Quote Of The Year

Timeless Quotes - Sadly The Late Paul Shetler - "Its not Your Health Record it's a Government Record Of Your Health Information"


H. L. Mencken - "For every complex problem there is an answer that is clear, simple, and wrong."

Friday, September 29, 2006

The Access Card Could be Really Expensive, Costly and Delayed!

In the last few weeks a general theme that has been emerging in E-Health Commentary, both here and overseas, has been the increasingly clear recognition that very large national IT projects have a habit of running well over time and budget, sometimes to quite amazing levels, and that, conversely locally driven and managed projects seem to be able to deliver increasingly successfully.

Witness the problems in the UN NHS Connecting for Health Programme which have come to light recently both in the choice of both lead contractor (Accenture) and key software provider (iSoft). It seems both these organisations have yet to fully disclose just how bad the losses and outcomes will be for the UK.

Hard on this news we now find another major project in a different country is similarly apparently running off the rails. The following release from Ovum (The Global ICT advisor) says it all.


Update on the German electronic health card: more costs, more delays...

Hot on the heels of further delays to the introduction of the electronic health card, comes news of much higher costs than previously expected. An independent cost-benefit analysis produced by Booz Allen Hamilton and commissioned by Gematik, the company in charge of the implementation and the running of the project, concluded that costs are likely to be around €3.9bn rather than €1.4bn previously expected, and could be as high as €7bn. And this sum doesn't include the €585m cost of issuing of the cards.

Taking into account the five-year introduction phase, overall cost is estimated at €5.2bn, which will exceed expected savings of €4.4bn by €800m.

Comment: Gematik's management board is still digesting Booz Allen Hamilton's analysis and is not ready to comment on its results. However, it is certain that the e-health card will go ahead, since its introduction is integral to the German code of social law.

However, the question arises: why is Gematik commissioning a cost-benefit analysis now, in the middle of the project? Before the project began, an initial study determined costs of around 1.4bn versus annual savings of €1.7bn, which sounded promising.

The German government's plans are regarded as the most ambitious telematics project in Europe currently under way. Though other countries such as the UK, France, and Italy are engaged in related projects, their scale in terms of functionality and number of users are smaller. The high complexity of the e-health card, involving 80 million insured citizens, 123,000 general practitioners, 65,000 dentists, 2,200 hospitals, 21,000 pharmacies and 270 health insurance companies, makes it a very large challenge. And the communication, or rather the lack of it, between the involved parties is causing delays in the execution of the project.

We are still a couple of years away before all 80 million insurants are due to have their e-health cards. Gematik has been issuing specifications of the necessary equipment and is testing its market suitability. No tests with patient have started yet, but they will begin in two states this autumn and will be extended to six other sates in 2007. In every step of this long-drawn process, specifications will be altered and adapted to arising problems.

This is a prestigious undertaking for the German government. Its success is not only important for its own standing, but would act as a showpiece for the German IT industry and help it win similar projects in other countries which are currently looking at introducing such a system. Every time one breaks new ground, unforeseen difficulties can arise. But given the many challenges that this project has had to face so far, this news will give more ammunition to its critics.”

The scale and reach of this project obviously has some parallels to the planned Joe Hockey Access Card, indeed while Germany is obviously a larger country, the scope of the Australian project appears to be broader.

A few points deserve to be especially highlighted.

First, even at the half way point, it seems the project will cost rather than save money. Over five years the net loss is presently estimated to be $A1.36 Billion (at today’s exchange rate. It leaves one to wonder just how credible the huge benefits identified in the KPMG report actually are. ($A3.0 Billion in benefits over ten years seems just a trifle optimistic!)

Second the total cost of the project must certainly give some pause for thought!. The current planned cost of the German card is estimated at €5.2 Billion ($A8.84 Billion). Given, on a population basis Germany is about four times the size of Australia this suggests a realistic cost for the Australian Access card (not assuming the Germans get any economies of scale) is $A2.2 Billion. The suggested budget of $A1.1 Billion would look to be a good deal short of what will finally be needed.

Third it seems clear the current Access Card time frame (System implemented by 2008 or 2009 at the latest) seems very, very ambitious indeed based on the German experience.

Fourth it is very clear that the Access Card implementation needs to be very carefully phased and piloted so that all the technical, change management and privacy issues are fully understood and solved on a small scale before a large scale rollout is attempted.

One is forced to the conclude that unless the Australian Access Card team are much smarter than the Germans (unlikely since this is their second generation health card implementation) or we are at serious risk of having a very under-funded, delayed and loss making Access Card implementation which carries all the risks of a very large and very complex IT implementation in the public sector.

It might be a very good idea to have Booze Allen Hamilton (who reviewed the German implementation) review thoroughly the Australian plans, and assure all concerned that all the known issues have been addressed, before we get stuck with a real loser.


Wednesday, September 27, 2006

iSoft and CCHIT – What’s the Link?

A key theme in any discussion of e-health is how to foster adoption and use of Health Information Technology (Health IT). In the last few days a few reports have come together to remind me that this issue is not being addressed in a reasonable way in Australia, but that at least some hopeful signs are emerging elsewhere.

Firstly we have had the reports of the last few days, from both The Australian and e-Health Insider in the UK, of the apparently continuing problems about iSoft plc’s contracts and viability both here and in the UK. The essential messages seem to be that there were some distortions of the selection process by which iSoft has been engaged and not enough scrutiny of the future plans the company said it was assured of delivering in now well past time-frames. This is bad news both for the company and its customers despite all public announcements to the contrary.

On the good news side we have the news announced yesterday regarding the Certification Commission for Healthcare Information Technology (CCHIT) release of the most recent drafts of its functional and interoperability criteria both for ambulatory and inpatient systems.

The mission for CCHIT is to “accelerate the adoption of health information technology by creating an efficient, credible and sustainable product certification program.” These specification are evolving in a studied, obviously competent and purposeful way towards a vision of really excellent, clinically sound and valuable systems which, as they are certified, purchased and implemented, will make a real difference to the quality and safety of the US Healthcare System.

How are these two items linked? I would suggest they are linked through the lack of a national Health IT certification process in Australia than has permitted purchases by State hospital systems of software of poor quality that, it appears, lacks a future. We have seen issues in hospital software selection, cited here, in Tasmania, Victoria, NSW and Queensland (who are still being sued by a disappointed vendor as far as I know).

As far as ambulatory care systems are concerned we also have a situation where both functionality and interoperability between different system providers is hardly assured (to say the least).

CCHIT works by taking only the approved and fully implemented and tested standards, merging them with the priorities of the American Health Information Community and developing a functional and interoperability requirements that are required for certification. They also signal their direction well in advance to give the vendors time to develop what is required that they may not have at a particular point in time.

Having the CCHIT does two important things. Firstly it provides system developers with a clear set of system requirements and objectives. Secondly it provides system purchasers with an assurance, if they stick with the approved products, they will be purchasing competent systems that are being developed to meet real clinical and operational needs, and which have a future.

What is needed, to avoid further unwise purchases both in the private and public sectors, is for NEHTA to rapidly move to replicate the role the CCHIT is playing and for the Commonwealth to ensure there is a clear plan and clear strategic guidance as to the directions e-health needs to move in. This inevitably means resurrecting and funding an Australian Health Information Council like entity and charging it to provide the big picture directional guidance to both NEHTA’s certification arm and the software development community.

Very useful documentation already exists and could be swiftly tailored to meet Australian requirements. The time to get such certification and strategic direction setting capability in place is now to avoid further waste and “spinning of wheels” and to give the software providers confidence to invest for the benefit of all.

It will be the development of strategically and clinically valuable systems by commercially viable and confident software providers that will make Health IT adoption easier and be one further step to a better and safer healthcare system.


Saturday, September 23, 2006

Electronic Prescribing – What is Needed to Move Forward?

Both in the USA and in the UK there are major efforts underway to increase the amount of prescribing done electronically. Additionally, as reported a little while ago in an article here, the Commonwealth is moving to ensure that by early next year there will be no regulatory or legislative barriers to introduction of E-prescribing (EP) in Australia.

The reason adoption is sought is that it is now very good evidence that EP has the capacity to substantially reduce the frequency of Adverse Drug Events (ADEs) and that if this is achieved considerable human suffering and cost can be avoided.

The objective of EP is to deliver to the dispensing pharmacist a prescription from the prescriber that is error free and which can then be dispensed in an error free fashion to the patient. Subsidiary objectives may include maximising the use of generic medication, where appropriate (to also reduce treatment costs), and assisting the pharmacist with accurate and timely claiming of the costs of medication from either the Pharmaceutical Benefits Scheme or the patient depending on the circumstances.

Analysis of the prescribing process identifies three distinct phases (plus financial settlement and inventory management which will not be discussed further as these are simple business processes which are already quite highly automated and well understood.)

Phase 1 is Prescription Creation.

Prescription creation can be done electronically in a number of ways. The simplest is to use a computer to capture the patient details, and then from a data base of available preparations select the appropriate medications and package size and print out a form ready for manual signing. This is now quite widely done and offers the benefit of providing the pharmacist a legible prescription from which to work to dispense. This approach is grossly sub-optimal in 2006 as there is no error prevention or decision support contained in this basic model and the risk of errors in re-entry of the medication information in the dispenser’s system is real and demonstrable, despite the legibility.

The much to be preferred option is that the clinical encounter which is to result in an EP should be documented in an Electronic Health Record for that patient that will contain a range of relevant information to assist with the quality of the prescribing. The system ideally will have a list of the patients active diagnoses, the patients current problem, current regular medication (and ideally complementary substances taken) and basic physiological and other information such as height, weight, age, renal function and so on as well as such things as known allergies etc.

With this information available, and with access to tools such as the electronic Therapeutic Guidelines, as the prescription is developed the clinician not only is alerted to possible interactions and other contra-indications but can easily confirm the appropriateness of the therapy proposed. The literature evidence that well designed systems with these capabilities save lives and money is now unequivocal (see article on this site from a month or so ago).

Such EHR based systems are really the basic client the prescribing clinicians should be using in 2006, especially as the requirements for such systems and what is needed for utility and interoperation is well understood.

Phase 2 is Prescription Transport.

In essence once the quality prescription is created there are two possibilities for . Firstly the prescription can be printed out and given to the patient to present for dispensing or, if legally acceptable, a secure token, containing the prescription, can be given to the patient to be used by the dispenser’s system.

The simplest way of linking the prescriber and dispensing computers I believe is to have the prescribing system write a two dimensional barcode onto the printed prescription. Such barcodes can hold the full written information on the prescription and can be scanned into the dispensing system is less than a second or so. The dispensing system then displays the medications to be dispensed for checking and one the pharmacist is satisfied the dispensing and label printing is completed. The prescription is then marked as having been dispensed and if repeats are authorised the necessary paper work is created. This process benefits the patient (accurate communication with pharmacist) and the pharmacist (avoids the need for data entry). Fraud is prevented by using appropriate encryption of the information stored on the barcode to ensure the clear-text contents of the prescription matches the barcode.

The second approach would be to electronically transmit the prescription directly from the prescriber to the dispenser. This is done in the USA to an increasing extent. In Australia community pharmacy is very concerned that direct transmission might give the prescriber too much commercial influence and so the Pharmacy Guild is totally opposed to any proposal of this sort – despite its obvious attraction in a technical sense.

It seems likely that this problem is best overcome by the creation of a national “store and forward” EP Network. The patient presents at the pharmacy of their choice and provides the paper script or a token and the full prescription is then pulled down from the network. (The 2 dimensional barcode seems simpler and cheaper I must say)

This would seem likely to involve a greater cost than simple point to point messaging of barcoding and it would seem reasonable that any additional costs be bourn by the pharmacists as a whole.

A network of this sort would also have major privacy and security implications, as it creates a large database of essentially every prescription in the country, and may need to be very carefully thought through. Secondary use of this data may however provide some useful and clinically relevant information.

Phase 3 is Prescription Dispensing.

Community pharmacy has been using pharmacy systems for dispensing for many years and once an electronic copy of the prescription is available within the pharmacists computer dispensing and labelling can proceed as usual. The advantage for the pharmacist is avoiding any data entry and any possibility of error in the prescription assessment process. Of course the wrong pack can still be picked off the shelf but this is known to be very rare indeed in the presence of a clearly legible prescription.

Before concluding it is important to realise this article has oversimplified a number of aspects of EP. The medication terminologies to be used in prescription communication are still to be standardised and are important as is some remaining work on other aspects of EP Standards, not to say the excellent work has already been done via the MediConnect Trials, flawed though they were in their final implementations.

Standards Australia have already published work covering the use of HL7 messaging to transfer prescription information the it is important this work is progressed and utilized.

Essentially there a major community benefits to flow from a considered and comprehensive implementation of EP in Australia, there are very few significant barriers remaining to its progress. The work needs to be proceed as soon as possible under the agreed standards frameworks.

What is needed now is the availability of effective, quality EP client systems which provide reliable, consistent and safe decision support and the definition of the technical approach(s) to be adopted the get the prescription from the clinician to the pharmacist.


Monday, September 18, 2006

A Brief for the Australian National Audit Office regarding E-Health

Reflecting on yesterday’s commentary it occurred to me that it may be useful to offer some suggestions as to the rocks the Australian National Audit Office should look under in developing a performance review of Australian E-Health.

In broad terms Performance Audits (Which is the type of audit I feel is needed in e-health) address the following:

1. The existence of, and the suitability of the Information and Communications Technology Strategy that has been or is being implemented.

2. The practicality, quality, project management skills and resource availability applied to ensure successful implementation the project plans.

3. The quality and insight of the Risk Management Plans associated with the project.

4. The business case for implementation of the ICT Strategy being implemented.

5. The outcome of the project in terms of service improvements, financial savings or other relevant evaluation criteria.

6. The degree to which lessons learnt during the project have been disseminated to ensure minimum repetition of mistakes and financial waste.

7. The closeness of the actual delivery of the project and its expected outcomes to those identified in the strategy, planning and business case documentation.

It seems to me that the implementation of e-health, both at a national and state level, has been littered with a range of major projects which have not met expectation (for timing and delivery) and for which there has been very little evaluation made public to foster organisational learning.

First among these must be the HealthConnect initiative. To date there has been a minimum of transparency as to both costs and benefits for this whole program. Despite repeated claims that the notional $128M project is on track and on budget there seems to be very little to show for these funds. A hard look is clearly warranted.

It may be that what is actually required with respect to HealthConnect is a review, in detail, of each of the pilots and implementations as well as the overall strategy. Most important will be to understand what benefits, if any, have been delivered in terms of improved patient care and patient safety.

Second it seems there needs to be an audit of the performance of the governance structures surrounding e-health in Australia. It is no secret that since 1995 there have been a number of reports into the area.

These have included the 1995 Health Communications Network Report, the 1997 House of Representatives Report, the 1998 NOIE Reports such as the 1998/9 Unstoppable Rise of E-Health Report, the 1999 Health On-Line Report, the July 2000 Report to Health Ministers of the National Electronic Health Record Task Force and the 2004 Boston Consulting Group E-Health review at least. In parallel there have also been a range of State Health Department Reports. To date these reports have led to a range of trials which are admitted to have not resulted in any significant national implementation. After all this time the National E-Health Transition Authority has the view that “the momentum for e-health is rising and that the stage is set for Governments to consider a national system of electronic health records". Dr Ian Reineke (CEO, NEHTA - As of April 2006). ANAO really needs to investigate what has gone wrong for over a decade and what is needed to fix things. The opportunity cost of a wasted decade must be assumed to be massive.

Thirdly it has been suggested by Mr Abbott (Federal Health Minister) that the Commonwealth has invested close to $1.0 Billion over the last decade in provision of such programs as the Practice Incentive Program and Broadband for Health. Both these were aimed at improving GP computing. An public audit of the outcomes, learnings and benefits of this expenditure is clearly overdue.

Fourth it seems delivery of benefits from Supply Chain Reform are coming much more slowly than they could or should for the Health Sector. Careful review of the issues here could be very valuable and save real money.

Lastly a strong case can be made for a review of the range of identity and identification programs being sponsored by the Commonwealth which are clearly needing to be rationalised. The importance of the requirements of the Health Sector in this area cannot be underestimated.

Someone needs to be asking just how the NEHTA IHI and IPI initiatives, Minister Abbott’s Health Smartcard, the Access / Smartcard Initiative, Passport ID, the Document Verification System for Attorney General's and Medicare / Centrelink's current ID systems are to be co-ordinated and managed for both efficiency and cost effectiveness.

While not the responsibility of ANAO (but rather the state equivalents) there seems little doubt the procurement processes of Health IT in NSW Health, the Victorian HealthSmart Project, the continuing delays in Queensland Health’s IT implementations and the use of scanned records in Tasmania could all stand careful audit scrutiny.

Clearly there is lots to be done. Let’s hope some one will take up the torch and get all this back on the rails.

What score out of ten do you think these various initiatives would achieve if fairly audited?


Sunday, September 17, 2006

Is it Time to have the Auditor General Review E-Health?

Last week Government Health IT in the US published an article entitled “HHS needs focus despite health IT progress, GAO says

The article said, in part, that:

“The Department of Health and Human Services has made progress in its efforts to promote the use of health information technology, but it still lacks the detailed plans, milestones and performance measures necessary to meet President Bush’s goal for electronic health records, according to a recent Government Accountability Office report.

The report cites as positive developments the Certification Commission for Healthcare IT’s recently defined parameters for certifying ambulatory electronic health records and the group’s certification of several dozen vendors’ products.

It also pointed to the 90 interoperability standards selected for tools such as electronic health records and the proposed functional requirements for a nationwide health information network.

However, the report states that although HHS has set those objectives and developed high-level strategies for accomplishing its goals, it still hasn’t defined the kinds of plans and measures it will use to meet those goals.”
It went on to say that:

“Last year, GAO told Congress that federal agencies still faced many challenges in their efforts to improve the public health infrastructure, including integrating current initiatives into a national health IT strategy and adopting consistent standards for interoperability.”

And the GAO concluded without there being clear plans and time lines in place “ it’s unclear how the government will achieve Bush’s goal of widespread adoption of interoperable electronic health records by 2014.”

Reading this, I wondered to myself has our equivalent of the GAO, the Australian National Audit Office (ANAO) ever reviewed Health IT in Australia, and if so what was concluded.

The short answer to that question would appear to be no, although there was an audit of the internal information technology within the Commonwealth Department of Health and Aging in 2002/3. There is also no audit of e-Health planned in the 2006/7 fiscal year.

As far as the States are concerned – I became quite excited to find an e-Health Audit report in NSW – only to discover the e-Health referred to was purely supply chain and not clinical e-health. At least, however, the Auditor in NSW has heard of the term! (The basic conclusion of the audit was that implementation and benefits were proving very slow to be realised).

With this background it seems to me the time has truly come for such an exercise to begin and for the work to be scheduled ASAP. Why? Essentially because a clear impartial view of the activities of the Commonwealth and State Governments and of the relevant Departments and Agencies and their successes and failures would surely provide a base of information on which to improve the likelihood of success with future investments.

There have been hundreds of millions of dollars spent by the Commonwealth and States on Health IT since 1999 and there has been no public accounting, at least that I am aware of, of what we the public have got for our money and what lessons have been learnt that need to be applied to the planned forward investments which are likely over the next decade to amount to at least a billion dollars according to the Commonwealth and NEHTA.

The Productivity Commission last year expressed a degree of unease about the Commonwealth plans for HealthConnect and the apparent lack of progress. The validity of these concerns has become even more obvious since that report.

As taxpayers we deserve to know what has been going on and who is to be held accountable for the apparent lack of progress and waste of money.

The time has surely come!


Saturday, September 16, 2006

NSW Health’s Dirty Little Health IT Secret Revealed

In the last few days I have become aware of a paper on the feasibility of implementing CPOE (termed Electronic prescribing decision support (EPDS) in the paper) in a NSW Hospital. The reference and abstract for the paper are as follows:

Bomba David and Land Tim : The feasibility of implementing an electronic prescribing decision support system: a case study of an Australian public hospital. Aust Health Rev. 2006 Aug;30(3):380-8

Centre for Health Service Development, University of Wollongong, Northfields Ave, Wollongong, NSW 2522, Australia. bomba@uow.edu.au

Medication errors are common in public hospitals, with the majority at the prescribing stage of the medication pathway. Electronic prescribing decision support (EPDS) is a rules-based computer system that can be used by clinicians to warn against such errors to improve patient safety and support staff workflows. Despite its apparent advantages, this technology has not been widely adopted in Australian public hospitals for inpatient prescribing. A case study using Sauer's (1993) Triangle of Dependencies Model was conducted in 2003 into the feasibility of implementing an EPDS system at an Australian public hospital in New South Wales. It was found not feasible to implement an EPDS at the hospital studied due to the legacy patient administration system, low availability of information technology on the wards, differing stakeholder views, legislation, and the Independent Pricing and Regulatory Tribunal of NSW report recommendations. A statewide standard was preferred, with an agreed specification framework identifying basic core data items and functions that an EPDS must meet which can then be used by area health services to: (i) choose a solution which best meets their contextual needs; and (ii) engage vendors to tender for building an open source (non-proprietary) system based on the specification framework.

PMID: 16879097 [PubMed - indexed for MEDLINE]

I must say this is a quite astonishing paper. I offer absolutely no criticism of the work of the two authors or the project participants and indeed I am grateful to them for their honest and insightful reporting of the situation of Health IT in a large NSW public hospital. (The paper indicates the hospital has 146 medical staff, 25 nursing unit managers and 15 pharmacists on staff so we are clearly being told about a hospital with at least 15-20 wards and probably 400 or more beds).

On this basis, and the source of the paper, it seems clear the hospital is The Wollongong Hospital.

In promoting itself to potential junior medical staff the Hospital states:

“About Wollongong Hospital

Working in the Illawarra offers good pay, a great lifestyle and a highly supportive work environment. The Illawarra is highly regarded by Junior Medical Officers (JMOs) as a centre of excellence for postgraduate medical training. Many choose to return to us to do their further specialty training.

As part of South Eastern Sydney Illawarra Area Health Service we are a major provider of public health services to the people of the Illawarra and Shoalhaven region (341,058 people).

Our service provision includes a range of specialist medical services including trauma, intensive care, surgery, medicine, maternity and paediatrics, and cancer care to people living south of the Sydney Metropolitan area and in the Shoalhaven region.

Cutting-edge technology and comprehensive healthcare services are two driving forces in our Health Service. Wollongong Hospital is the optimal size (450 beds) to provide stimulating opportunities for learning, research and development in a cooperative, friendly and supportive environment.

Comprehensive Pathology, Medical Imaging and Para-Medical departments serve the Wollongong, Port Kembla, Shellharbour and Shoalhaven hospitals.”

The claim of “Cutting-edge technology” is clearly a small exaggeration at the very least!

What is revealed in the paper is the utterly inadequate investment in information technology infrastructure that has occurred leaving the hospital with a core patient management system that does not record even the most basic of patient clinical information (allergies, weight and height etc) and which was almost certainly developed in the late 1980’s. (The legacy system is probably the legendary HosPAS developed around then by the Computer Division of the NSW Health Department based on a system that was older still. That it is still in use is a testament to a major determination to avoid change or upgrade for almost 20 years, despite the system's deficiencies.)

Additionally one is left with images of staff crowding around the limited number of available terminals and the use of group staff sign-on’s which ensures access to any data held in hospital system can be seen by virtually everyone who wants to see it, with no audit trails which will identify who it was that was browsing the potentially sensitive data.

Review of the most recent Annual Report (2004/5) for the Area covering the hospital shows that work to establish the new area wide Patient Administration System (PAS) and universal identifier is underway with an expect completion date of the end of 2006. That was the good news! The bad news is the PAS is being sourced from the increasingly likely to fail iSoft. Not only does this mean the possibility of fully integrated clinical and patient management systems is off the agenda for another few years as Lorenzo (the iSoft Clinical System) will not be available until 2008, but that progress may be even slower as the iSoft PAS is replaced with a system that has a future and ongoing support.

Had the 2003 Independent Pricing and Regulatory Tribunal of NSW report recommendations for statewide systems been adopted this potentially major problem could have been avoided and almost certainly some useful clinical systems would arrive much earlier.

As the paper rightly points out CPOE can have a major impact on patient and prescribing safety, so much so that increasingly it is being seen as a core indicator of hospital quality and safety. It seems there is neither the will or the funds to address such issues in the Illawarra. Who actually cares that Hospitals are not maximising patient safety? Only the patients I guess. Certainly not the Health bureaucrats in North Sydney who have persistently underfunded e-Health in NSW for at least the last 15 years.

All in all a useful insight into how bad things really are in the clinical trenches in NSW.


Thursday, September 14, 2006

Call For Sightings - Have you Seen HealthConnect in Action?

In last Tuesday's Australian, this blog's report of the demise of the Australian Health Information Council (AHIC) was confirmed. It is clear that AHIC is not presently operational and its chairman has resigned. Better news from the article was that meetings were underway to get together a new AHIC, to press on with the clearly vital work.

In the same article,the Health Department (via Kay McNiece, spokeswoman for Health Minister Tony Abbott )stated:

"The 2006-07 HealthConnect budget is $31.5 million," she said. "The funds will be used for the National E-Health Transition Authority's baseline work program, the implementation with Tasmania, South Australia and the Northern Territory taking priority, and program running costs."

This seems to be a quite large sum of money for something that has seemed to be going nowhere and the question arises what are we actually getting for this money?

My suspicion is that the vast bulk of the funds is going to operate NEHTA and that virtually nothing at all is being spent on HealthConnect.

I wonder, can any readers of the blog who are aware of any HealthConnect branded activity actually happening please let us all know?

The simplest thing to do is e-mail to the address given on the "how to contact me" link at the top of the blog!

This will allow us all to know if HealthConnect is really alive or on its last and terminal gasp! I will report back with what I discover in a week or so. Of course any other "comments, corrections, clarifications, and c*ckups" (as Crikey.com would have it) as well as tips about anything I have missed (good or bad) in the e-Health space would be more than welcome!

It's your blog..use it!


Sunday, September 10, 2006

The Electronic Medical Record you Have When you Don’t Have One!

A week or so ago the following release caught my eye. One more acute hospital, I thought, has taken the sensible step of moving to a computerised patient record. The release read as follows:

Lara Giddings, MHA

Minister for Health and Human Services
Thursday, 24 August 2006


The Royal Hobart Hospital has become one of the first hospitals in Australia to store patient medical records through a new computerised digital system, Health and Human Services Minister Lara Giddings announced today.

Officially launching the new Digital Medical Record (DMR) system, Ms Giddings said the new system would bring major benefits for the Royal, clinicians, nurses, other health care professionals and, most importantly, patients.

Ms Giddings said the move from a manual, paper-based way of managing many thousands of patient records to an on-screen system, was historic.

“The new Digital Medical Record system allows patient information to be scanned, stored, managed and viewed on-screen for the first time,” Ms Giddings said.

“The new digital service, which has cost just over $1 million, means that patient information will be more manageable, accessible and secure.

“And the system will allow more timely retrieval of vital information and will be more efficient.”
Ms Giddings said that health care had the dubious honour of being the world’s largest consumer of paper.

“At the RHH alone, it is estimated that the manual system of keeping patients’ medical documents has gobbled up some 5.5 kilometres of storage space,” Ms Giddings said.

“That secure storage space has been growing at around 100-300 metres per year, and is now very close to capacity.

“The new Digital Medical Record system is an exciting initiative that will prevent the Royal being swamped by paper.

“The project will free up more space at the Royal and eliminate the need to store additional patient records off-site – a very expensive option and a logistical nightmare if they need to be retrieved in a hurry.”

From the beginning of last month, all new patient information has been recorded on the Digital Medical Record, rather than being filed as paper form medical histories.

“The new system enables fast and secure multiple user access for all RHH staff involved in providing direct patient care,” Ms Giddings said.

“The DMR allows clinical information to be available on-line and wherever the patient is located, and there is instant access for those treating staff needing a patient’s medical record.

“The system has been designed from the ground up to link into existing clinical work practices.

“The system is safe and secure. There are three forms of backup including archival tape - stored off-campus in a secure facility - a backup server and a contingency system in the event of power and network loss.”

Ms Giddings said the hospital’s network was world class, and the project had enabled the establishment of state-of-the-art, secure wireless networking to almost all wards.

The hospital’s sophisticated scanning equipment is capable of scanning 60,000 pages a day.

“It puts us in a stronger position in what is becoming an increasingly technological and information driven industry.

“Going digital provides the RHH with a firm foundation on which the hospital can build towards fully electronic patient health records.

“And into the future, the advantages of the new digital system may not be confined to the Royal alone.

“The system has been developed as a single, Statewide system, but it only contains RHH patient data at present.

“However, because of its link with the Tasmania-wide patient identification system, it has the potential to act as the cornerstone of a secure, fully integrated health record for everyone.

“The possible benefits in terms of improved continuity and quality of care are immense,” Ms Giddings said.”

Oh dear, oh dear I was wrong! A close reading of the release reveals no such thing! What has been done is that the hospital has bought a large optical images scanner and all the paper that constitutes the patient medical record will be scanned into an image data base, presumably keyed on the patient’s medical record number.

Given that it would make no sense to be scanning paper records while they were in use during an hospital admission, given the impact on work processes of taking the papers away to be scanned as care was being delivered, it is clear the scanning occurs after the patient leaves the clinic or is discharged.

So what we actually have for the $1.0Million is an image archive of non-current records which can be accessed to assist current care. The key problem with this is that there are now two sources of information. Firstly the current paper record and accessible via the computer the “old patient notes”. How often these will actually be accessed is likely to be quite low – given that any current information will inevitably be transcribed into the current record for easy and quick access. The frequency with which older records are accessed after an initial review or admission is vanishing low in my experience.

Another issue with scanning the paper record is the lack of ease of access to the various components of the record when it is presented as a collection of images – even if there is some attempt to provide some structure to the record through the use of sectional tabs and the like. At the end of the day what the scanned record comprises is an image stream which must be searched largely sequentially.

Additionally, to make such an image stream at all useful, it is important to attach electronic descriptions (known as meta-data) to each image. The process of doing this requires manual human reading of the scanned image and then entry of appropriate descriptions and searching information. Clearly the amount of metadata that will be entered will be quite limited for each image given the number of images being scanned each day and the available work force to code the images. Search and retrieval of details and other useful information will thus be very limited indeed.

Purchase of this system, I understand, has been driven by the need not to accumulate more paper, given the storage constraints existing in the hospital and a desire not to spend the money that would be required on what could be termed a “real” electronic health record within a hospital information system.

This decision making is blinkered in the extreme and is to be condemned. This system is little more than an electronic document archive and offers very few, if any, of the advantages and benefits of a real integrated Hospital Information System.

There are Australian companies, such as IBA Ltd, who can offer a highly searchable, functional, workable and useable Hospital Information Systems which would offer a much greater cost / benefit ratio to the Royal Hobart Hospital than this misguided installation. Additionally there are US providers, such as Cerner, who also have installations in Australia who can also assist.

There must be a reason that virtually no significant hospital in the world, if any, have adopted a system like this as their record system. These is! It is a really, really bad idea for 2006. Indeed it was a bad idea in 1986 and every year since!

One hopes that Tasmania Health will see the error of their ways and resolve to provide proper electronic health records to their clinician sooner rather than later, rather than extending this inappropriate technology further into the Tasmanian Hospital System.


Wednesday, September 06, 2006

Has the Peak e-Health Strategy Council in Australia (AHIC) Vanished Unannounced?

Writing earlier this year on the demise of HealthConnect as it was initially planned in an article in New Matilda in early 2006 I noted in passing

“There are other worrying portents of the Commonwealth Government vacating the e-health space. Firstly, the formal role of the Australian Health Information Council (AHIC) to undertake national e-health planning was withdrawn after the AHMAC meeting in late 2005.”

What I wrote seems to be truer than I could have imagined.

AHIC was initially set up by Health Ministers in July 2003. AHIC, it was said “works closely with the National Health Information Group in to increase the effectiveness of IT investment in the health sector.”

After little practical outcome from the Council after two years, it was reviewed by the Australian Government (in secret it would seem as there was no public report I am aware of ever announced or released) and its role was changed.

The new role was described as follows:

“The revised operating arrangements for AHIC are based on an independent review of the Council commissioned by the Australian Government. These arrangements will enable AHIC to focus on providing strategic advice to Health Ministers about the more effective and efficient use of information management and information communications technology (IM&ICT) in the health sector.”

At the same time as this was done (November 2005) all references to a proposed National E-Health Strategy disappeared from the AHIC web-site. I am told that despite twelve months consultation and work by the AHIC secretariat the strategy produced was so bad as to not be appropriate for release and so the whole idea of developing a National E-Health Strategy was abandoned. Since that time administrative transfers, changes and resignations have ensured that any expertise and skills in the e-health domain that may have existed have been largely dissipated.

It now seems that the last rites have been administered to the last representative Australian e-Health peak body – with the web site (www.ahic.org.au or www.ahic.gov.au) now having disappeared as of the time of writing (6th September, 2006).

The days of open consultative development of e-Health Policy in Australia would now seem to be over given we now have nothing other than private discussions determining the Heath Ministers decisions and NEHTA having advisory groups whose membership seems to be a state secret.

It seems unaccountable bureaucracy rules! All in all a sad day.


Saturday, September 02, 2006

What’s the Secret? - Political Comments – Part 2.

A few months ago I discovered your humble correspondent had made a minute contribution to the Smartcard debate by providing a quote that permitted the Labor Party Spokesman on the Smartcard Project to ask a question, with notice, of Minister Joe Hockey regarding the costs of the project.

The question and the responses are as follows:

Mr Kelvin Thomson asked the Minister for Human Services, in writing, on 14 June 2006:

(1) Is the estimated cost of $100 million to register Australians for the Smartcard, attributed to consultant Dr David More in The Australian on 13 June 2006, accurate; if not, what is the correct sum.

(2) Does the $1.1 billion allocated for the Smartcard project in the 2006 Budget include a sum for Smartcard registration; if so, what sum has been allocated for that purpose.

(3) Is the estimated cost of $100 million to provide the Smartcard cards, attributed to consultant Dr David More in The Australian on 13 June 2006, accurate; if not, what is the correct sum.

(4) Does the $1.1 billion allocated for the Smartcard project in the 2006 Budget include a sum for provision of the Smartcard cards; if so, what sum has been allocated for that purpose.

(5) Is there an intention to allow private businesses use of Smartcard infrastructure.

(6) Has he, or the Smartcard Taskforce, received advice to the effect that the creation of a more valuable, single proof of identity instrument will increase the appeal and practice of identity theft.

(7) Does he, or the Smartcard Taskforce, plan to endow department or agency staff with the power to (a) confiscate and/or (b) deactivate a Smartcard; if so, (i) who will have that power, and (ii) will the exercise of that power be subject to appeal by the cardholder.

Mr Hockey—The answer to the honourable member’s question is as follows:

(1) The cost of establishing the access card system is $1.09 billion over four years. For commercial reasons, detailed information regarding costs, including the cost of registering Australians for the Health and Social Services (HSS) access card is not publicly available.

(2) Yes, the cost of $1.09 billion over four years to introduce the HSS access card includes funding for the registration of Australians for the access card. However, as noted in the response to question (1), information regarding the estimated cost of registration is not publicly available.

(3) See response to question (1).

(4) See response to question (2).

(5) The Government does not intend to build all Smartcard infrastructure such as cards, readers and microchips. This is not core government business. Therefore it is obvious that the private sector will need to service its equipment.

(6) Advice that the introduction of the HSS access card will increase the appeal and practice of identity theft has not been received by the Minister for Human Services, the Smart Technologies and Services Taskforce or the Access Card Consumer and Privacy Taskforce.

Indeed, as the KPMG Health and Social Services Smart Card Initiative, Volume 1: Business Case notes:

“KPMG considers that greater trust in the overall system will be strengthened by consumers being confident that their card cannot be used by someone else. Having a photograph on the card and all the other securities in place, in our view, is likely to strengthen that confidence.” (Public Extract, Page 18).

(7) The abilities of staff from the Department of Human Services or its agencies to confiscate or deactivate access cards is not yet determined, this will be the subject of detailed design work and the advice of the Lead Advisor and Chief Technology

To prepare this answer it has taken approximately 2 hours and 21 minutes at an estimated cost of $137."

I would suggest you would have to score this answer 2/10 for provision of useful information and 9/10 for stonewalling.

What amazes me is why a breakdown at the level of enrolment costs and smartcard costs could not be provided. Details that might compromise the tendering process for the cards it is reasonable to withhold until such tendering is complete and pricing is determined, but providing estimates to the nearest 10-20 million (as the Government must have to provide the precise total cost of $1.09billion over 4 years) seems secretive in the extreme. It is, after all, a lot of public money and it would seem reasonable for the public to know a little more than just to total cost.

The response to question 5 is really bizarre. The Government would be not be expected to build any of the equipment involved – given there is not even a microchip fabrication plant in the country and it simply has neither the staff or capability to manufacture such products. But this was not the question. The question asked sought to understand if any Government infrastructure would be accessible or usable by the private sector i.e. if a new Government network is to be built to support Smartcard services will be private sector be able to use it.

The answer reveals a very poor understanding on the part of the public servant who drafted the response as to just what was being asked and what the implications were.

In fact, what is virtually certain, is that either a beefed up Medicare Australia network will be used or the private sector will provision the Access Card requirements for a fee which will most likely be transaction or usage based. The cards and readers will simply be purchased or leased commercially on behalf of the Government.

The response to question 6 is equally unsatisfactory. The question was going to the issue of the robustness of the identity services to be implemented to prevent identity fraud. Clearly what was needed in the answer were the reasons how the new card would reduce ID theft and evidence that backed that assertion. It should be noted that systems such as the Access Card are only as robust as their weakest link and the events of the last week or two surrounding the security of Government tax and Centrelink records make it clear where one potentially major weakness lies.

All in all an opportunity wasted for the Government to re-assure the public regarding the Access Card, its costs, its security and its workings.


The e-Health Fiasco in Australia Is Now Recognised – What Should be Done?

Finally at least one side of politics has recognised there is a major problem with the Australian e-health strategy (or lack of it) and has pointed out the “waste and mismanagement” that has been bedevilling the area for years.

The following is the Sydney Morning Herald’s report of the Opposition Spokeswoman for Health.


National health record system 'stalled'
August 29, 2006 - 1:29PM
The government has wasted hundreds of millions of dollars in stalled and failed attempts to introduce a national electronic health record system, Labor says.

Opposition health spokeswoman Julia Gillard said on Tuesday it was widely considered that using information technology to integrate patients health records could help prevent over-referrals, over-prescribing and minimise medical mistakes.

But the government had scrapped the Medicare Smart Card and its new proposed $1.1 billion Smartcard would not provide access to patient medical records, Ms Gillard said.

The much-lauded e-health records system HealthConnect no longer existed as a program and had all but disappeared, she said.

"Recent developments suggest that our national e-health strategy has not only stalled, but is dangerously close to being considered an expensive failure," Ms Gillard said in a speech to the Australian College of Health Services Executives in Adelaide.

HealthConnect - a national health information network designed to integrate patient records from hospitals, doctor surgeries, nursing homes, medical laboratories and pharmacies - was launched in 2000 with claims it could reduce accidental mishaps in treatment by as much as 30 per cent.

But Ms Gillard said "just a handful" of small HealthConnect initiatives were currently running in some states.

"And there do not appear to be any reports about what we have learned from those projects, how they might be further extended or why they succeeded or failed," she said.

"In terms of a coordinated national initiative, we are not much further advanced in this area than we were back in April 1999.

"The problem is that hundreds of millions of dollars have been spent on programs launched with much fanfare and then allowed to die."

Ms Gillard said changing the health care management and delivery system was not an easy task, but the government had missed some opportunities and made some obvious mistakes.

She said states and territories have started their own e-health efforts, raising fears of a fragmented and disconnected system.

Australia now had to face the reality that a national e-health system was at least a decade off, Ms Gillard said.

"To fix the problem we will need a national, collaborative approach and strong national leadership," she said.

Health Minister Tony Abbott in 2003 said the health system would be in "systemic paralysis" if a smart card carrying an individual's medical history was not available within five years.

But the federal government said the HealthConnect project was on track and a major agreement had been made at the most recent Council of Australian Governments (COAG) meeting.”

Ms Gillard made a number of points which were, in my view, absolutely spot on.

These key ones were:

1. “To fix the problem we will need a national, collaborative approach and strong national leadership.”

2. “In terms of a coordinated national initiative, we are not much further advanced in this area than we were back in April 1999.”

3. “The government has wasted hundreds of millions of dollars in stalled and failed attempts to introduce a national electronic health record system.”

The Government’s response to this considered and utterly accurate assessment of the current e-health state of play was that the most recent COAG meeting “had agreed to have a work schedule in place by 2009, a "considerable" step involving consensus about protocols and terminology had been taken with the provision of “an additional $130 million to be invested in the National E-Health Transition Authority, the body responsible for developing the electronic records”.

It also made the utterly ludicrous claim that “HealthConnect is still operational and on track and we are learning some very valuable lessons from the trials that have been going on in Tasmania and the Northern Territory”. This is a barefaced untruth as has been widely reported and thoroughly documented, if in no other place, in this blog. The development of HealthConnect has been totally downscaled and essentially defunded.

The sole element of the minister’s comments I can agree with is that “the minister has expressed his frustration with how slow things are moving, but it is very complicated, and it's moving ahead”.

I would suggest that it is time to say that the HealthConnect centralised model for e-health service delivery has failed in Australia and that what is needed is a radical re-think of approach.

This is implicitly recognised in the timeframes now being talked of by NEHTA for delivery of the Shared EHR Concept of Operations and Version 2.0 of the Interoperability Framework (Both now apparently due some time in 2007).

Evidence would seem to be emerging globally that centralised approaches bring with them high cost, high risk and excessive complexity. Witness the problems being experienced in the UK NHS Connecting for Health Program.

Equally it is now becoming clear that there are models for regional health information sharing that are becoming both technically as well as financially viable. Witness the successes seen in Scandinavia and in some of the nascent Regional Health Information Organisations in the USA.

As I have argued previously there are e-health projects that can make a difference, are affordable and which offer considerable benefit for both clinicians and their patients that could be undertaken in Australia. These include provision of effective General Practice and Specialist Practitioner computerisation, the automation of Acute and Long Term Hospitals, the computerised support of pharmacy, radiology and laboratory practice and the introduction of a common interoperable form of secure health messaging.

That would be a major two to three year agenda that could be sponsored and delivered by either side of national politics with enough will, understanding and determination. One can only hope that both Ms Gillard and Mr Abbott can recognise the value of such an approach – as well as the lower political risk to themselves personally, and move towards having NEHTA adopt such an approach, while possibly continuing some of the important long term infrastructure work they have in their work plan. To just do the latter, without the former, delays benefits to all Australians and carries a high risk of virtually total failure with the associated need to start again in 2010 or so. A quite unacceptable outcome.