Sunday, September 01, 2013

It Is Really Hard To Follow Just What Is Being Claimed Here. It Does Not Seem As Though What Has Been Done Was Successful.

The following abstract appeared a little while ago.

Ensuring Clinical Utility and Function in a Large Scale National Project in Australia by Embedding Clinical Informatics into Design

Authors: Christopher Pearce, Cecily Macdougall, Michael Bainbridge, Jane Davidson
Pages : 28 - 32
DOI  10.3233/978-1-61499-289-9-28
Across the globe, healthcare delivery is being transformed by electronic sharing of health information. Such large scale health projects with a national focus are a challenge to design and implement. Delivering clinical outcomes in the context of policy, technical, and design environments represents a particular challenge. On July 1, 2012, Australia delivered the first stage of a personally controlled electronic health record – a national program for sharing a variety of health information between health professionals and between health professionals and consumers. As build of the system commenced, deficiencies of the traditional stakeholder consultation model were identified and replaced by a more structured approach, called clinical functional assurance. Utilising clinical scenarios linked to detailed design requirements, a team of clinicians certified clinical utility at implementation and release points.
Here is the link:
The full paper is downloadable from the same page.
The discussion I found particularly interesting.


CFA and clinical safety

As outlined in the introduction, the difference between CFA  and clinical safety needs to be emphasised, especially as  clinical safety is often assumed to encompass function.  Clinical safety within NEHTA has a wide ranging brief that  encompasses all aspects of the program, from health  identifiers, to technical document reviews. Members of the  clinical safety team were part of the CFA team, which allowed  discussions on the tradeoff between safety and utility to be  resolved and presented in a unified way. It also allowed safety  to be involved in the user interface design issues, an area often  overlooked.


The decision to conduct CFA testing was determined during  the design closure period. A worldwide search was conducted  as to how other programs were conducting clinical functional  assurance at the level we were. Significantly, there appeared  to be little literature around the concept, and contact by the  team with other large programs confirmed the absence of  similar programs. The most significant input was sourced  from the UK and its Business Impact Matrix. The use of  functional assurance was limited in many of the other  programs investigated. Most areas focused on Clinical Safety.
CFA embedded clinicians, particularly those with informatics  experience, in all aspects; detailed design work, assessing  specifications, and monitoring build. Without CFA and its
functional assurance, the experience of the PCEHR na├»ve  clinicians during User Acceptance Testing (UAT) would not  have been as worthwhile. Conducting CFA prior to UAT  minimised the risk to Go-Live. Testing the delivered system  also identified potential problems for software providers who will be designing systems to deliver into the PCEHR.
The development of the CFA by the Australian program takes  large-scale program development to a new level of assurance.  The preparation for CFA works in collaboration with clinical  leads, the business analysts, and the technical testers. The  process itself is led and conducted by clinical leads, and at the  end of the day, clinical leadership can assure that the system  delivers as intended, and patients can be reassured.


All of the authors worked on the PCEHR program during the  development and implementation, and would like to thank all  of the team involved in the PCEHR program.
----- End Quote.
As I read this the authors seem to be suggesting that they have and have applied a process called ‘Clinical Functional Assurance’ (CFA) that has resulted in a PCEHR that is working as intended.
They also point out that the came rather late to the design, build and delivery process.
My problem is that while the system may be working as intended it is not working - as far as I can tell - to meet the needs of either clinicians or patients at present so one is left wondering just what this process has delivered.
To suggest ‘clinical utility’ and function has been delivered is rather a stretch I believe.
This is rather confirmed by the recent poll of GPs conducted by Australian Doctor.

Most doctors reject e-health record system as 'white elephant'

A VAST majority of doctors continues to shun the government's $467 million e-health record system, with about 58 per cent saying they would never participate in the scheme.
Some have warned that the opt-in, personally controlled e-health system, designed as an online summary of people's health information, risks becoming a white elephant.
Patients decide who can gain access to their e-health record and it allows them to view and control information added to their record by doctors or other healthcare professionals.
Patients rely on their GPs to create shared health summaries - which include diagnoses, allergies and medications - in the system.
More than a year after its launch, doctors are still resisting using the PCEHR because of several factors such as security and privacy concerns.
Their views were reflected in survey when the members-only Australian Doctor magazine canvassed the views of its subscribers for PCEHR participation rates.
About 58 per cent of respondents said they would never take part in the scheme and will not be promoting its use to patients.
Around 29 per cent said they would be taking part but have yet to write a health summary.
Only 6 per cent have written health summaries for the PCEHR.
Seven per cent said they would not be personally taking part, but colleagues in their practice were.
Australian Doctor's online poll comprised 514 participants.
Lots more here:
The view that things have not actually worked out seems to be supported by the recent departure from NEHTA by the lead author of the paper.
What do others make of the paper?


Anonymous said...

I don't know if I should laugh or cry at how these clowns wasted tax payer money.

Should call it for what it is....

Clinical Fantasy Assurance

Anonymous said...

I have no idea what these people think they have been doing or what they think they have achieved.

Clearly they are living in a world of fantasy.

The most illuminating thing I have been able to glean from all this is the "All of the authors worked on the PCEHR program during the development and implementation".

How delusional are these people?

Anonymous said...

In short, fully comprehensively delusional!

As their track-record of undeniable failure and trail of taxpayer funded destruction unequivocally testifies...

Any ill gotten gains these fools have acquired at taxpayers expense should be fully refunded to their nearest ATO office to redeem themselves and possibly clear their consciences.

Yeah right!

Anonymous said...

Looks a lot like - we ignored NEHTA processes and quality control, ignore best practice, then near the end the clinicians and others made so much noise we made something up and published this so as to hide behind a process in place.

I wonder if they did this off their own backs or were paid by DOHA

Anonymous said...

Someone might want to ask NEHTA how much they paid Mike Bainbridge and his consulting company for his services over the last two or three years, and what value they got for their investment...

Anonymous said...

Gee another academic paper that states the bleeding obvious...we tested the functionality using what is novel or informative about that? Just a lot of words and hoohaa designed to add to the published paper tally of the authors. Probably see a few more of these yet.

Anonymous said...

When the lead author, who has been a NEHTA Clinical Design Lead for 5 years, publishes this sort of clap trap it is little wonder that NEHTA has been led into such troubled waters. Christopher Pearce joined the exit of clinical leads. It is bewildering to ponder why he put his name to such rubbish.

Anonymous said...

Really, sometimes we can get a little too parochial, dear friends.

To all those foaming at the mouth about this conference paper, may I just remind you that the paper was peer-reviewed by an international panel, and that most papers submitted to this conference did *not* pass this review stage. Typically only about 30% of submissions get to be published. So, to be accepted is quite an achievement.

So, whether we are happy with NEHTA locally or not, an international audience was interested to hear this story. We live in a world where there is a freedom to write what you think. Even if I personally disagree with some of what is in this paper, I defend to the hilt their right to have their say.

Too those who remain cranky, where was your submission to the conference outlining the failure of the current Australian approach? I'm sure a well written paper on that would also have been well received.

Anonymous said...

”Too (sic) those who remain cranky, where was your submission to the conference outlining the failure of the current Australian approach? I'm sure a well written paper on that would also have been well received. “

Anon. (9/03/2013 10:23:00 AM) is obviously a PCEHR advocate and can’t help themselves in becoming “defensive” by mistaking honest and duly warranted criticism of the PCEHR and this flaky piece of supportive “research” and disparaging the critics as angry and frothing at the mouth malcontents…

If you are such a “friend” then please provide your evidence of the PCEHR success that you so passionately advocate? No need to craft any fancy pseudo research paper and base its “authority” on claims of acceptance by any conference panel, just present your unvarnished facts here and support your argument of PCEHR success for all the community of readers here to review and scrutinise!

In addition:
• Can you provide the membership of the review panel accepting papers at the conference and including where their primary as well as direct funding sources for their conference participation originates from?

• Can you provide the number of papers submitted and rejected by the panel that were “critical” of the PCEHR within the Australian healthcare context?

• Can you provide the number of papers submitted and rejected by the panel that were “supportive” of the PCEHR within the Australian healthcare context?

It’s markedly easier to author such research drivel as that referenced by David above when you’re funded by the taxpayers’ dime and operating on the taxpayers’ time to promote the party line PCEHR bureaucratic propaganda, and don’t kid yourself that that is *NOT* the case in this instance. Others on their own dime and their own time most likely have much better and more valuable things to do. On the other hand, posting honest criticisms here on David’s BLOG site (even anonymously so the arguments can stand on their own logic and reason unencumbered by unreasonable bias and/or prejudice) has no cost other than the opportunity cost for the time to post, and isn’t subjected to any unnecessary filtering by “expert” panels of questionable authority and credibility…

For an informed contrarian view of the PCEHR and other Health-IT efforts of its ilk, good old Enrico always provides a contrarian voice of reason with great regularity, and it’s more the pity the incumbent bureaucrats continuously making misguided decisions and consistently wasting taxpayers’ money don’t pay more attention and listen to him!

Bending the eHealth benefits curve (Coiera E., Jun-13)

Anonymous said...

Actually I am not a fan of the PCEHR at all, and I don't much like the paper, but that is not the point. It is simply that we should never allow ourselves to silence people from saying things just because we disagree with them.

FYI, the conference review committee is listed here :

In line with all conferences the papers that were rejected are never named, just the aggregate statistics published.

Maybe at the next conference we can have some considered papers outlining the alternate view. Its in two years time so get scribbling!

Anonymous said...

"Its (sic) in two years time so get scribbling!"

In two years’ time, hopefully if sanity reigns the only thing authored involving the PCEHR will be:

1) It's Requiem, and;
2) Forensic Analysis Report conducted by the Federal Auditor General for how so much Taxpayers' money can be wasted for naught.

The authors can have their say and publish their papers, but open candid criticisms should never be mistaken for attempts to silence the authors.

It is the scientific method after all so I'm still unsure why you interpret legitimate criticisms of the PCEHR and this published paper as an act to silence the authors, and why you deem this a "parochial" act at that?

Authoring such content on the Taxpayers’ dime is definitely a valid criticism, especially when it touts a very questionable bureaucratic self-serving party line!

I do agree they have a right to voice their opinions, even more so when conducted on their own time and dime… But absolution from open valid criticisms is only applicable and required for intolerant (and insecure) authoritarian regimes!

DOHA and NEHTA’s behaviour and consistent petty retaliatory responses springs to mind methinks.

Back to David's original statement:

"It Does Not Seem As Though What Has Been Done Was Successful."

To determine this we need "Success Criteria" for a start (conspicuous in its absence for the PCEHR and especially this paper) and then objective measures assessed against the defined success criteria to determine and appraise any success or failure. (Note: Interesting observation that the terms “success” and “value” are not even present in the paper itself!)

One certainty for sure, this paper has failed to deliver on this count so what's the point and more importantly, what's the value in its content and publication?

Oh it was accepted by an uninformed International Panel of “experts”: Big F’n Deal!

Anonymous said...

"...more importantly, what's the value in its content and publication?"

The value is purely in the number of papers that academics must now publish to maintain their status and their pay/perks.
Publish or perish. Doesn't matter if the project or the research was a failure or was was silly. If the general topic (ehealth and EHRs) is of current interest, and the paper has some big words and sassy diagrams, then it has a good chance to be published. Yet another perverse and ineffective measure of success. (Almost as silly as the 'measures of success' for the PCEHR.)

Anonymous said...

Really, this is starting to sounds like an anti-intellectual academic bash.

" If the general topic (ehealth and EHRs) is of current interest, and the paper has some big words and sassy diagrams, then it has a good chance to be published."

You seem to have forgotten that 70% of the papers here were rejected (so the chance of being published is not "good"), and they were all on the same subject matter (e-health). So your point does not hold.

I get it - you hate the PCEHR (mostly we all do), you don't like the fact that a pro-PCEHR paper was published internationally, and so now by extension, all academia is crap by your reasoning. Except that the academic voice in Australia has been clearly warning AGAINST the current PCEHR choice since the beginning.

If its so easy to get published academically, have a go yourself.

Anonymous said...

Anon: 9/05/2013 01:52:00 PM

Looks like you may be confusing and conflating differing points of view contributed here...

As you're unable to keep track of and keep straight different arguments, Anonymously posted though they may be, you've embarked on a slithering slippery slope using inaccurate mass generalisations so it's best you carry on on your own.

Getting Published is not the toughest challenge or the most valid method to claim any academic authority, but creating something unique, insightful and of great value to the wider community is, which this paper fails on all counts.

Citation counts are usually a common proxy of academic value and authority, so it will be interesting to see over time how "little" this paper is authentically cited!