Here Is A Considered And Very Useful View Of the NEHRS (PCEHR) And Its Problems.

I came across this in Pulse+IT a few days ago and Emma Hossack (the author) has told me she is happy if I re-publish her ideas here on this blog.

Over to Emma.

MSIA: The eHealth paradigm and the PCEHR

Written by Emma Hossack on 18 May 2012.

This article first appeared in the May 2012 edition of Pulse+IT Magazine.

The 2008 National eHealth Strategy set out a number of noble aims that were supported by industry and government alike. Industry confidence was at a high when then-Health Minister Nicola Roxon outlined her plans for a national eHealth system. Things have not progressed according to the plan, however, and there are a number of lessons that we can all learn to ensure this doesn’t happen again.

“A healthy population underpins strong economic growth and community prosperity. Australians therefore have a strong incentive to ensure that our health system is operating efficiently and effectively, and continues to deliver a high standard of care that aligns with both community and individual priorities[1]. One of the ways to realise this is through eHealth. The benefits of eHealth are clear[2] and Australia’s current health expenditure is not sustainable if it remains on the current trajectory[3]. Consultations and reports on the need for eHealth in Australia have been persistent and bipartisan since 1994 and many have been calling for an end to all the talk, and for eHealth to begin with more than unsustainable pilot programs.

So why is there so much controversy about the federal government’s $467 million spend on eHealth reform[5]? And just why is it so heavily focused upon the PCEHR? The implementation of any new national system is a huge challenge, and can expect to attract controversy. In the field of health it affects everyone — so opinions abound. At present there is politically fuelled criticism, concern about how well it will serve the Australian health consumer[6], and trepidation about whether the personally controlled electronic health record will be useful, privacy compliant, secure[7], safe[8] or efficient[9].

Probably of greatest concern of all is the theme which eschews all these as unnecessary worries — because, this line of thought goes, there is not any real likelihood that the PCEHR will be used once the pilot sites have achieved the various goals including Healthcare Identifier matching (an interesting imperative in itself).

Yet despite all of this debate, there is an overarching air of genuine optimism in the Medical Software Industry Association about the underlying rationale for the current investment, evincing as it does a clear recognition of the value of eHealth solutions working today, and the willingness of the government to invest in eHealth and reap the benefits of interoperability.

eHealth is a noble cause as health is the most significant barometer of a country’s success. It is also Byzantine in its complexity, which means it captivates a unique array of players, all sharing a desire to see eHealth benefits maximised. As one of the consumer stakeholders has aptly pointed out, eHealth, unlike banking and almost every other industry, is an arena where many systems must communicate seamlessly with many other disparate systems for it to work[10] in the multi-tiered, distributed eHealth space. This is not your average bunch of vendors.

At the April 2012 MSIA CEO Forum[11] one of the most persistent themes was the participants’ pride in the success of eHealth projects with which they were involved in with their clients, inside and outside the current government spending initiatives, and beneficence — the desire to promote the clinical benefits which resulted from the use of information — not simply the technical prowess of the software solutions[12]. Consequently, there is naturally disappointment when things have not gone to plan and a keen desire to help get things back on track[13]. It is in this context that some observations will be made on the comparison between what Australians will have on 1 July 2012, and more importantly, what was promised.

The path to success is rarely swift and straight as indicated by the recent Parliamentary Library paper ‘The ehealth revolution — easier said than done’[14] which provides a useful summary of Australia’s eHealth over the last decade.

The much lauded Deloitte eHealth strategy 2008 was supported both by the National Health and Hospital Reform Commission and the federal government. Apparently it still is — at least in speeches. It proposed that the eHealth reform should:

• Be a 10-year journey.
• Build on the success of existing eHealth solutions.
• Not be prescriptive but focus on strong infrastructure and where possible robust international standards.
• Be sustainable. Provide incentives for clinicians to take up the eHealth solutions.
• Have a strong and transparent governance framework to ensure confidence of the industry, clinicians, consumer and governing bodies[15].

The NHHRC endorsed this. It went further in Recommendation 123, which stated that the government should not design, buy or implement eHealth systems. The government endorsed the report, which augured well for Australia. Minister Roxon added to the confidence felt by industry and stakeholders generally when in her launch of the eHealth “revolution” on 30 November 2010[16] she announced that $467m would be spent on “major infrastructure” for a PCEHR[17], and, significantly, she stated:

“We’re getting on to deliver the next steps which will result in empowering patients, linking vital information to make doctors and nurses lives easier. We’re doing this based on the hard work already achieved, not trying to build a one-size-fits-all system from scratch. Let me take you through some examples.”

Whereupon the minister described the first three “Wave” sites of Brisbane North, Melbourne East and Hunter Valley. GPpartners in particular was singled out as “an Australian leader in eHealth for many years”. The sites were tasked to deploy and test eHealth infrastructure and standards, provide evidence-based results, influence change management processes and inform the process for implementations elsewhere. The message on governance was strong: DoHA was to assume ultimate oversight of the project and NEHTA was its contractor to develop and to deliver infrastructure.

“We want the best available expertise and experience so there will be an open approach to the market for key elements of the program. I can confirm to you all that this Government is not looking to run the whole system. Our job is to contract partners to build the infrastructure and the linkages and to set the standards and regulations. It will not be our job to deliver all of the technological advances — that’s what we’re looking for from the innovators in industry.”[18]

In essence we were told that the reform would follow the Deloitte eHealth strategy. However, even on 30 November 2010 the first three Wave sites had been chosen and funded without an open tender process. Tragically for Australian taxpayers, there was no governance around how they would procure eHealth services or manage conflict of interest — be it to continue with existing suppliers following an open tender process, or instead resolve to make an internal selection and start building something new[19]. The appropriate governance emphasised by the minister, and later embedded in the PCEHR Concept of Operations, had been ignored and raised questions about the transparency of NEHTA as manager of the procurement process.

The industry and specifically providers of robust solutions should probably have banged their drums louder about this sleight of hand. This may have prevented unnecessary cost to the Australian taxpayer by trying to reinvent the wheel rather than using, extending and upgrading current systems.

For example, Ms Roxon was shown the HRX system in July 2010 by Dr Richard Kidd, director of GPpartners, just one month before she awarded funding for the Wave 1 sites. A press release[20] issued on the day of the visit stated:

Dr Kidd said he was grateful Ms Roxon had the opportunity to view the HRX first hand as it was necessary at this stage in the health reform process that the government was kept fully informed regarding the system’s extensive capabilities.

“GPpartners is confident that the HRX already provides an effective solution to some of the difficulties health providers face with regard to the sharing of patient medical information across multi-sector, multi-disciplinary care environments,” Dr Kidd said.

The speed of testing for the infrastructure could have been faster, and a more effective use of funds could be made on change management and not software development which the minister had specifically eschewed previously. Sadly, this was a wasted opportunity to get some solid and valuable results for the promotion of eHealth to Australians. It behoves the industry to ensure that in future the funding bodies are crystal clear on the facts relating to procurement of technology so that the taxpayer gets value for money. Fortunately the second Wave projects followed clear procurement guidelines and whilst there were only nine ‘winners’, the procurement methods were appropriate and there was no concern about probity.

The decision to put out tenders for GP clinical information systems was possibly limited. In the health market there and numerous GP desktop systems; some clearly have a market share and others provide more specific needs, such as those for indigenous health practices. As recognised by the RACGP and MSIA in 1995:

Standards in general practice information management contribute significantly to a better practitioner working environment [and] better or more accessible information pertaining to patients and their health problems. [Standards] will work to ensure that components will work appropriately, will work in concert with one another where appropriate, and will perform tasks according to a level of efficiency and reliability that is of assistance and utility to the general practitioner as an individual and the general practice community as a whole[21].

A standard application programming interface (API) requirement for all clinical systems would create immediate value for interoperability. Where these are not provided, there are serious risks that data will not be shared, or will be extracted or uploaded without both parties’ co-operation to ensure that changes and upgrades do not compromise the doctor’s record and thus patient safety where the data is used to inform decisions. The concerns relating to this practice are documented[22].

If instead of selecting a vendor panel, an invitation to apply had been released for the creation or enhancement of APIs for a myriad of other valuable applications, this could have resulted in Australia taking a huge leap ahead in both interoperability, and importantly, realisation of clinical benefits. As it stands, the duplication by many vendors of interfaces to the same system, usually paid for with government funds, create no value after the first interface has been developed — just waste and lack of conformity. Safety risks too, are avoidable. The danger to the market place should not be overlooked either — if your clinical system was not one of the ‘winners’ does that impact on prospective markets?

In the period after the Deloitte eHealth strategy, the NHHRC report and the Wave bids, the Shared Electronic Health Record concept seemed to undergo a metamorphosis into an IEHR, PCEHR and now a National Electronic Health Record System (NEHRS). This is not in line with the broader objectives of an eHealth paradigm or successful overseas experience. Indeed, it was not what the minister signed up for in her very specific 30 November 2010 speech. It can only be assumed that someone else with a Svengalian skill of transformation had quite a different vision, or simply wanted to transplant a system built for a different market and population into Australia.

This created a bewildering and unnecessarily complex national architecture suited specifically to large-one-size fits-all system. It also created quite a different and unexpected role for NEHTA which became deeply involved in the very activities which the NHHRC warned should not be in the government’s remit[23]. The PCEHR Concept of Operations extended some of the original goals beyond recognition and whilst recognising value in the federated conformant repository model[24], the clear mandate of the National Infrastructure Partner was to build a one-size-fits all system, or bring it from overseas, irrespective of well-documented evidence that nowhere else in the world had experienced success this way[25].

However, this work is not easy or necessarily useful, as we know from the UK experience, which had many of the same players. In 2005 the British Medical Journal printed a case study by Sheila Teasdale on the failed early implementation of Kaiser Permanente in Hawaii[26]. The report was written in the vain hope that the English National Programme for IT would learn from these mistakes; namely, to quote Professor Trisha Greenhalgh’s advice to government following her study of the failed UK exercise:

• There is no ‘tipping point’ for big IT.
• Don’t try to build systems or write standards.
• Don’t throw money before you’ve sussed the complexity.
• Don’t equate knowledge with what is passed up the line.
• Don’t impose political milestones.

In Australia, now that the 10-year plan proposed by Deloitte has been compressed into 18 months, we have witnessed the inevitable pressure which has resulted in ‘pauses’[27] and questions being raised by a Senate inquiry[28]. Not surprisingly, there has also been a clear campaign to reduce public expectations to little more than a patient sign-in to an empty national database. The medical software industry has been providing healthcare solutions for decades, long before the current PCEHR program, and the HealthConnect one before that. There is no doubt that it will continue to do so. However, it is worth reflecting that if the government is going to spend on eHealth again in the future, it would be great if the medical software industry could be empowered to:

• Build for real needs not political aspirations.
• Use local development for local communities.
• Listen to the healthcare providers, privacy practitioners and software industry to support what is working and build on that to get some concrete health improvements.

Starting the eHealth reform was a bold move and without doubt a well-intentioned one which should be commended. The plan was good, but not followed. The criticism has been public, but at least it has kicked off the requisite debate and public education. The industry remains optimistic that once the political imperatives are removed, the stakeholders’ desires for systems to be useful rather than useless, extensible not expedient and provided amidst a transparent framework, then greater focus can be given to the improved health outcomes possible with the many eHealth tools. Next time around we will surely be given the chance to get a lot more of it right — and from a lot less — and maybe even see some of the magic in it[29].

Author Details

Emma Hossack
B.A. (Hons) Melb, LLB (Melb), L.L.M
Committee member: MSIA
ehossack@extensia.com.au

In addition to being a Medical Software Industry Association committee member, Emma has been CEO of Extensia for several years following her life as a corporate lawyer. Emma is currently vice president of the International Association of Privacy Professionals and is a regular speaker on privacy.

Competing Interests

Emma Hossack is CEO of Extensia, a medical software development company. One of Extensia’s principal products is RecordPoint, a shared electronic health record.

The full article (with references etc. ) is here:

http://www.pulseitmagazine.com.au/index.php?option=com_content&view=article&id=999:msia-the-ehealth-paradigm-and-the-pcehr&catid=16:australian-ehealth&Itemid=327

I really have nothing to add - other than to point out that had the 2008 National E-Health Strategy actually been funded and implemented I suspect the rather dysfunctional mess we now have might have been avoided - at least to a large extent and we would not - at the same time - have done so much damage to the small Australian Health IT vendors.

David.

The Numbers Never Lie. The Federal Commitment To E-Health Seems To Be Weakening.

----- The Following is A Draft Article For a Print Magazine - Comments welcome.

In mid May 2012 we had the most recent Federal Budget released. Along with seeing just how the promised surplus was to be achieved, not surprisingly, my main interest was to see what had been done with e-Health Funding over the next financial and the three out years.

To get a full picture of what is being planned there are a couple of ways it is important to view the announcement(s).

first consider, in isolation what has been announced for the next financial year. Here is the specific e-Health funding for 2013/13 from the Ministerial Press Release:

“eHealth spending in the 2012-13 Budget comprises –

• $161.6 million to operate the Personally Controlled Electronic Health Record (PCEHR) system for the next two years, including registration and customer support, adoption support and benefits monitoring and evaluation;
• $4.6 million to maintain safeguards for privacy-related aspects of the PCHER system. This will mean that people can be confident that the privacy of their personal health information is fully protected; and 
• $67.4 million as the Commonwealth’s share of joint funding with the states and territories for the National E-Health Transition Authority (NEHTA) work program for the next two years. This is to operate and maintain critical services and standards for the secure electronic exchange of health information, including healthcare identifiers, authentication services and eHealth standards.”

This $233.6 million follows the $466.7 million over the previous two years. Interestingly, of the new $233.6 million the cash flow is actually spread over three years.

2011/12 (Present year) $ 33.4 million

2012/13 (Next Year) $ 79.2 million

2013/14 (Year After) $121.0 million

As far as can be determined the specific PCEHR spend is an additional $33.4 million for the year to June 30, 2012 and then a total of $166.2 million for the next 2 years after that. The other $67.4 is spent on NEHTA over two years bring its annual budget to approximately that figure allowing that the funds are spread equally over the two forward years (This is well down from the 2 previous years)

A few other points from the Budget Papers and announcements subsequent that are worth making are:

1. That to date the investments in consumer and practitioner education, GP and specialist software, call-centres and so on which will be needed to actually implement the PCEHR have been very small indeed and indeed pretty late coming.

2. A review of the full 4 year e-Health Program as now budgeted shows that about $20 million has been cut from the 4 year program with major cuts in the Telehealth program in the later years.

3. Yet again there has only been two years of funding committed for both NEHTA and the PCEHR program rather than the traditional 4 years window for continuing programs.

4. Oddly two weeks after the 2012/13 Budget was announced we have had another $50 million added to the e-Health domain.

In summary and to quote the release “Health Minister Tanya Plibersek has announced $50 million over two years will be made available to Medicare Locals – networks that support frontline health providers – to assist GPs and other health care providers to adopt and use the Australian Government’s new eHealth records system.”

You really have to wonder why this was not included in the Budget?

5. The operational expenditure for the PCEHR and Health Identifier Service have disappeared into the huge bucket for funds ($4 billion +) supporting Medicare Australia and are not dissected as far as I can see.

6. The targeted adoption of the use of the PCEHR appears to be only 25-30% of the population after five years which seems very low. Only the first two years of the program are supported in a budgetary sense so it is hard to know what will happen after that.

7. Despite the apparently rather low adoption targets the Ministerial Press Release announcing the e-Health Budget claims the Government strongly supports e-Health because it will deliver $11.5 billion of savings over 15 years - but then says the supporting evidence for this claim has been used for Cabinet Discussions and so cannot be revealed. A big call I would suggest!

8. In another part of the Budget (under Outcome 10.5.3) there has been a change to the requirements for Practice Incentive Payments (PIP) related to e-Health which imposes quite a high technical barrier to the continuing receipt of these quite significant payments (up to $50,000 p.a. per practice). The AMA and the RACGP have expressed ‘concern’ about this change in the requirements and are clearly not happy.

For those who have an interest in the topic area there is also a very recently published review of this topic which has been prepared by Dr Rhonda Jolly of the Parliamentary Library. This review may be found here:

http://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/pubs/rp/BudgetReview201213/Ehealth

Overall I would describe the Budget as an incoherent and fragmented mess lacking any strategic vision or integrated approach to reaching the goals we all broadly support. e-Health deserves much better leadership and governance than is presently evident.

Enough on the Budget and to follow up on the article from the last quarter’s issue I can now confidently assert that when the PCEHR launches (on July 1, 2012) it will actually be a PC-LES (a Personally Controlled Largely Empty Shell - Jenny O’Neill MSIA.) for which consumers will be able to register and then wait for some useful functionality to be provided at some point in the (distant) future.

All I can suggest at this point is that people keep a watchful eye on the PCEHR Program and consider registering to use it when it is clear there is some value to be had from spending the time to do it. That time may be a good way off.

----- End Draft

David.

Here Are Two Speeches You Really Must Read and Think About. Shows You Where The Battlelines Are.

The Committee for the Economic Development of Australia had a ½ day session recently (May 16, 2012). Here are the speakers:

PROGRAM OUTLINE

Keynote address:
The Hon Tanya Plibersek
Federal Minister for Health

Session 1 - Policy and progress: the road to health reform

• Dr Steve Hambleton
  President, Australian Medical Association
• Elizabeth Savage
  Professor of Health Economics, University of Technology Sydney
• Pam Williams
  Director - Policy Coordination and Projects, Department of Health (Victoria)

Session 2 - Health and Productivity: Gains for the workplace and society

• Allan Fels AO
  Chairman, National Mental Health Commission
• Emma Hossack
  Chief Executive Officer, Extensia
• Wayne Kayler-Thompson
  Ambassador, Workhealth

Here is the link:

http://ceda.com.au/events/eventdetails/2012/05/v120516?EventCode=V120516

As it was there was a lot of discussion of e-Health.

Here is the full transcript of what the Health Minister said (important in the light of the benefit claims):

THE HON TANYA PLIBERSEK MP

Minister for Health

SPEECH

Committee For Economic Development of Australia

16 May 2012

E&OE

Thank you for inviting me to be with you this morning.

I acknowledge the traditional owners of this land, the people of the Kulin nation and pay my respects to their elders past and present.

I’d also like to acknowledge the CEO of CEDA, The Honourable Professor Stephen Martin, and all CEDA members who’ve joined us here today.

CEDA plays an important part in advancing the national conversation on economic and social policy. Having a strong contest of policy ideas is central to my approach to the health portfolio, and I thank CEDA for its role in promoting informed, thoughtful debate.

I was very pleased to have been asked to speak with you today about eHealth. It’s a priority for me as Health Minister, and for the Government.

Australia’s health challenge

Like many developed nations, Australia is ageing.

Forty years ago, about 8 per cent of Australians were aged 65 and over. Today, it stands at about 14 per cent (Australian Government Department of the Treasury. Australia's Demographic Challenges. Appendix – the economic implications of an ageing population. Accessed 14.5.12. http://demographics.treasury.gov.au/content/_download/australias_demographic_challenges/html/adc-04.asp).

By 2040, this is projected to double to around a quarter of our entire population.

Of course, this is good news. More Australians are living longer. It means our medical treatments are better and we’re making healthier lifestyle choices.

But the trend is putting ever-increasing pressure on the public purse.

This is compounded by an increase in chronic and complex conditions like dementia, cancer, and diabetes – as well as the rising cost of new treatments.

If we don’t act to help ease this pressure, over time the cost of healthcare will become too much for taxpayers. If we don’t move to a more sustainable model, some estimate that within 30 years healthcare spending will outstrip the total revenue collected by all state and local governments (Australian Government Department of Health and Ageing. National Health Reform progress and delivery (p.1) DoHA. Canberra, September 2011).

Making the most of the health dollar

This means more than ever before, we have to make the most of every precious health dollar.

We must be guided by the evidence and invest wisely.

We must find efficiencies and return the benefits to patients.

And that’s what we’ve done in this Budget.

Where the evidence said things weren’t working, the Government’s done things differently.

We’ve made sensible saves to fund smart policy.

It’s how, in the face of tough economic circumstances, we’ve been able to deliver both a surplus and a reforming health Budget…

- a Budget that’s delivered dental care to those Australians who need it most…

- that’s delivered bowel screening to help detect cancer early…

- and that’s delivered $233 million for the next instalment of the Government’s eHealth program.

The case for eHealth

The case for the Government’s eHealth program is a strong one. That’s why we’re continuing our investment.

eHealth has helped computerise our paper based medical records system.

It has helped healthcare professionals, clinics, hospitals to communicate electronically with their patients, and with each other.

And now the Government’s national eHealth records system is drawing all those threads together.

It will be the cornerstone of the eHealth system in Australia.

It will mean a patient’s medical information is available in one place. Available online, wherever and whenever it’s needed - which is a particular benefit given how mobile we Australians are. We spent 262 million nights away from home in the year ending September 2011 (Travel by Australians ¡V September 2011 Quarterly results of the National Visitor Survey, Tourism Research Australia, Canberra. 2011.)

The national eHealth records system will mean better, more efficient, more convenient healthcare. And the benefits will flow to patients, healthcare professionals, and to government.

You may be surprised that in any one week, one in three Australian GPs see a patient for whom they have no current information. More than one in five GPs face this situation every day (Australian Government Department of Health and Ageing. The readiness of Australian general practitioners for the eHealth record. Unpublished. 2011.).

We know that about two to three per cent of all Australian hospital admissions are medication-related. This represents about 190,000 hospital admissions each year, costing $660 million of which about 15,000 are due to inadequate patient information (Roughead, EE & Semple, SJ. Medication safety in acute care in Australia: where are we now? Part 1 : a review of the extent and causes of medication problems 2002-2008. Australia and New Zealand Health Policy 6:18, 11 August 2009.)

For patients over 75, up to 30 per cent of admissions are known to be medication-related, with up to three quarters of these potentially preventable (Runciman, WB, Roughead, EE, Semple, SJ & Adams, RJ. Adverse drug events and medication errors in Australia. International Journal for Quality in Health Care;15(1):i49-i59. International Society for Quality in Health Care & Oxford University Press. Boston, Mass., December 2003)..

For example, I recently heard the story of an elderly man who collapsed in a shopping centre. He collapsed from a perfectly preventable interaction between medicines. The incident occurred after the man’s GP, and his specialist, changed his medication independently of each other ¡X without knowing what the other had done.

With eHealth, stories like these should be a thing of the past. Doctors will have access to a patient’s medical information at the click of a button, including medication.

eHealth will also spell the end for the duplication of things like blood tests. One study I’ve seen showed more than 7% of all tests ordered in a hospital’s immunology lab were unnecessary duplicates (Huissoon, AP & Carlton, SA. Unnecessary repeat requesting of tests in a university teaching hospital immunology laboratory: an audit [letter]. Journal of Clinical Pathology 2002;55:78. 2002).

In our diabetes pilot in Queensland, the Hope Island Medical Centre showed me how GPs using eHealth will keep track of, and prompt, visits to allied health professionals like podiatrists and dieticians for their diabetic patients.

eHealth will also mean:

 - better co-ordinated care for patients with chronic or complex illnesses; and

- less of a need for patients to retell their story every time they see a healthcare professional.

And eventually eHealth also will work together with telehealth technology.

For people with diabetes this could one day mean blood sugar levels read from home, sent to the doctor, and uploaded straight to an eHealth record.

As benefits like these are realised over time, we estimate eHealth will save the federal government around $11 billion over 15 years (Deloitte, The national PCEHR system: relationship to the 2010 national IEHR business case, unpublished, Version 0.19, 22 June 2011)

That’s a long-term return of $11 billion for a government investment which includes around $465 million over the last two years, and another $233 million in the next two.

However you look at it, that’s pretty good bang for your buck.

eHealth: a journey

But the eHealth journey isn’t one that’ll be complete overnight. It’s not just a matter of ‘flick a switch’ and away you go.

During the last two years, the Government’s been building the foundations for the national eHealth records system. And progress has been strong.

We’ve been working hard to build the essential digital infrastructure – the virtual poles and wires for the national eHealth records system.

It will ‘join the dots’ — connecting up our medical records, and connecting the computers of our hospitals, GPs, specialists and allied health professionals to each other.

And the foundations for this will be ready on 1 July this year.

Over the last two years, the Government has also provided more than $160 million to general practices across Australia (up to $50,000 per practice) to upgrade their computer systems for eHealth.

Government support has helped more than 96% of Australian practices to get the IT they need for eHealth – more than two times better than practices in the United States. That makes our GP workforce the fifth most computerised in the world The Commonwealth Fund. Why not the best? The Commonwealth Fund Commission on a high performance health sector. October 2011. p.50..

Now many practices have most of the IT in place, we want to make sure government focuses its investment on the roll-out and take up of the eHealth record.

We've supported GPs to develop their IT systems. And from next year, by raising the bar for incentive payments, we'll encourage them to offer eHealth to their patients through the eHealth record.

Already we’re seeing around 70% of community pharmacies now using ePrescribing. One prescription exchange service reported 4.2 million prescriptions dispensed in the week before last Christmas alone.

Once the digital infrastructure is in place from 1 July, patients will be able to register for their own eHealth record through Medicare shopfronts and over the phone. And mums and dads will be able to register for their kids.

When they’re registered, patients will be able to go online to view their record and add a range of their basic health information. This will include things like emergency contact details, the location of advanced care directives, allergies, and medication.

Patients will also be able to create their own private ‘diary’ area of the eHealth record, where they can enter their own notes.

We’ve always said the rollout of the national eHealth system would be in gradual, carefully managed phases. That is the sensible, responsible way to deliver the reform.

Over time, as patients and doctors register, more detailed and sophisticated features will be available as part of an eHealth record.

Eventually things like immunisation records, Medicare and pharmaceutical benefits information, organ donation details, and hospital discharge papers will be able to be added.

And healthcare professionals will start to integrate patient eHealth records with the software they use in their practices. That way they’ll easily be able to add new information to a patient’s record.

As many of you would know, the Northern Territory introduced a form of eHealth records a few years ago.

What that example shows us is that take up tends to be slow in the first couple of years. But, as the system matures, take up starts to grow exponentially. We would expect that to be the case for the national eHealth records system too.

Looking to the future – the role for government in eHealth

As we move forward with our eHealth agenda it makes sense that we regularly reassess the appropriate role for government.

Back in 2008, the National eHealth Strategy suggested the best role for government was to stimulate investment in high priority computer systems and tools.

In a general sense, I think that holds true still. But what that means in practice is beginning to shift as eHealth in Australia evolves.

Since day one, we have called on expertise from the private sector to build the foundations for eHealth, to develop a common electronic language, and new software for GPs.

To date, this is work that’s largely been driven by government. And so it should have been. Investing in foundations, building infrastructure for the benefit of the whole nation – that’s the kind of work government is uniquely placed to lead.

But as we bed down the core infrastructure, I believe we need to turn our minds to how government can help unleash the creativity and inventiveness of the private and not-for-profit sectors.

As long as the strict security and privacy regime is maintained, we should work to make it easy for private providers and NGOs to offer eHealth related services to health professionals and patients.

I am particularly excited about the potential for some seriously interesting innovation in the consumer applications space.

As I’m sure you all know the recent growth in the number and functionality of apps has been staggering.

Google has reported 300% growth in the number of apps available in its online store in just one year – from 150,000 to 450,000 (ComputerWorld UK, March 2012).

And several different sources show that healthcare apps already make up approximately 4% of the overall active apps market Mobilewalla.com, May 2012 (Active apps are those that have been recently downloaded).

A few years ago we couldn’t have even imagined some of the incredible apps we enjoy today – apps that turn phones into metal detectors, apps that can tell you the name of a song just by listening…and the list goes on!

If we can partner with industry to create the right environment, eHealth has the potential to act as an innovation hub for app designers.

And I trust if we get it right, that many talented designers out there will create new, revolutionary eHealth apps.

These tools, working together with the Government’s national eHealth records system, will allow patients to keep track of their own health better than ever before.

Conclusion

eHealth is a great example of how the Government is working to get the best value from each health dollar.

We’re investing in eHealth because the evidence stack ups.

---- End Speech

Here is the link:

http://www.health.gov.au/internet/ministers/publishing.nsf/Content/23EC1FAE627A2282CA257A00000F673C/$File/TP044.pdf

Also speaking was the AMA President:

Dr Hambleton speech to CEDA on health reform

16 May 2012 - 11:15am

Speech: AMA President, Dr Steve Hambleton

TO THE COMMITTEE FOR ECONOMIC DEVELOPMENT OF AUSTRALIA (CEDA), MELBOURNE, WEDNESDAY 16 MAY 2012

Health reform – from ‘big bang to a whimper’

Just a few short years ago, we were in the middle of what was being called the biggest reform of the Australian health system since Medicare.

There was excitement in the air.

And, of course, there was caution and concern and consultation … lots and lots of consultation.

There was a mood for change, but change to ‘what’ and ‘how’?

Like most groups in the health sector, the AMA was supportive of ‘big bang’ reform, just as long as it was the right ‘big bang’ reform.

A lot of the plans – many of which had been recommended by the National Health and Hospitals Reform Commission – had the conditional support of the AMA.

We were firmly engaged in the reform process.

We supported the idea of a single funder, the end of the blame game, greater responsibility and accountability, enhanced safety and quality, less waste, and a guarantee of clinical input to decision making.

Then political circumstances changed and political courage fell away.

The unique ‘once in a generation opportunity’ for genuine health reform fell away.

State Governments changed complexion and COAG became a battleground once again.

The Government changed leaders and faced a tough election with the polls working against it.

And then we had minority Government … and chaos.

The ‘big bang’ became a ‘small bang’ and then all we had left was a sparkler.

To be fair, the Government has pushed through some pieces of the original health reform big picture.

There are Medicare Locals and Local Hospital Networks, a Pricing Authority, a Performance Authority, a Safety and Quality body, and a national funding pool.

The AMA likes some bits, dislikes other bits, and is seeking changes where there is insufficient input or management from doctors.

It will be some time before these changes are fully bedded down, and even longer before we know the impact on patients and communities.

But, in a difficult and dramatically altered political environment, we must be thankful for some change.

So where does that leave us?

Realistically, the biggest element of health reform now confronting us is electronic health, with the biggest headline item being the Personally Controlled Electronic Health Record – the PCEHR.

I want to concentrate on e-health today.  It is the health reform ‘news’.

As a busy general practitioner, I am personally always interested in improving productivity in health care. 

A key productivity tool in health is the electronic health record.  While it will take longer in general practice, it should save both time and lives in the rest of the health system.

The PCEHR – due to commence implementation from 1 July this year - holds the promise of reducing adverse events and reducing duplication of treatment.

Most AMA members are enthusiastic about the shared electronic health record vision.  They know that, with the right system, they can improve the patient healthcare experience. 

And hopefully save themselves some time in quickly and accurately understanding the nature of the patient’s problem based on ready access to reliable health information.

The right sort of shared record system will help doctors deliver better care. 

They will have important information about their patients to help them make good clinical decisions.

We know that if we just share an accurate medication list, lives will be saved.  Some of my elderly patients can only tell me the colour and size of their tablets. 

These days it is very important to know whether those little blue pills they take at night are round or diamond shaped.  One makes the heart stronger, the other might wear the heart out.

With new patients to the practice it often takes quite a while to work out that medication list.  Often there is no choice but to phone the last pharmacy to piece the information together.

With a properly constructed e-health record, I could confirm my assumptions by reading the medication prescribed by the last doctor.  Or even see what has been dispensed by the last pharmacy.

This would be an improvement over the current situation, and would save time.

A good system will save extra costs for duplicate tests when the originals can't be found or retrieving them would take too long.  Treatment can happen more quickly and better decisions can be made.

The proposed system could be improved to make it much more useful to treating doctors.  A past AMA President, Dr Mukesh Haikerwal, has tried to facilitate this through NEHTA by engaging Clinical Leads.  They need to be listened to.

The introduction for this forum today notes the importance of getting the technological landscape right for e-health. I agree.

But today I also want to point out that introducing technology reform needs the right policy setting.

It needs an e-health policy environment that recognises that health care providers are keen to implement e-health for their patients – but only in a ‘light touch’ regulatory environment.

If the burden looks too great in time, cost and resources needed for the task, very few will adopt the new system.

The reality of patients having to opt-in means that, when doctors look for a patient’s record, they will often find there isn’t one. 

The PCEHR has been designed from an ideological point of view. 

Patients will decide if they want one. But there is no information about what the opt-in rate will be.  We might have fast take-up by patients, or it might be very slow.

In the meantime, in clinical practice there are only so many times that doctors are going to stop and look to see if their patient has opted in and given them access to their PCEHR.

If doctors were to find that most of their patients had a PCEHR, they would be more likely to keep using the system.  We hope that the opt-in feature proves successful. 

We know that, from 1 July, patients will be able to register for their PCEHR.

Just last week the Government launched the e-health.gov.au website.  Through that website, the Government is encouraging patients to register an interest in having a PCEHR.

But there is still much work to be done to roll the system out to hospitals and general practices.

There is still uncertainty about when and how well the system will be connected to health care providers.  There is a lot of technical work being done behind the scenes. 

And there is still a long way to go until we have appropriate, interoperable, tested, and affordable practice software to connect doctors and nurses to the system.  Every practice will need an upgrade.

At this stage, the Government strategy appears to be a ‘build it and they will come’ approach to supporting healthcare providers like me to tool up to use the PCEHR.

As announced in last week’s Budget, the Government will require general practices like mine to participate in the PCEHR in order to attract e-health practice incentive payments.

The Government is going to force us to make an investment in terms of redesigning our practices’ processes to integrate a system that, at this stage, we have relatively little information about.  This is a ‘stick’ to encourage us to do more for the same reward.

There is plenty of commentary recognising that general practice will have to make the most investment in the PCEHR both in time and money and will realise the least amount of benefit from it – and that is a real concern for us.

It will be interesting to see how non-GP specialist medical practices warm to the PCEHR without any incentives at all.

The legislation underpinning the PCEHR carries a lot of new obligations for medical practices, hospitals and other organisations providing health care. 

There is a large administrative impact on medical practices.

Medical practitioners who decide to use the system will have to adapt their clinical workflows and train their staff to work within the requirements of the legislation.

Doctors will have to consider the impact of this additional workload, and the changes to clinical workflow, on the fees they charge their patients.

As I said, the biggest impact will be on GPs.

GPs will take on the role of “nominated healthcare providers” and create and maintain the “shared health summary”.  This is a key feature of the PCEHR.

But without specific MBS items for this work, it will have to be absorbed into the standards consultations.

As things stand, GPs are being asked to provide a new service for free.

Providing a shared health summary is a very specific task requiring clinical skills.

GPs will work with their patients to ensure that a complete and accurate summary is available to be used by other health care providers in their clinical decisions. 

It is only reasonable that patients should receive an additional Medicare rebate for this very important additional service.

There needs to be some investment by Government to support medical practices that are private businesses – to invest in the infrastructure that is needed to make the PCEHR work.  There needs to be a business case.

Doctors need greater support than that what is on offer if the PCEHR is going to truly work to improve patient care and reduce waste and risk in health care.

The AMA is a great supporter of, and advocate for, accurate electronic communication.  It is the future.

We support the introduction of the PCEHR – but it has to be the right PCEHR.

At the moment, we do not think the proposed PCEHR is the right PCEHR.  And the Minister knows our view.

The implementation process may start on 1 July but the completion of the implementation will be some time off, unless there is genuine consultation and agreement on the final product.

----- End Speech.

Here is the link.

http://ama.com.au/node/7799

On the Health Minister’s speech there are two things that leap out at me - other than the obvious slowdown and increasing care with roll out.

First there is a secret (apparently) report with this title that explains where the benefits will come from.

(Deloitte, The national PCEHR system: relationship to the 2010 national IEHR business case, unpublished, Version 0.19, 22 June 2011)

Second we have a range of statistics offered as to the scale of problems in the Health System but no idea just what proportion can be fixed by e-Health. It is more likely to be 10% rather than 100% using the PCEHR! (see yesterday’s blog)

On Steve Hambleton’s speech it seems clear the AMA is just not on board with what is being done. That is a pretty serious issue I would suggest.

We still lack the leadership and governance to get all this to come together!

David.

Talk About Being Treated Like Mushrooms - Kept In The Dark and Fed BS - That Is The Way The Federal Health Minister Is Treating The E-Health Community.

The following article appeared in the Australian Financial Review today.

eHealth to save $11bn for budget

David Ramli

22^nd May, 2012

The federal government has claimed its troubled electronic health programs will save more than $11 billion over the next 15 years as it guns for a budget surplus.

Health Minister Tanya Plibersek made the comments during a speech to the Committee for Economic Development of Australia in Melbourne last week.

“The national eHealth records system will mean better, more efficient, more convenient healthcare,” she said. “We estimate eHealth will save the federal government around $11 billion over 15 years. However you look at it, that’s pretty good bang for your buck.”

The savings target, which would equate to more than $733 million a year, comes as Labor stakes its economic reputation on a $1.5 billion surplus by 2012-13.

In a copy of her speech, Ms Plibersek attributes the figures to an unpublished 2010 Deloitte report.

.....

Dr  Southcott said he’d only seen an earlier version of Deloitte’s report and that the key financial assumptions it had made should not be used by ­governments to calculate savings.

Ms Plibersek declined to be interviewed. Her spokesman refused to release the Deloitte report, saying Cabinet was using it to inform decisions.

Lots more material is found here:

http://afr.com/p/technology/ehealth_to_save_bn_for_budget_XmtgYIfwO1enjkONhZmecK

There are 2 problems with all this.

The first is that the figure is clearly a gross exaggeration unless I badly miss my mark. While we don't have the later Deloittes document we do have their earlier work on the topic.

In the 2008 Deloittes National E-Health Strategy - which can be downloaded from this link:

http://www.health.gov.au/internet/main/publishing.nsf/content/604CF066BE48789DCA25751D000C15C7/$File/National%20eHealth%20Strategy%20final.pdf

We read on page 96.

7.2.3 Benefit Summary

There are significant challenges associated with attempting to quantify benefits associated with EHealth, not least of which is the paucity of quality data on Australian health care system costs, activities and outcomes. Despite these limitations, it is possible to develop indicative estimates based on analysis of local and international literature. This analysis shows that the tangible benefits associated with implementation of the Australian E-Health Strategy are estimated to be in the order of A$5.7 billion in net present value terms over ten years.

The annual savings associated with a fully implemented E-Health Strategy are estimated to be approximately A$2.6 billion in 2008-09 dollar terms.

----- End Extract

As for costs which are required to be spent page 90 gives the summary.

7.1.5 Funding Considerations

The total indicative estimated cost of the implementation of the national E-Health Strategy is A$1.5 billion over five years or A$2.6 billion over ten years. This represents a relatively modest investment program when scaled against total annual recurrent spending on health (approximately A$90 billion) and the total annual recurrent spending on health by all levels of government (approximately A$60 billion).

----- End Extract.

If my figures are right we are this looking at a net benefit of $5.7B - $2.16B over 10 years which is about $2.9 billion over 10 years. If you make the heroic assumption that all e-Health IT will all be done after 10 years - and will have no costs for replacements, staff, upgrades and so on then you might come up with a figure like the Minister has - but that far out who can possibly know?

The bottom line to me is we need to see the unpublished report mentioned:

Deloitte, The national PCEHR system: relationship to the 2010 national IEHR business case, unpublished, Version 0.19, 22 June 2011)

So we can try and distinguish fact from fantasy.
Remember the PCEHR is a less useful approach to e-Health than that recommended by Deloittes.

Without this later report being made public we are really being mushroomed big time!
The second problem is that it is clear any idea of a bi-partisan approach on e-Health is obviously dead. Who thinks any of this will be happening 3 years from now?

I note others agree with me (see italics):

http://spectrum.ieee.org/riskfactor/computing/it/troubled-healthsmart-system-finally-cancelled-in-victoria-australia-

Troubled HealthSMART System Finally Cancelled in Victoria Australia

POSTED BY: Robert N. Charette  /  Mon, May 21, 2012

----- Huge Amount Omitted

That said, at the national level, the Australian government is still continuing its support of the controversial personally controlled electronic health records (PCEHR) system, which is supposed to begin its roll out across Australia this July. Prime MInister Gillard's government has recently even allocated $A233 million in this year’s budget (on top of the original appropriation of $A466 million) to bolster the effort's probability of success.

At the same time, the government has also been trying to dampen down expectations about the PCEHR system, saying that it will take years before it will actually be useful. But the government predicts that the changes it will make in the way medical data is handled will eventually save Australia $A15 billion in government-related health costs by 2030. Given the current state of the PCEHR system and the lukewarm support of it by the Australian populace and medical profession, that amount sounds more like political wishful thinking that an estimate grounded in economic reality.

David.