will continue to be a focus for us.
Senator FIERRAVANTI-WELLS: What about the comments by the Australian Privacy Foundation in that article that the audit trail data was 'absolutely meaningless'? The quote continues: 'How the heck is a consumer expected to interpret machine addresses, that's all they've got to track their record.' And you have comments there. What is your response to those comments?
Mr Madden : Again, the feedback we got when the blog was first published was a very important set of feedback that has actually turned our focus to how we present that information in a more user-friendly style. Again, the information we have collected and will maintain is the audit trails and logs of all of the activities in the PCHR, and we are turning that into a user-friendly log that is more usable and easier for people to read.
Senator FIERRAVANTI-WELLS: Have you done that or do you have a time frame to do that?
Mr Madden : The first part of turning that into a user-friendly audit log has already occurred.
Senator FIERRAVANTI-WELLS: In relation to the glitches, I mentioned hyphens and commas. Have apostrophes been sorted out.
Ms Halton : There is no issue there.
Mr Madden : No. We only ever had issues with the apostrophes. We did not have issues with the hyphens.
Senator FIERRAVANTI-WELLS: Well, Mr Madden, I had a problem with hyphens.
Mr Madden : Okay.
Senator FIERRAVANTI-WELLS: I have a long name with a hyphen. I was told 'Can't do hyphens.' If you tell me there is no problem—
Ms Halton : I can guarantee you that you can do hyphens.
Senator FIERRAVANTI-WELLS: I might go back and try.
Ms Halton : When you try—and this is important—because of the front end, there are a series of questions you are asked that enable Medicare Australia database to confirm that you are you. We put this information on the website, but as I said there are still some useability issues about it, which is why we are not out promoting this very hard at the moment as we try to sort through those. When you try, have with you the information about the last time you went to the doctor—so, the last time you claimed a Medicare benefit. If you have that kind of information—where it was, when it was and how much it was—that will help you verify your identity to the Medicare database. It basically says that, if you know that, that is really who you are. That is a little hint.
Senator FIERRAVANTI-WELLS: I will try again. I now have questions in 10.4 and 10.5 and that will complete my questions.
CHAIR: As there are no further questions in 10.2 or NEHTA, thank you for your evidence. Are there questions on 10.3?
Senator FIERRAVANTI-WELLS: I will put those on notice.
Here is the direct link to the relevant - very long segment.
Here is the link to the offending blog on the Audit Trail.
I just had another look at the Audit Trail and it is better spaced out but I still think it just needs a ½ page description of what you are looking at. I have to say it is great that the Department is actually listening and trying to fix the more obvious issues.
I will leave it to others to reflect on the take-up rates and what it means.
As far as the claims of progress in all the various areas traversed in this rather short session I am sure readers will feel free to clarify just what is happening as far as they are seeing things on the ground.
Re: NASH Mr Fleming has told us the contract with IBM has been cancelled but what is not clear is just what has been delivered for how much, what is still to be done and who owes whom at the end of the day. We also note from the NEHTA comments that the NASH saga is still not over. It also is, of course, hardly widely implemented as yet. Another ‘time will tell’ situation I would suggest.
I also note the 'using the early users as testers' approach seems to be very much alive and well!


Anonymous said...

That's funny, I wonder why those 13000 people have registered for a record - since there is not much in any record at this point.
I reckon it is all the DOHA, Nehta, Vendor, lead sites and people working in state health systems/industry that have something to do with their work - just curious so they can see how it works. Would be nice to see how many of those 13000 work in eHealth. And how many of them are actual consumers (aged, mothers and newborns, etc).
Now I have seen it, I am looking hard for the 'opt-out' button - is there one?

Anonymous said...

"Yes. Certainly the national infrastructure has the capacity to upload shared health summaries, event summaries and discharge summaries. So that functionality has been delivered."
Well yes - but this is only one part of the interface, and the other parts are to be delivered by the vendors and DHS and implemented by health service providers. There is a long way to go yet - this next stage will be the most difficult and risky part of the system, and will need to be thoroughly tested before it goes live. The HI Service, and the NewNASH will also have to work correctly. No live testing this time I hope. It was one thing to struggle with hyphens and apostrophes when resgitering, and incorrect age calculations, but an entirely different kettle of fish to get a clinical aspect wrong. They will probably find that 'that functionality that has been delivered' in the core system will need some more delivering. This is always the case with interfaces, and especially for new interfaces, and this system has many new interfaces, between many new components. Anticipate problems with dates, sorting of records, and any view that combines data from more than one document. There are likely to be a lot of ' reject messages' coming from the core system - e.g. IHI unknown, template error, etc - and this will be a nightmare for software vendors and their sites. But yes...
" Certainly the national infrastructure has the capacity to upload shared health summaries, event summaries and discharge summaries. So that functionality has been delivered." So if it doesn't work - it must be the fault of all of you out there - not the national infrastructure!

K said...

Right, the National Infrastructure has been delivered. And clearly, DOHA didn't rush it towards the appointed date, so clearly there is and can be nothing incomplete about it. Further, the specifications were already withdrawn once to get them correct, so clearly there is nothing wrong with them either.

So DOHA can go full stream ahead scure in the knowledge that while there is a little ill-founded and crassly venal resistance to e-Health and/or the pcEHR, the design and delivery are good and right and all that remains is a little change and adoption stuff to work through.

And, of course, the fact that DOHA has adopted the user-unfriendliness of the audit trail is a priority for them to work on is *not* indicative of a micro-managed process where the project managers strain at a gnat and swallow a camel.

Anonymous said...

Live testing on vulnerable consumers with chronic disease, the aged, etc, is unconscionable.

It would be good to know how many sign-ups to the PCEHR have been assisted sign-ups and to what degree patients or the aged have put their hand up and asked for it or have been approached or coerced by others to sign up, the degree of transparency, the degree of understanding of what they were signing up to, etc.

Anonymous said...

Live testing, where it might involve risk, without informed consent, I would say is illegal. Any journalists out there paying attention?

Anonymous said...

All the good healthIT journalists have been given the flick - the news media is in turmoil as revenues spiral downwards. This means the 4th estate is no longer watching DOHA and NEHTAs stuffups - so its open slather for them with no holds barred.

Dr David More MB PhD FACHI said...

All I can say is we know Government at all levels and NEHTA read here so if you have something to say a comment or e-mail (confidential) can get the ball rolling. Additionally the specialist medical and IT press are still watching and publishing and you can expect some more mainstream coverage soon!


Anonymous said...

Well then thank goodness for the infamous serial blogger!

Anonymous said...

Dear Jane 10/25/2012 02:55:00 PM you know you shouldn't talk about David like that, it doesn't become you.

Anonymous said...

"Ms Halton : Mr Fleming is not the operator so he will not have that information. ", Mr Fleming isn't but Ms Halton is - the operator that is. So why didn't she (or her helpers) have that information and why did the question have to be taken on notice?

Anonymous said...

Yeah I would have thought there would be 3 things you would take with you to Senate estimates:
How many consumers have registered
How many providers have registered
How many shared health summaries (or any other clinical document)s have been lodged.

There can only be two reasons why you have to take it on notice: Either the NEHRS does not have the functionality to measure it! Or the answer is very embarrassing.

Anonymous said...

So why didn't she (or her helpers) have that information ...... because she is known as Teflon Jane - a master at deflecting anything where the truth might be embarrassing.

Keith said...

The questions about the number of registrations and the number of health summaries uploaded are really quite immaterial. Of course the numbers are small and will remain so while there is no medical information in the NEHRS.

One of the more significant exchanges was that concerning NASH. In response to the question "What is the status of the National Authentication Service for Health?", Mr Fleming responds "As you are probably aware, we did terminate the contract with IBM. We have been working with DOHA and DHS. We have implemented a NASH solution with DHS, which is in operation and rolling out. That is progressing." Then to the question
"When will this be complete?", he replies "NASH is doing what we need now. For PCEHRS there is a second component which will support secure messaging. DHS is working with some final phases there, and they will make some announcements in the very near future. Certainly everything we need NASH to do it is capable of and it is doing."

Notice, firstly that Mr Fleming completely ducks the questions. IBM got a $23.6M contract to build NASH, worked for 18 months and failed to deliver a product, but DOHA and DHS can conjure up a perfectly acceptable solution at short notice and presumably with little effort? Bollocks! Either NEHTA and IBM have both been monumentally incompetent or someone is not telling anything like the truth. Are we to believe that this Clayton's NASH is able to scale to satisfy the whole of Australia and all of the demands of the various cases for which NASH was specified? And do it with the standard of security and reliablilty which the system demands? Please explain Mr Fleming, Ms Halton, Mr Madden.

Also, Mr Fleming seems to believe that the PCEHR requires secure messaging. He should know, but as far as I can tell from reading the PCEHR Concept of Operations and several other docments the PCEHR does not rely on secure messaging (at least not as described in the SMD standards). As Karen Dearne usefully pointed out in one of her articles for The Australian "The PCEHR is not a communication system."