Sunday, December 24, 2006

Happy Christmas and A Successful New Year to All.

Just a short entry to wish all the readers of this blog compliments of the season and all the very best for 2007. I hope we can see some real progress next year!

I plan a week off to consider some of the more complex issues and also to review some papers for Medinfo 2007.

Early next year I plan articles covering

• Personal Health Records

• The Opportunity Costs of not Implementing E-Health

• Shared Electronic Health Records – How can They Be Made to Work?

• NEHTA's Pre Christmas Document Releases – Do they Add Anything Useful?

• The IHI And the Access Card – What Total Policy Overlap and Stupidity.

See you in 2007!


Thursday, December 21, 2006

NEHTA’s Contraction of Scope and Role – What does it Mean?

All of a sudden there has been an outbreak of discussion in the GP_TALK e-mail discussion list regarding the role, scope and purpose of the National E-Health Transition Authority (NEHTA).

The discussion was prompted by a correspondent asking - is NEHTA meant to be an Authority that ‘manages a transition’ (e.g. to much wider deployment of E-Health) or is it a ‘transition authority’ which is to be replaced by another authority when its job is done (in 2009 or so).

The official view – from the main Government entry point is not hard to find.

“National E-Health Transition Authority

The National E-Health Transition Authority (NEHTA) has been established to accelerate the adoption of e-health by supporting the process of reform in the Australian health sector. To enable this to occur NEHTA will develop the specifications, standards and infrastructure necessary for an interconnected health sector. The development of the foundations for widespread adoption of e-health is NEHTA's core mission. “

However NEHTA seems to have moved away from this – now saying on its home page (dated September 2006):

“Welcome to NEHTA Limited, a not-for-profit company established by the Australian, State and Territory governments to develop better ways of electronically collecting and securely exchanging health information.

Electronic health information (or e-health) systems that can securely and efficiently exchange data can significantly improve how important clinical and administrative information is communicated between healthcare professionals. As a result, e-health systems have the potential to unlock substantially greater quality, safety and efficiency benefits.”

And that their “website outlines the work that is being done by NEHTA to deliver a secure, interoperable e-health environment.”

The key difference is a much narrower role focussed on facilitation and enabling rather than direct intervention and support. It seems that NEHTA no longer sees itself as having a direct role in accelerating the adoption and use of Health IT, and also that NEHTA perceives it has no direct infrastructure or implementation role. Clearly, NEHTA sees these roles as being for someone else! (This view is supported in the recent “Privacy Blueprint” where there is much discussion of what sort of entity will deliver identity services – making it clear it won’t be NEHTA).

This view also fits with the NEHTA work-plan which focuses on developing services for provider and individual identification and for clinical terminology which will be used by other systems. NEHTA also says it is developing specifications for Shared Interoperable Electronic Health Records although it seems this work has progressed little in the last year as nothing significant has been published recently in this area that I can find.

This is most likely because similar initiatives overseas (UK and Canada) have hit quite difficult times and the levels of complexity in developing such shared records are becoming much better understood (I plan an article on this topic in due course).

The change in emphasis is of very considerable concern.

The reason for the concern is that with the establishment of NEHTA a lot of planned activity by both State Governments and the private health IT sector was put on hold, awaiting NEHTA guidance, support and direction.

It now seems this is not going to come promptly or the strategic way expected and with the HealthConnect program in mothballs (if not formally dead) NEHTA has now become a “dead hand” on innovation and progress in e-health in Australia.

In the last few days I have been approached by and chatted to both academics and industry players involved in secure messaging, software development, standards development, e-Health consulting and supply chain reform. All are concerned at the loss of momentum, lack of communication and strategic uncertainty.

What needs to be done to ensure there is a crystal clear understanding by all stakeholders of what NEHTA is actually now planning? NEHTA must urgently and clearly articulate just what it will deliver and by when and more importantly what it will not or cannot do and leave innovation and progress to others.

The problem we all now face is that, with the inertia and confusion that has now been engendered by NEHTA’s changes in emphasis, it may take some time for effective leadership to re-emerge. One can only hope the revamped AHIC can provide the needed strategic leadership and rapidly regain some much needed momentum.


Tuesday, December 19, 2006

Australian Health Information Council Resuscitated – What Should Be on the Agenda?

I am told that the Australian Health Information Council – the new and resuscitated version is to have its first meeting in February 2007.

I am also told the new chair is Professor James A Angus, BSc (Syd.) PhD (Syd.) FAA, Dean, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne. It seems Professor Angus is a very distinguished Australian pharmacologist with an interest in all sorts of receptor classes. His biography does not mention any clinical experience or health information technology background.

I am not sure whether congratulations or commiserations are appropriate for Professor Angus – time will tell I guess! (At present I have not seen an official announcement so this may be wrong in whole or in part.)

What would I want to see addressed at the first few meetings? The following, in priority order, are what I would (gratuitously) suggest.

1. The first meeting needs to work out how many seats should be around the table and who should occupy them. There is an embedded clique, I believe, of government committee attendees in this domain, many of whom have led the E-Health agenda for the last 15 years. As progress has been less than stellar it is not inappropriate to suggest that perhaps a transfusion with some new blood would be advisable. While some old blood should be maintained for corporate memory etc – at least half of the committee should have never been involved in the old AHIC or any of the committees that report to it. Perhaps it would be sensible if the Chair initially enrolled a foundation core of three or four independent experts to consider the issue of subsequent enrolments.

There should also be minimal, if any, crossover of membership between the NEHTA board and AHIC.

2. The reporting lines and governance of AHIC should be such that it is genuinely independent and is able to provide quality strategic advice to Ministers unfiltered by any external influences.

3. The new committee needs to make sure it has the resources and the independence to get things done – this means a real and tangible budget and a competent, dedicated, expert secretariat. There must no part-time bureaucrats who battle through. Ideally there should be a staff of three or four real experts to advise and assist. If it is not clear this will happen prospective committee members should just walk away in my view.

4. The new committee should closely review the terms of reference. These were watered down in November 2005 from the original 2003 version to read:

“Set up by Health Ministers in July 2003, AHIC works closely with the National Health Information Group to increase the effectiveness of IT investment in the health sector.

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.”

I would suggest the following terms of reference for the revamped AHIC.

A. To promptly review the progress and current status of E-Health in Australia (E-Health being broadly defined as the use of ICT in the health sector – and especially in Health Service Delivery) and benchmark and evaluate it against progress in the rest of the OECD.

This review should be of strategic and major operational systems only – not every isolated trial system in the first instance.

B. To develop a National E-Health Strategic Plan, Business Case and Implementation Plan, for presentation to and funding by Ministers within 12 months of the February 2007 meeting.

This plan needs to reflect the Health Service business drivers. These include efficiency and effectiveness of the health system, patient safety, quality of care, public health monitoring and reporting, clinician job satisfaction and retention and so on.

Issues of use and adoption of Health IT and aspects of security and privacy will also be critical to address.

Any plan must also be practically focussed and based on proven technology. It must embrace the use of standards which can be demonstrably implemented and which meet health system requirements. Benefits which flow from implementations should be focused on those who actually use the systems, not those who would like a free ride from the ‘uncompensated’ efforts of the ‘users’. This probably means introducing meaningful financial incentives for some stakeholders.

C. To advocate with all appropriate stakeholders the importance of planned, consultative action in the E-Health space.

D. To work with the Jurisdictions, the IT Industry and the Private Health Sector to obtain predefined optimal national E-Health outcomes.

E. To ensure NEHTA’s plans and directions are brought into alignment with the National E-Health Agenda and that NEHTA’s resources are focussed where the majority of CLINICAL and PATIENT benefits are to be found.

After this has been achieved I would be more than happy to let AHIC develop the rest of its agenda itself – but the members may want a long, well earned rest!


Sunday, December 17, 2006

Are The Wheels Coming off in the UK NHS Health IT Program?

It has been clear for some time now that the English National Health Service (NHS) National Program for Information Technology (NPfIT) has been meeting a range of difficulties.

The initial vision was that, with the expenditure of approximately 4% of the NHS budget on IT, it would be possible to create a national E-Health environment that would provide a major improvement to the quality and safety of care both in the ambulatory and hospital environments over a period of about a decade and that this investment would support the dramatic re-shaping and modernisation of the NHS.

In concept a central data “spine” was to be developed which had a range of common services and which used common Informatics Standards (HL7 V3.0, SNOMED CT etc) and standardised products from a range of hospital and ambulatory care vendors to create and maintain a spine based shared Electronic Health Record for all UK citizens. The project was huge, involving expenditure of $A30 Billion over the decade.

The whole thing is one of the most ambitious public IT projects ever undertaken anywhere in world.

Two recent events have prompted the present commentary. Before this there have also been major controversy regarding patient consent issues, the financial difficulties of a major technology provider (iSoft) and contractual difficulties and changes in providers as well as some key delays. This is said to have contributed to major morale problems and uncertainty.

The two recent events have been:

1. Lord Warner the health minister responsible for the £12.4bn NHS IT project is to retire at the end of the year. Lord Warner was a strong proponent of the NPfIT and his departure is undoubtedly a major blow to confidence.

2. The British Computer Society’s (BCS) Health Informatics Forum has produced a careful and generally critical strategic summary of the current state of play.

This report is available on line at:

“Key recommendations of the report include:

• The provision of a business context for the English National Programme for Information Technology (NPfIT) at national and local level.

• A focus on local implementations at Trust and provider unit level, for example hospitals, diagnostic and treatment centres, community and mental health Trusts, practices. Providing specialty and service-based systems within provider units will encourage clinical involvement and give quicker benefits.

• There needs to be a major emphasis on standards to enable systems to interoperate effectively, rather than focusing on a few monolithic systems.

• The strategy should be evolutionary, building on what presently works and encouraging convergence to standards over time, rather than revolutionary.

• To adopt a truly patient-centred approach at the local health community level

• There are major issues about the sharing of electronic patient data which need to be resolved. These must not be hijacked by technical issues, and informed patient consent should be paramount.

• Transform NHS Connecting for Health (CfH) into an open partnership with NHS management, users, the informatics community, suppliers, patients and their carers, based on trust and respect.

• The clinical professions, NHS management and informaticians should collaborate to provide clear and comprehensive guidance for all sectors on good record keeping and data management – clinical and other, and embed this in undergraduate and post graduate training. The NHS should facilitate the take-up of this guidance.”

Interestingly the summary of the report also says “The NHS CfH programme can still make a massive contribution to safer and more appropriate patient care and remains in full agreement with the Wanless report that 4 per cent of NHS turnover should be spent on business-led informatics, according to the BCS Health Informatics Forum (BCSHIF) Strategic Panel.”

On these eight bullet points, above, I would offer the following commentary:

1. The length of time between the original strategy development in 1998 and the present has allowed alignment of the IT and business needs to drift. This is a major risk and the BCS report very correctly says it needs to be addressed.

2. The BCS recognises the need to get quality basics in place quickly – and this is very sound. People need to see success to believe further success is possible.

3. The BCS is keen on standards based interoperability. I have some reservations this is achievable in the short to medium term – but if a sensible messaging strategy is adopted there is very little downside. The detail of the report makes it clear the BCS understands the practical difficulties of implementation of some of the standards and that time may be required to get things right.

4. The suggested movement from a centrally controlled implementation model to a more collaborative approach is clearly very sensible – although how this can be done at a practical level will need to be thought through.

5. The move to a patient-centred approach at a local level is sound if what is intended is more patient control of their information. The detailed text makes it clear this general direction is supported.

6. The BCS Forum clearly understands the complex issues around information sharing, consent and the like and wisely suggests progress be dramatically slowed until practical and acceptable solutions are found and properly evaluated.

The report also is keen that initiatives around PACS, Choose and Book and GP Record Transfer (GP2GP) continue saying they seems to be working as are some of the central spine services (Patient ID etc).

Overall I think this is a very, very sound twenty pages that has many answers for the UK and also is a valuable document for Australian readers as well. I commend it to you.

The real risk is that central NHS bureaucrats will loose their nerve and funding for the program will dry up, rather than an appropriate review and continued support for a forward direction and continued investment. (There is a real likelihood this is what happened in Australia with HealthConnect)

Should this happen the “I told you so” pundits and the risk averse will have a “once in a generation” win and IT enabled healthcare delivery globally will be a major looser. I really hope those involved in the UK can work through all this.


Wednesday, December 13, 2006

Is SNOMED CT a Practical Usable Clinical Terminology Today?

In a recent posting at the E-Health Insider web-site it is reported that the Royal College of Physicians is urging a “universal and rapid SNOMED deployment” to be undertaken by the UK Connecting for Health IT Program.

The article can be found here:

More interesting than the article is an anonymous response to the suggestion found at the bottom of the article. This is worth quoting in full as it goes to make some points and provide some useful resources for those interested in the area of practical, clinically useful SNOMED CT implementation.

“12 Dec 06 12:29

SNOMED: caveat emptor

Readers of this article (and the RCGP) are advised to check the detail before rushing into demands for immediate SNOMED implementation.

Major suppliers, would be implementers and academics are on public record stating SNOMED has manifest and significant quality control and implementation issues.

On a purely pragmatic level, clinical code sets supporting QOF/QMAS on the DoH website (URL changes almost daily :-( ) for SNOMED have not been updated since 2005 release (unlike those for the Read Codes which are up to date). This latter alone is unlikely to encourage jobbing GPs to queue up as guinea pigs for the 'imminent' releases of SNOMED enabled systems from EMIS, In Practice and others.

It just isn't as simple as whip the system suppliers I'm afraid.”

A review of the material found on these pages certainly raises some interesting and very complex questions and I would suggest anyone with an interest in the area review these two sites and the links / downloads provided carefully.

The messages I came away from all this material with were as follows:

1. If David Markwell’s presentation from March 2006 is to be believed the work of encapsulating the complexity for SNOMED CT behind a useable clinically friendly interface has yet to be completed. Without well engineered seamless interfaces to the use of SNOMED CT adoption and use of the terminology will be very slow indeed

2. The Kaiser Permanente implementation of SNOMED CT within its EPIC software implements a narrow subset of the full contents of SNOMED to make clinical coding and billing easier.

3. Professor Alan Rector (a global terminology guru if there is one) from Manchester University has recently said in a presentation that “Unless we can formalise the mutual constraints ... HL7 v3 + SNOMED = Chaos'. 'The documentation is beyond human capacity ... to write or to understand'.”

4. Other groups appear to be really struggling to deploy usable clinician friendly systems.

5. There are some significant academic linguists and ontologists who have very significant concerns about the underlying data model on which SNOMED CT is based.

6. The emergence of supporting terminologies in areas where localisation to a specific country is needed (e.g. in the local formulary) has been slower that might have been expected.

7. There is at least some concern regarding the overall data quality of the material already contained in SNOMED CT.

8. There also seem to some harmonisation issues between HL7 V3.0, CEN/ISO Standards and OpenEHR with Archetypes which indirectly impinge to some extent of terminology use.

What does all this mean practically?

I think that it is at least possible that large scale deployment of clinician friendly SNOMED CT may be more delayed than is anticipated at present – i.e. out to beyond 2010 and there is even the possibility that it may all prove ‘too hard’ and some simpler better designed approach – based on the lessons learnt from SNOMED CT – may need to be engineered.

Whatever happens it seems clear all those interested in the area should spend some time getting familiar with the current state of play so they can formulate, for themselves, informed estimates of just when systems which fulfil the promise of SNOMED CT are likely to be available.

I for one will not be holding my breath. Just as HL7 V3.0 and openEHR have taken over a decade to be developed and are not yet quite ready for ‘prime time’ as far as I know I suspect history will repeat with SNOMED CT.

I hope I am wrong!


Monday, December 11, 2006

The Access Card Debate Begins in Earnest.

ABC Radio National today broadcast a very useful review of the proposal for an Access Smartcard which is currently under development by the Commonwealth Government with the pointman being the Minister for Human Services, Joe Hockey.

The show, Background Briefing, is summarised by the ABC as follows:

Getting smart: the Access Card

The government is bringing in a new national card, called the Access Card. Everyone who uses Medicare, Centrelink, or any government service, will have one. And they're not just normal cards. They have mini-computers inside them that can store data about your name, address and anything else. The government says they're like mp3 players, and big business loves them, but opponents say they're a new version of the Australia Card - an ID card in disguise. And they say that privacy is in peril. Reporter: Sharona Coutts”

The fifty minutes of audio, suitable for playing on both a PC or portable .mp3 player can be found here:

Among the interesting points made in the show were the following:

1. Enabling legislation for the Access Card has not been passed and is due to be introduced in the first half of 2007. Mr Hockey recognises that this will be the time when the project will be under most challenge. It would be a ‘courageous decision’ to spend too much before that approval is obtained. At present the Opposition is saying they don’t have enough detail to be sure which way they will vote. It seems unlikely the Greens or Democrats will support the proposal so the numbers in the Senate are likely to be tight. In the House of Representatives it is hard to know how things will play out with some Liberals being philosophically opposed to ID cards or anything like them.

2. The Government has developed a Privacy Impact Assessment for the Access Card proposal (with the assistance of Clayton Utz, a major national law firm), but it is not being released for reasons which have to be very hard to understand.

3. The Government asked a Privacy Task Force to review the proposal and when the Task Force said the individuals signature and ID number should not be human readable (i.e. written in clear text) on the card these recommendations were rejected. The concern with this information being readable is that this will make it easy for anyone to obtain (or demand) an individual’s key number and maximise the risk of “function creep” of the card. Over time it is feared everyone from the video shop up will want to record the card number and use the signature to verify identity.

4. The Government (and Mr Hockey) are not prepared to disclose even his estimates how long and complex the access card enrolment process for each citizen. This leads to concern about just how accurate the start up costing estimates and the actual proposed start date are.

5. Mr Hockey claims the Secure Customer Registration System (SCRS) will hold less information than an individual’s driver’s license but fails to disclose the range of linkages to other huge databases (e.g. CentreLink and Medicare) that will be required for the system to work.

6. It does seem that it will be technically very difficult to have citizens use their Access Card and their PC to securely store information on their card without creating highly exploitable security weaknesses as Mr Hockey has been suggesting.

7. A system as centralised as the one proposed here, but having so many users, is inevitably going to be abused by Departmental insiders for profit, curiosity or worse. (Witness the breaches at the ATO, CentreLink and the Child Support Agency). There seems to be an emerging sense of concern in the community regarding the risks such systems pose to some vulnerable parts of the population (e.g. separated wives who are being sought by their abusive husbands etc.)

As I have pointed out before, those of us who are interested in the deployment and use of Health IT have a vested interest in this project and similar identity management efforts. If the public and political contention around the Access Card becomes significant there will be negative impacts on all efforts to improve access to, and the flow of information, in other domains – including health.

It seems unlikely, for example, that NEHTA’s plans for an Individual Health Identifier (IHI), delivered as a web service it is assumed, would not be caught up in any Access Card contention and debate. It is interesting that NEHTA plans have thus far not attracted much, if any attention from the various privacy and security lobbies.

Equally, concern may emerge regarding the efforts of the various State Health Departments to deploy State-Wide universal identifiers (I wonder how many State Health Departments would want to record the Access Card Number once it becomes available? Unless they were legislatively barred I suggest the number would be close to 100%).

It seems to me that if both the privacy and function creep issues around the proposed Access Card are not handled both more robustly and more sensitively that presently appears to be the plan E-Health may wind up a major collateral casualty of a potentially failed Access Card implementation.

I commend the show as a very good listen.


Availability of Electronic Decision Support Evaluation Guidelines

Some good news has just been received from Professor Enrico Coiera. I thought it was worth posting the information here.

"Subject: EDSS Evaluation Guidelines

The AHIC EDSS evaluation guidelines have been unavailable for some time, with the demise of the AHIC website.

I'm happy to announce that we are now hosting the guidelines at our site:

Please let me know if there are any difficulties in accessing the material, and any thoughts on how we keep this project alive are most welcome.

Also, please do circulate the url to your EDSS colleagues.

Prof. Enrico Coiera
Centre for Health Informatics
University of New South Wales
UNSW 2052 NSW Australia
T: +61 2 9385 9026
F: +61 2 9385 9006"

Professor Coiera can be reached at the following e-mail address e.coiera (-at-) if required for comment etc.

These guidelines were developed by the UNSW Centre for Health Informatics two or three years ago having been commissioned by the now apparently defunct Australian Health Information Council. While maybe now very slightly out of date they are an invaluable resource for all interested in the field.


Sunday, December 10, 2006

Sometimes It’s Vital to Just Opt-Out!

Underneath the calm exterior of the NSW HealtheLink project it appears there is a little policy anxiety and confusion.

Prior to the trial commencing a Privacy Policy was published dated March 17 2006. As regular readers will be aware the policy was based on automatic opt-in and capture of clinical information with notification to each patient that they had thirty days to ‘opt-out’ before any information held on the Healthelink database would become available to all registered healthcare providers.

Regular readers will also be aware that, although there is an audit trail to record access to records, once any provider has access to Healthelink they can search for and locate any patient for which the most basic identifying information is known (e.g surname and approximate age).

The only patient control available is essentially to opt-out of the entire system.

We now find seven months later the Privacy Policy has been updated. The new document is dated October 22, 2006.

Two things appear different.

First the residential postcodes 2170 (around Liverpool) and 2560 (around Campbelltown) have been excluded from the paediatric trial. It’s hard to know what motivated these changes – unless maybe these areas lacked co-operating GPs.

Secondly the following has been added to the Privacy Policy.

2.3 Information specific laws and policies

All personal health information is generally considered to be sensitive personal information, dealing as it does with matters that are personal and which an individual will generally expect to be shielded from public disclosure.

Sometimes individuals will have different expectations about how some of their personal health information will be used or disclosed. These expectations can be based on their own cultural or personal background, family situation, a feeling that certain information is particularly stigmatizing. Some common examples include information collected by services providing specialist genetics services, child protection services or sexual health services. There are additional legal restrictions imposed on use or disclosure which apply to the release of a person’s HIV status, adoption and organ donation information.

Whilst the Healthelink pilot system does not have the ability to identify and restrict access to these different types of personal information, some information is able to be filtered out prior to being lodged with Healthelink. These are:

• Data received from community based sexual assault and PANOC (Physical Abuse and Neglect of Children) services. NSW has special restrictions on access to adult and child sexual assault records and PANOC records, in accordance with the Criminal Procedures Act, the Children and Young Persons (Care and Protection) Act , the NSW Interagency Guidelines on Child Protection, and other NSW Health Policy.

• All molecular genetics test results (e.g. familial cancer gene status) and all cytogenetics test results (e.g. karyotyping) received from community based genetics services in the Hunter New England Area Health Service.

• All HIV associated test results (e.g. HIV antibody, HIV conformations, HIV viral loads) received from Hunter New England Area Health Service. .

Unless the individual requests otherwise, health professionals who access the Healthelink record will be able to see all other personal health information contained in an individual’s Healthelink record. If an individual has concerns about this, they may choose which organisations can have access to their record, or the individual may elect to opt out of the system.

Alternatively, healthcare providers can contact Healthelink to request that access to individuals’ records by the individual or their associate be restricted if they consider there are risks to the individual. Further information about managing sensitive information generally is provided in a number of NSW Health policies which guide staff on the management of personal health information. These are summarised in the NSW Health Privacy Manual, Section 15.9.”

Essentially, what we have here is a confession that some very private and sensitive information can slip, unknown to the patient, onto the Healthelink data-base. Were this not the case the change shown above would not have been necessary. I can only assume it is to avoid Government liability for breach of trust and / or disclosure of a possible serious risk.

Given the inevitability of security violations – even in the best regulated environments – the inability of a patient to have sensitive data actually removed from the database – rather than simply made inaccessible - is a serious worry.

That better and more robust privacy controls were not developed before the trial commenced is also a real concern. Clinicians really need to look very hard at the contents of their clinical records before permitting automatic transfer of their patient’s record to Healthelink in my view, despite being assured they are indemnified.

Before posting there is another gem I noticed in the Privacy Policy as I was reading it through. After saying that personal private information can be disclosed for emergency, compassionate, audit legal and a range of other issues there is one last reason.

11. Use and disclosure as required by the Minister or Premier

NSW Health may use or disclose personal health information if the information is required by the Minister or Premier.

Further details: Privacy Manual, Section 11.3.14

Just exactly why the Premier or Minister would be so empowered beggars belief. No wonder there are problems with community trust in such projects when things like this are said to be acceptable. One has to be grateful the authorisation was not “the Premier or delegate” – which might ensure any public servant could disclose and use - I guess.

I note in passing some of these information categories are held on the Oacis databases in South Australia. I have yet to hear back as to how these sensitivities are handled there.


Thursday, December 07, 2006

The Government Has Absurdly Low Expectations for Practice Incentive Payments.

The Australian General Practice, Practice Incentive Program (PIP) has been in operation since 2001. In this program accredited General Practices are provided with financial incentives to reach various performance targets. The PIP grew out of the Better Practice Program in response to a series of recommendations made by the General Practice Strategy Review Group (GPSRG) that reported to the Government in March 1998.

Payments are made on the basis of a factor termed the Standardised Whole Patient Equivalent (SWPE) which is an estimate of the level of practice complexity and activity based on information gathered by Medicare Australia during its payment processing for Medicare funded services.

The typical General Practice will be about 800 – 1600 SWPEs per full time doctor – e.g. a 4 man practice will have a SWPE of about 4000. The statistically average FTE GP sees 1,000 SWPEs annually according to Medicare Australia.

The overall program is by no means trivial having cost $250+ Million in 2005/06.

One component of the PIP focuses on the deployment and use of Information Technology in General Practice.

The IM/IT PIP program used to cover three areas until it recently was updated – with different requirements for payment eligibility – in November, 2006.

In the earlier version the payments were as follows:

Tier 1 - Providing data to the Australian Government - $3.0 per SWPE

Tier 2 - Use of bona fide electronic prescribing software to generate the majority of scripts in the practice - $2.0 per SWPE

Tier 3 - The practice has on site and uses a computer/s connected to a modem to send and/or receive clinical information - $2.0 per SWPE

Thus to receive $7000 a year per practitioner a practice essentially had to fill in a few practice profile forms, utilise prescription printing software that could be obtained very cheaply or free from HCN Ltd and have a modem to pick up results electronically from a local pathology provider.

Given the economic life of a PC is about three years this amounts to a very substantial payment for a PC and a printer. Even if a networked environment for three to four practitioners was deployed $60,000 - $80,000 would be more than enough to fully fund the system, its installation and a considerable profit!

It should also be remembered that prescription printing – and most especially repeat prescription printing - is one GP computing function that has been demonstrated to save GPs time and thus money. Despite this we (the public) paid them to start using it!

Under the new payment scheme the criteria have been updated.

For Tier 1 the practice has to record electronically the allergies of a majority of their active patients and to have in place adequate internet and anti-virus security measures. This gets the first $4.0 per SWPE.

For Tier 2 the practice must record major diagnoses and current medications in the patient’s electronic record. This generates an addition $3.0 per SWPE.

On the basis that there are a little over 4000 practices are signed up for the IM/IT PIP payments, and that they have an average of three practitioners each, this is costing approximately $84 Million per annum. A non trivial sum I would suggest.

What is actually going on here is that the Government via Medicare Australia is paying GPs to undertake the most basic parts of electronic patient record keeping and setting the expectations so low that only minimal benefits are likely to flow.

Were there requirements to actually code diagnoses and medication so useful practice statistics could be generated and issues such as tracking ADE’s for newly introduced medicines could be undertaken there would possibly be some real value.

Additionally coding would enable basic clinical decision support relating diagnosis and treatment to be achieved – a major benefit.

Also it seems the software requirements of the present program could be, clumsily, met using a simple spreadsheet or database program with no ability to be improved and extended to deliver more benefit. That there is no requirement for certification of the functionality and safety of the software used by GPs to obtain PIP payments is appalling and a major policy failure.

For the money to be claimed there should be quality, functionally rich software supporting advanced clinical support insisted upon and used. Anything less is really risible.

As a concerned citizen I believe we should all expect more certainty of benefit for our GP computing money.

When we combine these funds with other Commonwealth funding of programs such as Broadband for Health (BfH), which is funded to as much as $40 Million per annum, as well as other smaller initiatives such as the Eastern Goldfield's Project, we really have the federal Government throwing a lot of money at GPs in an amazingly profligate fashion.

It seems to me, just as there is a need for strategic clarity from NEHTA, there is an equally strong case for the same from DoHA in terms of clear objectives and evaluation of the expenditure.

Simple, relatively inexpensive, proven to be effective, initiatives such as replicating the NSW Health Department’s Clinical Information Access Program (CIAP) nationally for GPs and specialists would be likely candidates for investment as would the sponsorship of the development of quality, certified clinical systems for clinical use.

I wonder, has a business case to justify all this spending ever been developed or has there ever been a retrospective review of the impact of the spending?

To quote Mr Abbott from a press release of December 2005 which was based on a speech entitled: Better records make better doctors

A speech by Minister for Health and Ageing, Tony Abbott, to the Australian Medical Association E-Health Forum, Canberra, 8 December 2005.

“Five years ago, the Health Ministers' Council first committed all Australian governments to the development of an integrated IT-based health record system. Over the past decade, the Commonwealth Government has paid some $600 million in IT-linked GP Practice Incentive Payments. Over the past 18 months, the government has committed $60 million to the Broadband for Health initiative, designed to ensure that every general practice and pharmacy has access to business-grade connectivity. So far, the government has committed more than $110 million to developing HealthConnect, including $9 million in half-funding the National Electronic Health Transition Authority which aims to standardise usage and facilitate inter-operability of federal, state and private health IT systems.”


This is almost $780 Million in all over the decade. I wonder what benefits we have really received for all this investment?

I am sure any other program of this scale would have to have been rigorously evaluated. Has anyone seen the report?


Wednesday, December 06, 2006

The Children of HealthConnect – How are They Going – Part 2?

This is the second article on the children of the now defunct Federal HealthConnect program. It covers initiatives that are branded as HealthConnect in Tasmania and the Northern Territory (NT).

Northern Territory.

There are essentially two projects under development in the NT, with the initial Shared Electronic Record being in abeyance either permanently or until NEHTA develops and publishes implementable standards some time in 2008 (on the current plans).

HealthConnect NT does not appear to have its own project web site.

The Northern Territory Department of Health and Community Services (DHCS) is responsible for implementing HealthConnect and other leading e-Health initiatives in the Territory.

Project 1 is the Point to Point (P2P) service, a secure electronic communication network between health professionals across approximately 200 potential sites in the Top End commencing in Darwin and Katherine.

The HealthConnect funded Point to Point (P2P) Service is based at the Top End Division of General Practice in the Northern Territory started in September 2005. The technology used is secure e-mail using Argus as the e-mail client

As of June 2006 approximately 50 practices have been connected to a range of specialists. It is planned to gradually extend the network to also cover ancillary services, pathology and radiology etc as well.

Further extension to more remote areas is planned for 2007.

Project 2, which will involve electronic prescription transfer, is being planned to start in mid 2007 according to the ArgusConnect CEO in a recent e-mail.

As far as this all goes it is a distinctly good thing to improve communications between practitioners in the NT.

There are however a range of practical and strategic issues with all this.

First Argus is a software product that, while having the GP client being ‘open source’ has only a limited guarantee of long term supported commercial viability. That is not to say failure is guaranteed but rather that it is possible and this needs to be factored into decisions to adopt Argus. (As the user base grows this risk will hopefully drop).

Second the utility of the product is very much dependent on the network effect (i.e. it becomes more useful the more users there are – much like the telephone). The competition in this market segment makes reaching critical mass by no means certain.

Third the choice by Argus to make their client software free continues a trend that at least some would suggest has had a severely distorting effect on the growth of the clinical software market in Australia.

Fourth the need for a centralised directory for e-mail addresses etc to contact other Argus users introduces the ‘single point of failure’ issue that Argus competitors are said to have, albeit in a less acute form.

Fifth the choice of communication standards adopted by Argus – while practical at present – may prove to be somewhat limiting in the future.

With this said, this seems to me to be a worthwhile initiative that should be watched closely as it evolves and at some point evaluated to see just what level of value is being received for the costs involved and how the total costs of ownership and operation compare with the alternatives.

It does also need to be said that, although branded HealthConnect, this project bears scant resemblance to the 2004/5 Business Architecture (Version 1.9) envisaged for HealthConnect originally.


For some reason, seemingly associated with a certain Tasmanian Senator, there have always seemed to funds available for speculative technology ventures – especially of the electronic kind. Tasmania’s long path to success was chronicled in the Launceston Examiner last year.

LGH Launches New System

By Alison Andrews, Tuesday, 4 October 2005, Courtesy of the Launceston Examiner.

The days of doctors' notes are numbered with the launch of HealthConnect at the Launceston General Hospital yesterday.

The national health information network has been three years in the making and will mean that LGH doctors will be able to send a note about patients to their local general practitioners electronically rather than in traditional paper form.

The system was trialled in Southern Tasmania three years ago, concentrating on people with chronic diabetes, while the LGH was a test site for an associated initiative, MediConnect.

This offered secure electronic information between hospitals, doctors and pharmacies to help improve quality and safety in the handling of medicines.

The new system, to electronically link hospitals and GPs, will start in Tasmania at the LGH, and next month will include the launch of HealthConnect's admissions and discharge notification project, said the services' director Mary Blackwood.

"That will allow immediate notice of a patient's admission and discharge," Mrs Blackwood said.

HealthConnect is a national initiative supported by the Federal Government. Tasmania and South Australia are the first two states to introduce the new communication system.

Launceston GP Jennifer Barker welcomed its launch.

"GPs are always busy and it is good to know that we are moving beyond the trials to the implementation stage," she said.”

This exciting innovation is the so called Electronic Notification of Hospital Events (ENHE) project, where a fax or e-mail is sent to a GP, with the patient’s permission, to let them know their patient has been admitted or discharged from Hospital. No clinical information is sent – just an administrative notification.

Flush with the success of this awesomely complex project a new project has been commenced. This time the discharge notification will also have the discharge medications listed. The scale of the advance has meant the project is now termed the Patient Discharge Medication Record pilot (PDMR).

To quote the project site “The PDMR that is sent to the GP will contain comprehensive medication details, and will have a multi-disciplinary focus, allowing notes from doctors, allied health, and nursing staff to be added.” This project is at present just a future and no time line or additional information has been made available as yet. We will wait and see!

HealthConnect Tasmania is also involved in projects that have nurses communicate warfarin test results to GPs so they can adjust dosage, a GP Assist Call Centre to divert calls from the public to the right information source, and the use of laptops for the ambulance staff to record their transport details (a copy of an already operational Melbourne system).

The recently published 2006/07 Health Connect Tasmania work plan (dated 22/11/2006) bring tears to the eyes in terms of vagueness and obfuscation – as virtually all HealthConnect documentation has done since the end of 2004.

HealthConnect Tasmania Work Program 2006-07

In 2006-07 the HealthConnect Tasmania work program is progressing in three key areas:

• HealthConnect Tasmania Core Activities, including: eHealth promotion and communications, eHealth governance and evaluation, eHealth policy, planning and support, and eHealth core systems and services;

• HealthConnect Tasmania Partnerships which is largely the management and expansion of the HealthConnect Tasmania Outposted Officers program within key stakeholder organisations; and

• HealthConnect Tasmania Sponsored Projects, a program of projects which are collectively progressing the national outcome, “enabling health care providers to have access to a broader range of information through standardised secure electronic communication”.

It is hard to know just why this was published when the period affected is already half over. Typically plans are finalised and published before they commence. It is even harder to know just what all this actually means!

Again we find the HealthConnect banner being used to fund and sponsor conducting trivial, non-standardised, repetitive and utterly non-innovative projects. The lack of strategic direction and national value is really appalling and very sad.

As a final note, it is clear the HealthConnect web site, while updated regularly, has not been reviewed for content currency in a while. It is still – as of early December 2006 - extolling the virtues of the Medicare Smartcard – oblivious to the fact this has apparently been abandoned in favour of Joe Hockey’s Access Card months ago.

Overall these two posts have described a dramatic fall back and withdrawal of the Federal Government from old HealthConnect the vision and a sad collection of trivially simple, non-standardised, non-scalable projects which seem to have little intrinsic value and which lead essentially no-where. The $128 Million of funding supposedly spent on all this could surely have been much better spent than this.

The NT Point to Point Project (using Argus) is the only slightly bright light, despite its possible flaws, on a very dark landscape.


Monday, December 04, 2006

The Children of HealthConnect – How are They Going – Part 1?

It is clear, to all but the totally out of touch, that the transition of HealthConnect from a program to a “change management strategy”, which happened between late 2004 and mid 2005, after a secret and unpublished internal DoHA review, has meant the demise of the initial vision of a Shared Clinical Electronic Health Record for Australian citizens.

It is fascinating to read the three implementation plans / approaches for HealthConnect – dated November 04, June 05 and July 05. In the documentation we see the dramatic shift from a clearly serious project – a broad implementation plan for Australian E-Health - to vague ‘mumbo-jumbo’ in just seven months. This after four years and millions of dollars have been spent.

HealthConnect has three “Children” if one counts those projects which still carry the HealthConnect brand. In these posts I plan to review each of these and consider what has been achieved. An earlier post addressed the NSW HealtheLink project which no longer seems to be branded as HealthConnect on the basis of the press release announcing the initial patient recruitment in March 2006.

The first post considers South Australia. Tasmania and the NT will follow.

HealthConnect South Australia.

This series of initiatives are being delivered from the SA Health Department. The project office was established in July 2005.

The good first – the Project has a nice current web site that explains what is happening and what is planned.

HealthConnect SA is currently working on two major e-health initiatives: the Care Planning and Communication Trial and the roll-out of Broadband Security Packages to South Australian health providers.

With respect to the Broadband Security Packages it is hard to see what justifies these freebies and what distinguishes doctors from other professionals who would be happy to have free secure broadband access. With no requirements as to what is to be done with the connection it is hard to see this as anything other than a rort. I am sure lawyers, accountants and others wonder why they can’t have the same deal!

The $500 security review that comes with these packages is also questionnable. If the supposedly top 1% of the population intellectually cannot workout how to connect a PC to the Internet safely then who can?

The Care Planning and Communication Trial is a rather amazing initiative. It is planned that a service provider (Ozdocsonline) will sign up 50 practices in South Australia. It seems this will help them comply with the requirements for creation of care plans for ‘difficult patients’ which in turn will enable them to receive a higher Medicare payment for care co-ordination.

Using a web-interface to securely access a server in Sydney, the practitioner (and practice nurse) will create and store a patient record on the server in Sydney. The record will be made up of a patient clinical summary which is a MS Word Document created by a GP practice management system and ‘cut and pasted’ into the new record. The system then allows for the creation of planned actions (referrals, reviews, etc) which can recorded and also scheduled for review or action.

Having put a few of these together one can then print out a ‘care plan’ of actions for the patient. Also, where actions are required a non-secure e-mail can be sent to a specialist, podiatrist or whoever is asking them to log on-to the secure server to find out what they are required to do.

So, what do we have here?

What I see is a commercial, for profit (ie. Ozdocsonline), non-standardised and non standard, non NEHTA compliant, non guaranteed-data transportable, short term, privacy weak, functionally limited, exchange of MS word documents and a few other data elements which lacks the granularity in privacy control which is needed. Also, access to the ‘facility’ expires in 12 months unless the practitioner starts paying or moves to some non-existent prospective new system which at present does not exist.

Information held on this system does not interact with the practice management system. Unless the practice management system is regularly updated the two systems will rapidly diverge!

It is very difficult to see just what is in it for the practitioner or indeed other service providers other than the extra Medicare payment. Why go to the effort of logging on and doing all this when there are much simpler ways to go about doing the same thing?

In my view this is just the sort of non mainstream initiative which acts to prevent any real progress being made. Given that it has just started I am sure the evaluation report of early 2008 will make riveting reading – assuming it does not suffer the fate of so many other HealthConnect evaluation reports and is never published.

Also it is quite surprising to have the project established and underway prior to HealthConnect SA seeking applications from consumers interested in participating in a Consumer Reference Group to provide advice for its care planning project as of 20 November 2006. One would have thought that any well conceived and planned project would have had this Reference Group established long since and that it would have been involved in all phases from initial planning, project software selection, etc rather than confronting the Group with a fait accompli.

Independently I also hear GP consultation may not have been as robust and thorough as might have been expected.

Previous initiatives from HealthConnect SA have included development of a document on Change Management in E-Health for the GP Sector which identified that financial incentives had been a necessary but not sufficient driver of GP Health IT adoption (making a difference for patients also matters). This is hardly news given that the Practice Incentive Program and its predecessors have been shown to make a difference over the last 5-8 years.

Another initiative has been a High Level Connectivity Options Paper for HealthConnectSA which has as its most distinctive attribute the fact that it is classified!

The cover has the following statement.

“ This document has been re-classified as “C1 Low” Public Information and unrestricted access.

The complete document is classified “C3 High” Limited ‘need to know’ access and is available on application to the HealthConnect SA project office””

The document makes absolutely no startling conclusions and just why it is classified is really very strange. The fact that a classification system exists is a shock in itself for a health system organisation.

Overall the activity at HealthConnect SA seems to me to be either technically basic or very poorly conceived and well off the mainstream in terms of directions and standards adoption. Money is being wasted once again I suspect and I very much doubt very much of value will come of any of this longer term.

At the risk of repeating myself it is abundantly clear that the lack of any National E-Health Strategic Direction is a major contributor to the reasons why such ill conceived projects are given financial support – it should be obvious that just doing something for the sake of doing something is really not good enough.


Sunday, December 03, 2006

A Few Follow-Ups from Previous Articles.

1. Isoft.

It seems the news has gone from bad to worse.

Goldman Sachs Slashes iSoft Target >IOT.LN

Thursday, November 30, 2006 11:22:48 AM ET
Dow Jones Newswires

1459 GMT [Dow Jones] Goldman Sachs cuts iSoft's (IOT.LN) price target to 55p from 80p, to reflect estimate changes in light of the company's financial restatements, revisions to its banking facilities and the renegotiation of the NHS contract. The bank says "significant financial and execution risks remain, which could potentially bring the company close to breaching its banking agreements." The new target is based on "25% probability of bankruptcy, 45% probability of a maintenance DCF value of 65p, and 30% probability of 85p." Reiterates neutral recommendation. Shares trade -2.5% at 39p. (BBL).

This can hardly be good news for those in NSW, the ACT and Victoria who have believed the iSoft promise of a long stable commercial relationship.

2. Oacis Privacy Controls.

To date I have yet to hear from John Mleczko who is the Director Projects Branch ICT Services, Department of Health, South Australia regarding my few questions on just how patient control of information is preserved and managed in South Australia’s Oacis environment. It has only been since the 23rd of November, 2006 so I am sure I will hear soon.

3 Personal Health Records

On the 29th November, iHealthBeat ( reported on a major new PHR project in the following terms.

“Large Employers To Launch EHR Plan

Wal-Mart Stores, Intel, British Petroleum and other companies next week will announce a plan to provide and promote usage of portable electronic health records for their employees, the Wall Street Journal reports.

Last summer at the request of CDC, Wal-Mart and Intel joined together on the plan after meeting separately with the agency to discuss individual company efforts to reduce health costs. According to the Journal, the goal of the collaboration is to reduce health spending by having patients coordinate their own health care among hospitals, pharmacies and physicians.

The EHRs, which will be stored in a multimillion-dollar data warehouse, will be interoperable and routinely updated. Eventually, about 10 employers will collaborate on the plan, and each will contribute $1.5 million for the initiative. The companies maintain that portable EHRs will allow employees and insurers to evaluate price- and quality-performance data from millions of employees, as well as reduce medical errors, duplication of tests and administrative overhead.

In addition, physicians could use the records to measure the effectiveness of different treatments for groups of patients with chronic illnesses. The companies plan to use market pressure and incentives to encourage physicians and hospitals to participate in the program.

According to the Journal, the "employers will insist that health care providers adopt electronic records and prescribing as a condition for future business." Wal-Mart will use its purchasing power to put bar codes on products intended for use in hospitals and clinics. The companies also expect employees to select physicians who are willing to use and update their records, although employee participation is not mandatory, according to the Journal.

Meanwhile, the Patient Privacy Rights Foundation is discouraging employers from participating in the initiative until adequate privacy protections are put in place (McWilliams, Wall Street Journal, 11/29).

Clearly the majors in the US private sector see benefits in such initiatives.

4. 100 Posts

Amazingly the blog has now made it to 100 posts with this entry. A small sip of champagne I think.

Thanks to all who read and especially those who bother to comment!


Oh Joy, An Australian Politician Who Understands E-Health!

With the political turmoil happening in the Australian Labor Party – and an election for leadership positions happening on Monday 4 December, 2006 – it seemed important to bring to the attention of my readers the views on e-Health of one of the key protagonists.

On the basis of these remarks I would be keen to see her succeed I must say – all other issues laid to one side.



Remarks to the ACT Chapter of the Australian College of Health Service Executives

Date: 18 June 2006
Remarks by
Julia Gillard, MP
Shadow Minister for Health


Thank you very much for inviting me here this evening. It’s a pleasure to be able to join you for dinner once again, to celebrate the ACT Chapter’s 30th birthday, and to hear more about the work of the Australian College of Health Service Executives.

Health issues are never out of the news. Some days we hear of health care miracles, other days we hear stories of those for whom the system failed.

But whether today’s news story is a good one or a bad one, the fact remains that our health care system is in need of reform and we need strong national leadership to make that happen.

That’s why Labor has insisted that we must be bold enough to undertake long-term reform to address the gaps, holes and duplications in the system caused by the separate Commonwealth and State funding streams and to end the bickering, cost shifting and blame game that currently passes for the national management of our health system.

As individual health executives and as members of a key professional organization, you will be players in determining what reforms are needed, and in implementing them.

Which is why I thought that tonight I would address the issues around the information and communications technologies which must underpin these reforms.

Everyone agrees that new IT systems and capabilities can transform our health care system by revolutionising the way services are delivered, health care professionals work together, resources are managed and deployed, and research and its outcomes are communicated.

There is the expectation that the use of IT to integrate patients’ health records could help prevent over-referrals and over-prescribing and help minimise medical mistakes.

There is the hope that it can ensure that patients are more involved in their own health status and health care.

And without improved and consistent national data collection, we can’t assess the full impact of changes made, we can’t know the full costs and attribute them to the right funding source, and there can’t be full accountability.

Revelations from Senate Estimates

Let’s look at where we are today.

Recent developments suggest that our national e-health strategy has stalled. To be honest, I’m tempted to say it has been an expensive failure.

Following what the Department of Health and Ageing and Medicare Australia are doing in this regard is not easy. Responsibilities have shifted, programs have changed names, and the plethora of committees and advisory groups continues to grow.

One of the advantages of the Senate Estimates process is that you can, with a little effort, find out some of the things that the Government haven’t told us.

No Smart Card to enable patient access to e-health records

In Senate Estimates this time we around we discovered that Minister Hockey made the decision in May – unannounced – to scrap the Medicare Smart Card. At the same time, in his speech to the AMA Annual General Meeting, he let drop that the proposed Access Card will not have the ability to provide access to electronic health records.

In a speech to the National Press Club back in April 2004, I outlined how a second generation Medicare Card could link together the information that currently sits scattered across the health system and enable the management of a seamless health system for patients.

I spoke about a Medicare Card that could contain basic health information, the kind which would be useful in an emergency. I talked about how this Medicare Smart Card, when used with a unique patient identifying number, could give access to a patient’s full electronic health records. And I emphasised how important it was that the patient would control who was given access to their health data.

When Tony Abbott rolled out his Medicare Smart Card, with much fanfare in July 2004, I supported it.

But Tony Abbott’s Medicare Smart Card is dead, and there is nothing on the horizon to replace it, as Joe Hockey has made clear.

The whole-of-government Access Card now being developed under Joe Hockey’s oversight will replace your current Medicare Card and you won’t be able to access Medicare rebates without it.

But Joe Hockey’s whole-of-government Access Card isn’t about access to electronic health records.

We know that of funds committed through COAG to the National e-Health Transition Authority, $45 million will be spent on a unique patient number for every Australian, but there is no information as to how this system relates to anything else the Howard Government is doing.

We don’t know how it relates to Joe Hockey’s Access Card. We don’t even know how it relates to the fact that Medicare Australia will be spending even larger sums on developing a different unique identifier for each Australian.

What we do know is that Joe Hockey’s whole-of-government Access Card won’t do the job a Medicare Smart Card was supposed to do and his plans are fraught with uncertainty and privacy concerns.

HealthConnect has disappeared

From Senate Estimates we also learned that HealthConnect no longer exists as a program, leaving only three small HealthConnect initiatives currently running in South Australia, the Northern Territory and Tasmania.

Indeed, HealthConnect has disappeared from the lexicon of the Department of Health and Ageing and there is some revisionist history at work.

HealthConnect used to be described as a “the proposed national health information network to facilitate the safe collection, storage and exchange of consumer health information between authorised health care providers.” (2003-05 Health Connect Project Plan)

Now the Secretary of the Department of Health and Ageing says: “[HealthConnect] is not actually a program. We should be clear about that: HealthConnect is not a program. There were a series of projects that were funded historically. We have moved now from the trial stage. I think I said yesterday that we have continued with a couple of projects, but we are now moving into an environment where we are looking to a national approach to e-health.”

I think we can say that, in terms of a coordinated national initiative, we are not much further advanced in this area than we were back in April 1999, when the Australian Health Ministers agreed to set up the National Health Information Management Advisory Council (NHIMAC) to “oversee new strategies for more effective health sector information management”.

This Advisory Council then commissioned a National Electronic Health Records Taskforce to report on technology and health records which was done in July 2000.
As a result of the Taskforce report, the Health Ministers agreed to support the development and implementation of HealthConnect and the Better Medication Management System. The cost of the scheme was then cited at around $440 million over 10 years.

The Better Medication Management system morphed into MediConnect and then died after two small trials in Launceston and Ballarat.

HealthConnect trials began in 2002 and as I have noted, some of these continue today, but the reality is something considerably less than we might hope for after 4 years and an investment of more than $200 million.

To date the only real legacy we have is a document released in April 2005 entitled “Lessons learned from the MediConnect and HealthConnect Trials”.

It’s not what I would call bedtime reading. The report is pretty bland and the lessons learned are not obviously stated, but I guess this paragraph sums it up:

“An electronic health record system is technically feasible, but the underlying infrastructure and connectivity ….limited the success of most trails and will be critical to the successful implementation of HealthConnect.”

What went wrong?

Hindsight is always twenty-twenty and I’m certainly willing to acknowledge that introducing new approaches to the management and delivery of health care is not an easy task.

It’s as much about changing the culture and individual behaviour as it is about the sequences of putting the infrastructure and software in place, testing it, and spending resources wisely.

But I think there are some fairly obvious mistakes and some very real missed opportunities.

1. There was no real public statement of what a major investment in e-health would achieve.

The need for a major investment in e-health has been pretty well articulated at the macro level, with some very grand promises made. But at the grass roots level – the level where acceptance and adoption of new systems and approaches is required – individuals have found it hard to see the benefits and easy to see the disadvantages.

People in Tasmania saw no value in spending the time and money to get a full birth certificate and 100 identification points to get a Medicare smart card, with the only apparent difference from the current Medicare Card being the photo on it.

Busy GPs saw no value in spending more time in writing up electronic health records when many of their colleagues did not use the same IT system or in some cases, did not use an IT system at all.

Surely the single biggest objective should have been ensuring all hospitals could communicate with each other and with GPs electronically using the same medical terminology. To achieve this big objective would have required a true partnership with the States and Territories.

But rather than a single-minded pursuit of a big objective – an objective that would potentially save lives and dollars – what we have seen over the past five years is the Howard Government spraying funds on consultancies and individual projects.

Unfortunately, it seems the Howard Government is still on that same merry-go-round with Minister Hockey’s whole of government Access Card. Privacy issues in particular have not been addressed and already there are legitimate concerns about cost management.

Unless and until these issues are addressed and there is a clear statement of intent about the Access Card, the public are entitled to remain sceptical.

I am not the first person to criticise the Howard Government’s approach to e-health as unfocussed and uncoordinated. Back in 2004, the Boston Consulting Group released a report that made the following observations about a flurry of activity in e- health:
* The average project size was small with funding spread across many priorities;
* There were many areas of overlap, due in large part to a lack of national leadership;
* Decision-making was frustratingly slow and lines of responsibility were unclear; and
* There was a real need for the adoption of common standards.

Unfortunately these messages went unheeded.

2. People need to see the advantages of e-health systems for them personally.

There are some wonderful examples out there of how e-health can make a real difference in the effective delivery of health care services, with a positive impact on peoples’ health.

The use of IT to link specialists into the diagnosis and care of cancer patients in rural areas is a great example.

At Geelong Hospital Dr Stephen Bolsin has pioneered an individual performance monitoring system that uses small hand-held computers to continuously check doctors’ clinical performance against recognised standards, leading to better medical training, fewer adverse incidents and improved safety for patients.

But at the same time, grandiose talk about smart cards and shared electronic health records from the Howard Government has left many Australians concerned that
current systems to protect privacy and ensure secure transmissions are inadequate.

3. We must create a real partnership between the Commonwealth and the States.

As a consequence of the problems outlined in the Boston Consulting Report, the States and Territories felt they had to proceed with their own efforts in e-health, and several States have made some very significant investments.

This has led to the very real fear that we will end up with a national e-health system as fragmented and disconnected as the railway system once was. That means a lot of money and resources going to waste.

There was a real opportunity to address this issue in the context of the 2003-08 Australian Health Care Agreements. Unfortunately, that opportunity was lost.

4. Basic IT systems are not there in many parts of Australia

Finally, I think we must also acknowledge that until we have a situation in Australia where everyone can have ready access to super fast and affordable broadband access, there is no possibility of driving even the simplest proposals forward nationally. That’s why Kim Beazley has committed that a Beazley Labor Government would invest in a national broadband network.


I think we have to face the fact that a national e-health system is at least a decade off.

We have lots of good intentions and, finally, some important agreements in place between the governments. But we have very little of the needed infrastructure,
including the basics like broadband, only the first draft of a set of standard clinical terms, no current means of accurately identifying health care providers or patients, and no systems to ensure the privacy of shared e-health records.

A lot of money has been spent and I’m concerned that goodwill and opportunities have also been wasted.

I know you wouldn’t manage your health services in this manner, but the Howard Government’s management of e-health does matter to you and does impact on your work.

To fix the problem we will need a national, collaborative approach and strong national leadership. We will also need all your skills, insights and abilities. Only then can we begin to reap the benefits of the e-health revolution.

Thank you."


It is hard to take much exception to much of what is said here. Perhaps it would be good to see a recognition of the need to develop a consensus driven National E-Health Plan and some real commitment to actual investment in the plan to operationalize it once developed.

This statement is as sound as could be hoped for and reflects a degree of understanding of the issues I have yet to see from any other National politician.

More power to her e-health arm!


Saturday, December 02, 2006

Health IT – What is in the Way of Progress?

In the last few weeks I have been ruminating on what is in the way, and what are the roadblocks, to improved Health IT deployment and use in Australia.

There is no doubt that this is a multi-factorial issue that involves human, technical and financial aspects. If we consider the current situation there are some clear facts.

1. It is possible to build, deploy and have used computer systems that can assist with the operations, efficiency, safety and quality of hospitals. Suitable systems both from here and overseas are available to suit most of the patient management, clinical and administrative operations of both small, medium and large hospitals. The same can also be said systems to operate diagnostic laboratory and imaging services.

2. The same is true in the provision of support for General Practice and Specialist Office Practice with the market beginning to mature and evidence of significant contestability of system selection emerging. (Medical Director’s market share is no longer more than 2/3 of the market with IBA, Genie and Best Practice making some headway). Recent changes in the Commonwealth Practice Incentive Program is also ensuring more of the available functionality is actually being used.

3. Messaging of pathology and radiology results is being widely deployed via a number of providers (Argus, Medical Objects, HealthLink, Promedicus etc). Referrals to specialists are also gradually beginning to happen electronically – albeit as yet in pretty un-standardised form by and large. At present there is a great deal of prescription printing but very little, if any, in the way of prescription transmission electronically.

4. There has been considerable investment on development of a range of Standards which have facilitated the communication of pathology results at the individual test level using HL7 V2 which has made these results more usable. At present, however, a majority of results are still transmitted using the PIT format.

All this is very positive and if there could be near to complete penetration of these technologies where ever they are needed it would be a major public good.

Consideration of what has been achieved and what is known to work today leads to a recognition of there being a range of gaps.

First messaging of useful clinical content in computable, as opposed to “blob” forms is yet to be developed and needs to be as a priority.

Second the information held in many systems (both Ambulatory and Hospital) is held in forms which are not easily transferred between competing systems (leading to a level of ‘vendor lock in’) Indeed some vendors even encrypt information and them refuse to provide access keys without payment of maintenance fees – a most cynical exercise indeed.

Third the data, information and terminological standards to enable more that be most basic system inter-operation are still under development or unproven.

Fourth there is a very complex and highly contested debate about how information should be stored, versioned and structured within the EHR. Both the openEHR Foundation and HL7 have spent a very long time working in this area – especially trying to work out how to preserve the clinical meaning of patient information as it is moved from one computer system to another – and it is by no means clear if either have a practical and workable solution to the problem. This issue is in turn causing some difficulties as far as the finalisation of CEN/ISO 13606 (EHRCom) standard for the transmission and receipt of extracts of patient clinical records.

Fifth Australia’s full deployment of SNOMED CT is still years off given the need for localised subsets and other necessary enabling add-ons.

Australia at present has also not decided on the approaches it will use for clinical documents sharing in more general messages and in the shared EHR environment (CDA RII, plain XML and the CCR are all possible candidates among others I understand).

What is common in all the areas that are outstanding as not yet being easily soluble?

I would like to suggest that moving to the next level of information sharing and interoperation is an order of magnitude more complex than what has so far been achieved and that the standardisation and ontological issues that need resolution for confident forward investment to be made are not easily resolvable and may take many years of further effort for resolution and clarity to be achieved. If it were easy it would have been done by now!

My discussions with those close to and my readings of a range of sources from the key camps involved in these efforts (and in the harmonisation efforts) admit to very considerable levels of difficulty in defining a way forward – especially if consensus is to be reached. There are many strong opinions and a lot of conviction around forward paths which may not be easily harmonised.

It seems to me that this situation argues strongly for focus and investment on those things that are proven and known to work while there is continued (but lesser) investment in attempts to solve the five and ten year problems.

There is plenty to do to get the basics in place, develop the privacy and other necessary policy infrastructures and get some simple generalised messaging in place (covering referral, discharges and prescriptions) while waiting for the much more complex issues to be sorted by those capable of really ‘deep thought’.

I would suggest NEHTA would be better of sponsoring a set of proven basics as a major part of its forward work plan rather than the current laudable, but risky, push towards a form of health informatics nirvana which may prove essentially unreachable. If neither HL7 or openEHR have fully implemented scalable demonstration systems after a decade or more of development how much longer are we to wait on trust?