Quote Of The Year

Quote Of The Year - Paul Shetler - "Its not Your Health Record it's a Government Record Of Your Health Information"

Monday, December 31, 2007

The Abject Failure of the Howard Government in E-Health Catalogued!

As part of developing a short document on National E-Health Strategies around the world I thought it would be useful to sort out the HealthConnect documents I have retained and see, when organised, the story that would be told.

Here is a print out of the directories I created.

HealthConnect - Organised

199306 - HCN Business Case

199910 - Health On Line Action Plan

200007 - A Health Information Network for Australia

200008 - Health On Line Summit

200008 - Research Report on EHRs

200101 - HealthConnect Update

200102 - HealthConnect Setting the Standards

200108 - Health On Line Action Plan V2

200110 - Health Supply Chain

200207 - Consent Review

200209 - HealthConnect Board

200212 - Tasmania NT Trials

200304 - Business Arch V10

200304 - Interim Research Report

200307 - HealthConnect Implementation Strategy

200307 - HealthConnect System Architecture V0.9

200401 - HealthConnect Project Plan 2003-5

200402 - Benefits Studies

200404 - BCG Report

200405 - HealthConnect Implementation Brief

200409 - Gap Report - EHR

200410 - HealthConnect Newsletter

200410 - Wooding - HealthConnect

200411 - Implementation Approach

200412 - Business Arch V19

200412 - HealthConnect Overview - Update

200501 - Benefits Realisation Framework

200501 - Legal Analysis for HealthConnect

200501 - MediConnect Evaluation

200504 - External Analysis HealthConnect

200504 - Lessons Learnt Summary Report

200507 - Changed Implement Approach

200507 - Formal Implementation Strategy Change

200508 - Abbott Speech - Abandons HealthConnect

200508 - More Implementation Planning Change

200510 - HealthConnect Conference (Confirming Essentially Zero Implementation Progress)

200512 - Abbot Concern Speech (So much spent – so little progress)

200512 Last HealthConnect Newsletter

200606 - E-Health Newsletter (No longer even HealthConnect)

What is revealed is a seven year saga that ultimately led nowhere!

The waste of enthusiasm, hope and money ($200 million or so probably) is really a tragedy.

It is up to the new Rudd government to do much better that this. I certainly hope they will really learn from this history and develop a strategy and implementation approach that can really work.

They must also not let NEHTA try to repeat what has already failed – as they seem to be intending with their reported COAG submission.

As we move into 2008 – with a new government - I have great hope this may be beginning of a new e-Health era for Australia.

We will see!

Happy New Year to All!

David.

Sunday, December 23, 2007

The Blog Makes 30,000 Visits!

Well amazingly I was checking the site stats at the following date and I saw the blog had made it to a bit of a milestone.

The date and time were : Dec 17 2007 09: 28: 36AM GMT: +11

Here are the stats I saw:

VISITS

Total - 30,000

Average Per Day - 99

Average Visit Length - 2:13 mins

Last Hour - 7

Today - 28

This Week - 691

PAGE VIEWS

Total - 48,806

Average Per Day - 159

Average Per Visit - 1.6

Last Hour - 10

Today - 46

This Week -1,116

This really is a great outcome and helps to encourage me to keep up the typing.

With this objective past we can now wind down for Christmas.

Baring urgent breaking news normal services will resume Monday January 7, 2008

A safe and happy time to all.

David.

YouTube and the Electronic Health Record!

While browsing some articles regarding the current use of EHR’s in the UK to provide patients with access to their records I came upon the following URL:

www.youtube.com/watch?v=LW4OcgVyB4w

I watched and suddenly realised that this was just the introduction to a series of very interesting short videos around a range of issues and concerns about how proper patient access could be safely and sensibly provided and what the potential benefits and risks might be.

I then noticed there were all sorts of other related material available.

To check things out I then tried a search for “Electronic Health Record”

The results of my search can be found here:

http://www.youtube.com/results?search_query=electronic+health+record&search=Search

The top few finds were as follows:

The Electronic Health Record: Is It Worth It?

A discussion of the flaws and downfalls related to Electronic Health Records and Computerized Physician Order Entry Systems...Downfalls Electronic Health Record Computerized Physician Order Entry

Time: 05:59

Benefits of the Electronic Health Record

This is a discussion of the benefits of the electronic health record. Specifically the author evaluated CPOE and BCMA for cost and quality...BCMA CPOE EHR

Time: 05:02

Implementation of an Electronic Health Record

This is a narrated Power Point presentation of how to use Microsoft Project to facilitate the implementation of an EHR....EHR

Time: 06:59

Electronic Health Records

This presentation reviews the benefits and challenges of electronic health records....health

Time: 05:20

Add Video to QuickListProtecting Electronic Health Information

For more information, please visit http://hcmarketplace.com/prod-2978-EUTUBE.html...HCPro EHI

Time: 02:08

Electronic Health Records

Medical Practice Management Software...Amplus Practice Management Software Medical Doctor Nurses

Time: 05:41

Overview of the Continuity of Care Record (CCR) XML Schema

Care Record (CCR) standard is a patient health summary standard. It is a way to create flexible documents that contain the most relevant and timely core health This video gives a brief overview of the structure of the XML Schema. The intended audience is developers just getting started with the schema or want to learn if the CCR will fit their data representation needs.

From: http://www.ccrstandard.com/schemaoverview

The Continuity of Care Record (CCR) standard is a patient health summary standard. It is a way to create flexible documents that contain the most relevant and timely core health information about a patient, and to send these electronically from one care giver to another. It contains various sections such as patient demographics, insurance information, diagnosis and problem list, medications, allergies and care plan. These represent a "snapshot" of a patient's health data that can be useful or possibly lifesaving, if available at the time of clinical encounter. The ASTM CCR standard is designed to permit easy creation by a physician using an electronic health record (EHR) system at the end of an encounter.

From: http://en.wikipedia.org/wiki/Continuity_of_Care_Record
(more)

Time: 09:48

There is a huge range of material – up to and including long videos of near to an hour on digital identity management and so on.

This could easily cost a long Saturday afternoon just browsing!

Have fun.

David.

Useful and Interesting Health IT Links from the Last Week – 23/12/2007

Again, in the last week, I have come across a few reports and news items which are worth passing on.

These include first:

Health IT strategies ineffective, says HealthLink

Despite having created one of the world’s best IT-enabled primary care systems, New Zealand’s innovation has stalled

By Randal Jackson, Wellington | Sunday, 16 December, 2007

New Zealand’s health IT strategies and policies are seemingly confused and ineffective, says HealthLink chief executive Tom Bowden.

In a wide-ranging document addressed to “health IT opinion leaders”, he is severely critical of government, though he doesn’t single out any one government agency for criticism.

HealthLink was formed in 1993 as a public-private partnership. It specialises in the development of e-health infrastructures and services, and is active in New Zealand, Australia and Canada.

Bowden’s document is entitled Rethinking New Zealand’s Health IT Strategy and Delivery — a candid viewpoint.

He says that despite having created one of the world’s best IT-enabled primary care systems, New Zealand’s innovation has stalled. Very few new services are now being introduced, and there are significant problems ahead of the health sector unless the barriers to delivery of good information technology are removed, he says.

“New standards that have been developed are not being implemented. Very few new services have been developed of contemplated. A sector that has counted upon innovation is seeking little of no tangible progress year on year. There is no widely agreed strategy that will support investment in development of services.”

Bowden says that over the past six years there has been a major increase in central government’s role in delivery of e-health. “A number of government-funded agencies have attempted to play an active role in the development of new services . . . There is significant fragmentation of the process, and the complex range of government agencies has left little room for involvement by the private sector organisations that led the way prior to 2001.

“Promised additions of key infrastructure have not been delivered (a health provider index, data dictionary are examples). A coherent IT strategic plan is a thing of the past . . . The small amount of funding available is being expended upon projects under the direct control of government agencies rather than being used on the ‘frontline of care’ where users can make better purchasing decisions and create a competitive market for services.”

Bowden says HealthLink is not trying to apportion blame but that automation needs to be improved to unblock a log-jam of unimplemented infrastructure and standards that prevent integration companies from delivering new services.

He highlights three main issues:

— Lack of strategic direction.

— Lack of clarity of government’s role in IT.

— Lack of funding.

“Even Ministry [of Health] staff find the current strategy relatively unhelpful. A senior Ministry staff member recently described HIS NZ’s 12 action zones as the usual laundry list of solutions to the perennial basket of problems.

Continue reading below

http://computerworld.co.nz/news.nsf/news/D1E146A46F11CFB5CC2573B20078F376

It seems that at least some of those on the “Shaky Isles” – which have been a bit more shaky recently – are feeling that the progress of Health IT in New Zealand is off the boil – after a period go good progress. I must say the key issues raised have a certain familiarity about them!

Second we have:

http://www.healthdatamanagement.com/news/standards25357-1.html?type=printer_friendly

Feds Adopt More Data Standards

HDM Breaking News, December 17, 2007

The federal Office of the National Coordinator for Health Information Technology has announced adoption of three additional data standards for use in federal health care I.T. systems.

Federal agencies in recent years have adopted about two dozen other standards as part of an initiative to use the government’s purchasing power to promote standards-based I.T. The three newly adopted standards are:

* The Digital Imaging and Communications in Medicine multimedia messaging standard from the National Electrical Manufacturer’s Association.

* An allergy messaging and vocabulary standard using messaging segments from Health Level Seven, and codes from SNOMED CT, the National Library of Medicine, the Food and Drug Administration, and the Department of Veterans Affairs; and

* A disability and assessment standard using HL7 messaging standards and the Logical Observation Identifiers, Names and Codes from Regenstrief Institute.

Read the complete article here:

http://www.healthdatamanagement.com/news/standards25357-1.html?type=printer_friendly

The full announcement and links to all the other standards approved by the US government can be found here:

http://a257.g.akamaitech.net/7/257/2422/01jan20071800/edocket.access.gpo.gov/2007/07-6058.htm

With the adoption, and the continued support, for both DICOM and LOINC in defined circumstances it is clear the US is taking a more nuanced approach to Standards than is being seen from NEHTA.

It really makes no sense that DICOM is not also an Australian Standard in my view.

NEHTA’s Standards Catalogue can be downloaded from here:

http://www.nehta.gov.au/index.php?option=com_docman&task=doc_view&gid=405&Itemid=139

The disclaimer at the end makes fun reading. (Appendix A, Page 54 of Version 4.0 dated December, 2007). It essentially says you use all this at your own risk, it may or may not work, it may or not be adopted by others and we reserve the right to change our mind any time we feel like it!

Also of interest is this other Standards related announcement

HL7 Expands Board with New Members

HDM Breaking News, December 17, 2007

Standards development organization Health Level Seven has named three individuals to its newly expanded board of directors.

See the names here:

http://www.healthdatamanagement.com/news/standards_HL725359-1.html

It is of note that one each comes from the US, UK and Canada. Seems we don’t quite cut the mustard on the world stage. I wonder why?

Third we have:

Agency for Healthcare Research and Quality funds KP study of electronic records for heart disease

December 17, 2007 (Oakland, Calif.) – The Agency for Healthcare Research and Quality has awarded $600,000 to Kaiser Permanente’s Center for Health Research for a study that uses electronic medical records to examine heart disease prevention and management in 175,000 adults to find ways to improve the quality of cardiovascular care nationwide.

The two-year study, which will begin to yield findings next summer, will review medical records of 175,000 men and women at Kaiser Permanente’s Hawaii region to analyze how following care guidelines for cardiovascular disease prevention and management are connected to morbidity, mortality, and costs of heart disease.

This study, one of seven recent studies that leverage Kaiser Permanente’s robust electronic medical records system, will look at care patterns for heart disease prevention methods such as smoking cessation, weight management, high blood pressure, high cholesterol and diabetes management, and use of beta blockers and their related outcomes and costs. Despite advances in diagnosis and treatment, cardiovascular disease remains the leading cause of death and disability in the United States and one of the fastest rising causes of death and disability in the world.

The methodology of using KP HealthConnect™ to improve healthcare outcomes is being examined as a model by a growing number of researchers nationwide, several health systems and the National Committee for Quality Assurance.

Continue reading here:

http://www.eurekalert.org/pub_releases/2007-12/kpdo-afh121407.php

Again we see the benefits of a robust EHR system implemented to cover the service delivery by clinicians of millions of lives.

We must be very clear here. The NEHTA proposals for a Shared EHR will not deliver the depth and richness of data that are available from the KP HealthConnect. Yet another reason to try and make sure we have a thorough public review and discussion of NEHTA’s presently secret plans.

Fourthly we have:

NHS London orders data transfer review

17 Dec 2007

All deliveries of patient information in London have been halted, and the chief executive of NHS London has begun a review of data transfer arrangements after a CD containing details of 160,000 children was lost.

The encrypted CD containing names addresses and dates of birth was lost in transit from BT to St Leonard’s Hospital, Hackney in an incident that occurred on 14 November.

However, fears the CD could contain enough information to enable ID theft, or place children at risk, have been allayed thanks to BT and the NHS trust concerned – City and Hackney PCT - following NHS data protection procedures.

In line with Connecting for Health rules, the disk was protected using 256k encryption and sent by secure courier by BT to St Leonard’s Hospital IT dept. It was signed for by hospital staff but never reached the person in the IT department it was destined for.

Continue reading here:

http://www.ehiprimarycare.com/news/3317/nhs_london_orders_data_transfer_review

Another reminder of the importance of care with identified data. It is pleasing to see the data was encrypted to prevent un-authorised access.

Fifthly we have:

Study: A new federal tax to fund health IT could pay for itself

By Nancy Ferris
Published on December 18, 2007

A study by a private health care foundation identified options for public financing of health care information technology that could pay for itself within a decade.

If the federal government levied a tax on private insurance premiums and spent about $12 billion a year to subsidize and promote health IT, it could achieve net savings in future health care spending of about $88 billion over 10 years, according to the report from the Commonwealth Fund.

The report, “Bending the Curve: Options for Achieving Savings and Improving Value in U.S. Health Spending,” analyzes 15 steps the federal government could take to hold health care costs down over the next decade. The fund is a private foundation that aims to improve the effectiveness of health care, especially for low-income and uninsured people.

If all the proposed policies were adopted and a universal health insurance program were instituted, spending would be $1.5 trillion less than what the country would spend under the status quo, the report states.

The health IT proposal calls for putting the new revenues from a tax on insurance premiums into a dedicated fund that would finance health IT promotion by the federal Office of the National Coordinator of Health IT and by the states.

Continue reading here:

http://www.govhealthit.com/online/news/350149-1.html

The report can be found linked here:

http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=620087

This is a useful review of a range of possibilities that might be available to assist in funding improved Health IT in the USA.

Lastly we have:

eHealth Initiative Releases Results of 2007 Survey on Health Information Exchange

Trends show advancement in a small number of markets, but action is needed to support U.S. health information exchange sustainability now more than ever

WASHINGTON - December 19, 2007 - Today, the multi-stakeholder non-profit eHealth Initiative (eHI) released the results of its 2007 Fourth Annual Survey of Health Information Exchange at the State, Regional and Community Levels, taking stock of 130 community-based efforts designed to improve health and healthcare through the mobilization of health information electronically.

The 2007 survey results indicate that at least 125 communities across the U.S. are continuing to bring together multiple stakeholders to focus on the secure exchange of health data to improve health and healthcare for patients. Increasingly, such efforts are involving all stakeholders within the system, including clinicians, community health centers, consumers, employers, health plans, hospitals, laboratories, pharmacies, public health agencies, and government.

Twenty of the 130 initiatives included in the 2007 survey are just getting started, 68 are in the process of implementation, 32 are operational, five are no longer moving forward, and five did not respond to the survey question regarding stage of development.

As in 2006, and consistent with findings from eHI's June 2007 report, Health Information Exchange: From Start-up to Sustainability, the most difficult challenge for health information exchange efforts is the development of a sustainable business model. This was identified as a very difficult challenge by 56 percent of 2007 survey respondents and a moderately difficult challenge by 35 percent of respondents. One of the primary reasons that health information exchange sustainability has been such a difficult issue for national and local leaders is that the current reimbursement system, which largely rewards both volume and fragmentation, serves as a disincentive for sharing health information across healthcare stakeholders.

Despite difficulties with achieving sustainability, the 2007 survey report indicates that at least 32 health information exchange initiatives across the U.S. have made progress, identifying themselves as "operational" or "transmitting data that is used by stakeholders", as compared to the 26 initiatives which identified themselves as operational in 2006. The operational health information exchange initiatives identified by the survey are actively exchanging data including outpatient episodes (84%), laboratory results (73%), inpatient episodes (64%), and radiology results (63%). Three quarters of operational health information exchange initiatives are "delivering results" (such as laboratory results) as a service to their customers and 63 percent are providing "clinical documentation" services. In addition more than one fourth of such initiatives are offering services that are designed to improve population health, including disease or chronic care management services (32%), quality improvement reporting for clinicians or purchasers/payers (29% and 26% respectively), and providing laboratory results reporting for public health agencies (28%).

While one-half of advanced stage, operational initiatives received up-front funding from the federal government, many are now receiving ongoing revenues to support operations from non-governmental sources including hospitals (58%), private payers (46%), physician practices (46%) and laboratories (33%), and three-quarters of such initiatives are no longer dependent on grants to support their sustainability. eHI is working closely with operational initiatives to gain much needed insights regarding a set of near-term business cases for the use of electronic clinical health information to continue to advance both policy and on-the-ground progress in this area.

For the first time since the survey was conducted, the government was not cited as the top provider of up-front funding for all health information exchange initiatives. According to the 2007 survey, 53 percent of all initiatives received start-up funding from hospitals, while 44 percent received start-up funding from federal grants and contracts and 43 percent received funding from state agencies. One third of all initiatives have received start-up funding from private payers.

The eHealth Initiative began both tracking and supporting the efforts of multi-stakeholder efforts at the community level in 2003, recognizing the importance of not only national leadership, but also leadership at the local levels where care is delivered.

"The role of local efforts is critical in improving the quality and safety of healthcare in the U.S." said Janet Marchibroda, chief executive officer of the eHealth Initiative. "In addition to national focus on both standards and financing to address sustainability, both leadership and collaboration among multiple stakeholders at the community level is needed, to build social capital for information sharing, build business cases for sharing the costs of an infrastructure that benefits everyone, and facilitate the flow of the clinical information needed for care delivery--much of which resides locally."

Detailed survey results can be found here:

http://www.ehealthinitiative.org/2007HIESurvey/

All in all some interesting material for the week!

Happy Christmas to all!

More in a couple of weeks.

David.

Scotland Updates Its E-Health Strategy

It seems the end of the year is a good time to plan for a new National Health IT Strategy.

New e-health strategy planned for Scotland

13 Dec 2007

A new e-health strategy for Scotland in spring 2008 is promised in a national healthcare action plan, Better Health, Better Care, published this week.

The action plan says Scotland’s incremental approach to deploying technology will continue and the new strategy will build on this. “We do not plan to produce some large single database of patient information but will join up systems where there are clear benefits from doing so.”

Key features of the new strategy will be:

  • action around the three themes of supporting safe, effective, timely and efficient patient care, contributing to equitable, patient centred care and improving e-health capacity;
  • a vision of ever diminishing paper and increasing use by clinicians of secure IT to access the right information in the right place at the right time;
  • a clear focus on patient safety, safeguarding confidentiality, evidence based care and more efficient management of the patient's journey through care;
  • a new emphasis on 'Patient e-health', initially focused on long term conditions, with trials of patient/carer online access to their records along with knowledge to promote self and collaborative care.

Significant progress has been made in e-health, according to the action plan which was drawn up by the Scottish Government. “The Emergency Care Summary now contains key clinical information for over 5.1 million patients and is currently used around 25,000 times per week, if the patient explicitly consents, by clinicians in out-of-hours GP services, A&E departments and NHS24."

Continue reading further details here:

http://www.e-health-insider.com/news/3309/new_e-health_strategy_for_scotland

What is most notable about this is the dramatically different approach the country with approximately 5 million souls is planning to adopt compared with the much larger England and the enormous National Program for IT.

On the basis of the experience from a number of other smaller nations (Wales, Denmark, Sweden and Holland for example) this seems to be a sensible strategy.

I promise I won’t say we need a Plan again!.

David.

The Future of Regional Health Information Organisations in the USA.

This press release appeared last week – and is a useful survey of where the RHIO movement is in the USA.

http://www.healthaffairs.org/press/novdec0708.htm

New Survey From Harvard Researchers Casts Serious Doubt On Future Of Regional Health Data Exchange

Despite The Hype, Many Regional Health Data Networks Fail; Those That Survive Tend To Have Narrow Participation And Limited Information Exchange

Bethesda, MD -- The widely held vision of achieving electronic clinical data exchange across the United States is far from a reality, with few organizations facilitating such exchange and many failing in the process, says a new Web Exclusive study by Harvard researchers published today by Health Affairs. http://content.healthaffairs.org/cgi/content/abstract/hlthaff.27.1.w60

The study, based on a 2007 survey of 145 regional health information organizations (RHIOs), is a comprehensive assessment of the state of electronic health data exchange in the U.S. Electronic health data exchange between hospitals, doctors’ offices, labs, and other clinical settings has been hailed as the key to improving the quality, efficiency, and coordination of care.

But the new survey, funded by Harvard’s Program for Health Systems Improvement, identifies serious barriers to achieving this goal with the current approach.

RHIOs Limited In Spread And Size

At the time the survey was conducted, nearly one-quarter of the 145 RHIOs were defunct. Only twenty initiatives were deemed to be of at least modest size and exchanging some clinical data. Five of those RHIOs exchanged data for a specific population, such as Medicaid enrollees, the uninsured, or patients with a chronic illness like diabetes. Only fifteen RHIOs exchanged clinical data across a range of patient populations.

“These findings suggest that nationwide electronic clinical data exchange will be much harder than what many people have envisioned,” said lead study author Julia Adler-Milstein, a doctoral candidate in health policy at Harvard University. “The expectation has been that we will have RHIOs throughout the country that bring together all the providers in their region and engage in comprehensive data exchange. In reality, we’re seeing few established RHIOs, and those that are established only have a small number of participating groups exchanging a narrow set of data.”

Adler-Milstein’s coauthors are Andrew McAfee, an associate professor at the Harvard Business School; David Bates, chief of general medicine at Brigham and Women’s Hospital, and Ashish Jha, an assistant professor at the Harvard School of Public Health.

Most successful RHIOs started by focusing their efforts on exchanging test results from laboratories and imaging centers, Adler-Milstein noted, adding that that’s where she believes the clearest return on investment lies. Exchange of other data -- such as clinical notes -- is much more difficult to achieve, partly because cost savings from such initiatives are less tangible, she said.

Sustained Funding Sources Needed

Establishing a successful RHIO is not only hard work; it’s expensive, with significant up-front costs, Adler-Milstein remarked. The current approach to establishing RHIOs tends to rely on small start-up grants with the hope that participants will be willing to pay the RHIO once data exchange is initiated. The survey findings suggest that some RHIOs are struggling with the transition to self-sufficiency, as eight of the twenty moderate-size RHIOs reported that they continued to depend heavily on grants. In contrast, nine never received grant funding. Thirteen RHIOs said that they collected recurring subscription or transaction-based fees from participants to stay in operation.

“If we want RHIOs to attain the vision of comprehensive health information exchange, we need to increase our investments in them,” Adler-Milstein said. “Otherwise, many of these RHIOs will be unable to sustain themselves under the current market-oriented approach.”

Other facilitators of success include the following:

-- Data standards than enable different computer systems to “talk” to each other
-- Health data privacy and security safeguards
-- Community buy-in, including overcoming health care providers’ competitive concerns
-- Financial incentives to provide high-quality, cost-effective care

“While many RHIOs are struggling, some have figured out a way to sustain themselves and that is a reason for hope,” said coauthor Ashish Jha. Both authors suggest that meaningful financial incentives for high-quality, efficient care--the so-called “pay-for-performance” (P4P) programs--will help advance clinical data exchange. “Either we have to create the right market conditions or have much greater public investment, but the vision of a national health information network is unlikely to come to fruition without one or the other,” said Jha.

---- End Release

This paper is an important contribution to understanding just how things are going with the RHIO movement.

David.

Saturday, December 22, 2007

The USA Plans to Refine its National E-Health Strategy.

The following appeared a few days ago. All I can say is what a great idea!

ONC Will Issue Updated HIT Strategy in 2008, Says Friedman

By Cindy Atoji

December 11, 2007 | Charles Friedman, newly appointed number-two man at the Office of the National Coordinator for Health Information Technology (ONC) said yesterday than ONC will soon release a five-year strategic plan detailing the national health-IT agenda. Friedman wouldn’t reveal specifics of the plan, but said he hopes it will be submitted for federal review on Dec. 21 and be ready for release in 2008.

This will be the first release by ONC of a coordinated review of its work and that other of other federal agencies since 2004 when then ONC chief David Brailer issued the first strategic framework. Friedman spoke with Digital HealthCare & Productivity about his role and priorities at the ONC as second-in-command to Robert Kolodner. Prior to joining ONC, Friedman worked in research informatics and information technology at the NIH and also established a center for biomedical informatics at University of Pittsburgh.

DHCP: What are your priorities for ONC in the coming year?

Friedman: The number one priority right now is development of our strategic plan. The Executive Order, which created the ONC, called for the creation of a strategic plan, which is a hard thing to do in this very quickly moving field. We are the in process of creating a plan and hope to send it into the federal clearance process on Dec. 21. I’m not sure if we’re going to make it, but we’re going to do everything we can to make this deadline. The plan is shaping up nicely and will be a valuable document not only for office but the government and the nation as a whole when it’s finished.

DHCP: So what’s in this plan? Can you give us a preview?

Friedman: This new strategic five-year plan has a horizon of 2012 or 2014. It will take the spirit of the previously released framework as well as the activities and accomplishments achieved across many agencies along the way and project them forward to create a vision in pursuit of the goal of interoperable health-IT to fulfill the vision of Executive Order for interoperable health-IT by 2014.

Finish reading the interview here:

http://www.digitalhcp.com/hitw/newsletters/2007/12/11/onc-charles-friedman/

This seems to me to be exceptionally good news. Hopefully the document will analyse the progress that has been made over the last four years objectively and assist in identifying the factors that have contributed positively, and negatively, to the current situation.

An improved approach in a number of areas seems to be needed if we are to see the 2014 target even partially achieved.

The following press release makes it clear there are some issues to be addressed

http://www.healthaffairs.org/press/novdec0708.htm

New Survey From Harvard Researchers Casts Serious Doubt On Future Of Regional Health Data Exchange

Despite The Hype, Many Regional Health Data Networks Fail; Those That Survive Tend To Have Narrow Participation And Limited Information Exchange

Bethesda, MD -- The widely held vision of achieving electronic clinical data exchange across the United States is far from a reality, with few organizations facilitating such exchange and many failing in the process, says a new Web Exclusive study by Harvard researchers published today by Health Affairs. http://content.healthaffairs.org/cgi/content/abstract/hlthaff.27.1.w60

The study, based on a 2007 survey of 145 regional health information organizations (RHIOs), is a comprehensive assessment of the state of electronic health data exchange in the U.S. Electronic health data exchange between hospitals, doctors’ offices, labs, and other clinical settings has been hailed as the key to improving the quality, efficiency, and coordination of care.

But the new survey, funded by Harvard’s Program for Health Systems Improvement, identifies serious barriers to achieving this goal with the current approach.

RHIOs Limited In Spread And Size

At the time the survey was conducted, nearly one-quarter of the 145 RHIOs were defunct. Only twenty initiatives were deemed to be of at least modest size and exchanging some clinical data. Five of those RHIOs exchanged data for a specific population, such as Medicaid enrollees, the uninsured, or patients with a chronic illness like diabetes. Only fifteen RHIOs exchanged clinical data across a range of patient populations.

“These findings suggest that nationwide electronic clinical data exchange will be much harder than what many people have envisioned,” said lead study author Julia Adler-Milstein, a doctoral candidate in health policy at Harvard University. “The expectation has been that we will have RHIOs throughout the country that bring together all the providers in their region and engage in comprehensive data exchange. In reality, we’re seeing few established RHIOs, and those that are established only have a small number of participating groups exchanging a narrow set of data.”

Adler-Milstein’s coauthors are Andrew McAfee, an associate professor at the Harvard Business School; David Bates, chief of general medicine at Brigham and Women’s Hospital, and Ashish Jha, an assistant professor at the Harvard School of Public Health.

Most successful RHIOs started by focusing their efforts on exchanging test results from laboratories and imaging centers, Adler-Milstein noted, adding that that’s where she believes the clearest return on investment lies. Exchange of other data -- such as clinical notes -- is much more difficult to achieve, partly because cost savings from such initiatives are less tangible, she said.

Sustained Funding Sources Needed

Establishing a successful RHIO is not only hard work; it’s expensive, with significant up-front costs, Adler-Milstein remarked. The current approach to establishing RHIOs tends to rely on small start-up grants with the hope that participants will be willing to pay the RHIO once data exchange is initiated. The survey findings suggest that some RHIOs are struggling with the transition to self-sufficiency, as eight of the twenty moderate-size RHIOs reported that they continued to depend heavily on grants. In contrast, nine never received grant funding. Thirteen RHIOs said that they collected recurring subscription or transaction-based fees from participants to stay in operation.

“If we want RHIOs to attain the vision of comprehensive health information exchange, we need to increase our investments in them,” Adler-Milstein said. “Otherwise, many of these RHIOs will be unable to sustain themselves under the current market-oriented approach.”

Other facilitators of success include the following:

-- Data standards than enable different computer systems to “talk” to each other
-- Health data privacy and security safeguards
-- Community buy-in, including overcoming health care providers’ competitive concerns
-- Financial incentives to provide high-quality, cost-effective care

“While many RHIOs are struggling, some have figured out a way to sustain themselves and that is a reason for hope,” said coauthor Ashish Jha. Both authors suggest that meaningful financial incentives for high-quality, efficient care--the so-called “pay-for-performance” (P4P) programs--will help advance clinical data exchange. “Either we have to create the right market conditions or have much greater public investment, but the vision of a national health information network is unlikely to come to fruition without one or the other,” said Jha.

----- End Release

Given all the known issues in Australia, and at the risk of sounding like a cracked record it would be great if Ms Roxon decided 2008 was a god year for Australia to also have a plan!

David.

Thursday, December 20, 2007

I Wonder if NEHTA has a Plan “B” or Should They Be Out of the Loop?

As regular readers will know the NEHTA Board announced the following a few days ago.

“The Board of NEHTA also endorsed a business case for developing a national platform for personal electronic health records to be put to the Council of Australian Governments (COAG) early next year.”

This led me to start thinking what were the possible outcomes of NEHTA submitting this business case to COAG, and secondly should they manage anything at-all?

It seems to me there are five reasonably possible routine outcomes – and the required one!

First, COAG could endorse the Business Case and provide the funding that is requested for the four year project.

This seems to me to be a very unlikely outcome – in part for the reasons outlined in the previous blog – see here – and in part because COAG would want, at the very least, to make sure there are regular milestones and conditional benchmarks applied to the flow of funds and other resources.

Additionally, if COAG has its wits about it, it may say it would like this project to be positioned within the context of a National E-Health Strategy to ensure all the necessary ducks can be properly aligned.

Second, someone on COAG may remember HealthConnect, and suggest that as well as the present Business Case, a review of previous attempts – along with more detailed planning – be undertaken to firm up the project details, benefits, stakeholder consultation etc such that after that work has been successfully completed more substantial approval may be forthcoming.

This seems to me to be a much more likely outcome.

Third COAG may approve, say, an initial twelve months of funding and other resources, set some milestones and benchmarks and look forward to a progress report in a year’s time. This seems to me to be very unlikely as COAG will recognise the political risk of starting something like this and then having to stop it if it does not look to be going well – exactly as happened with HealthConnect Version 1.

It also is likely there will be sufficient corporate memory in the Commonwealth Department of Health and Ageing (DoHA) that there would be resistance to a project of this scale and risk setting out without very considerable proof of concept work being done.

There would be a lot of problems if, at 12 months, things were not going well..as is more than possible

Fourth, COAG might say that it is not comfortable that all the necessary pre-work has been done and ask for a more detailed business case to be presented for the next meeting or two. Given the poor view of the Boston Consulting Group on the readiness of the Shared EHR proposal and the inadequate level of public and industry consultation that has been undertaken this seems quite likely.

So, one way or another, I suspect a good deal more work and consultation will be requested before approval is given.

Lastly, of course, it is also possible that COAG will say that this looks too complex, difficult and risky for now, and defer the whole thing indefinitely. Go back a develop a plan that addresses these concerns and we will consider it much later! This is not impossible, but given that all the State Health CEO’s have agreed to move forward, and have NEHTA come to COAG, it is hard to see the Ministers delivering such a firm knockback.

I am no prophet, and I am sure other nuances are possible, but if I were NEHTA I would not have embarked on this without a carefully thought out Plan B. Without such a plan this could turn very messy and many may find themselves embarrassed. I wonder if it exists and what it is? I find it hard to believe COAG will just wave something like this through without some considerable review and discussion!

If NEHTA does not have a decent secondary way forward – that avoids much of the risk and complexity of the apparently envisaged Shared EHR – E-Health in Australia could languish for a long while. To hear what NEHTA and those they report to really need to do, read on!

The big picture alternative, which I much prefer, is that totally new governance structures for Australian E-Health will emerge, NEHTA will go back to doing what it should do – enabling infrastructure improvements and Standards – and a major policy and technical implementation – managed by experts - will develop – all I can do is hope this is the real outcome of COAG.

This is the outcome we really need – and this is what needs to happen now! The NEHTA Business Case must be abandoned and better more strategic brains must take over! As they say those who “Fail to plan, plan to fail”. By pretending they can proceed without an explicit articulated plan and new governance, NEHTA shows itself for the techo driven, non strategic, organisation it is.

NEHTA is not the organisation to deliver the Business Case for ( and the actuality of ) the Shared National EHR. It is as simple as that! That needs to be a done by culturally richer, better resourced and much more competent entity.

David.

Wednesday, December 19, 2007

NEHTA is Planning an Ill Conceived E-Health Catastrophe!

Given this could be the most important blog I write this year, I felt it needed to be started by a relevant quotation. My chosen quotation is 'Those who cannot remember the past are condemned to repeat it.' This is one of the notable quotations from George Santayana and can be found in the work entitled Life of Reason, Reason in Common Sense, Scribner's, 1905, page 284.

Why is this relevant? Let me explain.

On the day the NEHTA Review by the Boston Consulting Group (BCG) was released the Australian published an article – clearly prepared well in advance – informing an unsuspecting populace that they were about to all have a Shared Electronic Health Record (Shared EHR) made available to them within four years, if they wanted one! Clearly an attempt to distract from the bad news of incompetence in the BCG report and to obscure what they planned for the future.

From the press release associated with the release of the BCG Review of NEHTA we also learned that the Board has been busy. In their words:

“The Board of NEHTA also endorsed a business case for developing a national platform for personal electronic health records to be put to the Council of Australian Governments (COAG) early next year.”

The Australian article makes it pretty clear the information to be held on the Shared EHR will be (to quote):

“ Core elements of most profiles would include:

* Allergies, alerts and adverse reactions.
* Current and ceased medications.
* Problems and diagnosis, active or persistent disorders.
* Family and social history and immunisations.
* Implants such as pacing wires, joint prostheses and medication implants.
* Screening results such as the last date and outcome of Pap smears and mammograms.
* Key physiological measurements, height, weight, body mass index.
* Planned activities, care plans and history of recent and past procedures.”

What does all this mean. It means that NEHTA imagines (fantasises) that it is ready to approach the Council of Australian Government (COAG) with a business case to implement a quite advanced Shared EHR over the next four years!

Implied in all of this is that NEHTA has worked out

1. the details of how the Shared EHR will work.

2. how the planned record will interact and communicate with hospital, specialist and GP systems

3. how the data will be stored and secured

4. how privacy will be protected and

5. how much it will all cost and what the benefits are that will flow from the recommended spend.

Even more amazing is that the business case apparently suggests this can all happen within four years – i.e. by 2012.

If COAG buys this megalomaniacal hubris, and agrees to this, it will be a total disaster and set back E-Health in Australia for a decade in my view.

Why is this initiative doomed to fail (Here is where recent and more distant history comes in)?

First, as we learn from the recent BCG report, NEHTA does not seem to be able to manage even quite simple projects effectively (can’t get staff, can’t spend what is needed and lacks implementation expertise for starters). Doing a project of this scale is clearly way beyond them – even with partners such as IBM and Telstra which you can bet they are hoping will do the heavy lifting.

Second, again as we learn from the BCG report, NEHTA has virtually no capability to engage with the Health Sector and simply does not ‘get health’. A project of the scale contemplated by NEHTA is not doable in that circumstance.

Third, when similar ideas were trialled in the years 2002-2005 by the Commonwealth, under the HealthConnect banner, the pilots were such dismal failures that not a single one was continued with in its planned form and ultimately the whole program turned into a ‘change management strategy’ having wasted $100 million +.

Fourth, to have a Shared EHR it is vital that the data that is shared from operational systems is of high quality and integrity – i.e. is ‘data for sharing’. NEHTA does not even have a plan for GP and Specialist data quality enhancement (it has cost the UK hundreds of millions of pounds over many years to make progress) and so ‘garbage in, garbage out’ will be the order of the day.

Fifth, the UK, Canada and the US have has EHRs on the political agenda for 4-5 years to build public support for a Shared EHR project – we have had one article in the Australian two days ago after a hiatus of years.

Sixth, it seems that we have had a collection of NEHTA boffins who, according to the BCG are not seen by practicing Health IT experts as being of much use, invent this business case in secret away from the public eye as well as those who actually understand the risk and complexity of such undertakings. So much for the new open NEHTA and for any substantial chance of success!

Seventh, any maturity analysis of the Australian status in E-Health would quickly show we are a full 5-7 years away from being able to successfully conduct such an ambitious project – lacking the people, implementation skills and technical infrastructure to make it work.

Eighth, Australia does not have a National E-Health Strategy that positions a proposal of this type sensibly. All elements including the doctors and nurses, support staff, technologies, partners and training need to be co-ordinated and managed. This is a strategic national effort which will take many years – not something to be rushed through COAG on the opportunity of a Government change.

Lastly, from what is known of NEHTA’s benefits work, there are a lot of assumptions based on effective Clinical Decision Support. Systems with these capabilities are still largely aspirational at this point of time in terms of widespread use and it seems likely NEHTA’s benefits case will be little more than wild guesses dressed up with flash graphics. COAG beware!

How should NEHTA actually be proceeding?

First NEHTA should engage with COAG to fund the development of a genuinely inclusive and practically based National E-Health Strategy. This could address many of the present uncertainties about what is practical, what is possible and what might work.

Second it should review, refresh and release all the documentation associated with HealthConnect Version 1.

Third the reality of the costs and benefits case needs to be subjected to hardnosed analysis through proof of concept implementations that can be shown to deliver in the real world. Hand waving assumptions should simply not be accepted.

Fourth NEHTA should release, for public review and discussion, the current business case so we all know what is planned, what will be the outcomes and can bring the Health IT Communities expertise to bear on the entire project to maximise the chance of cultural, technical and financial success. This should lead to a much more robust plan being approved late in 2008 – and having some chance of success when implemented.

Fifth – at the very least – the Shared EHR should be piloted in one State (it needs a pilot of that scale I believe to be credible) and once all the issues are resolved – a move to national implementation can be commenced. Just jumping in with the whole country is clearly crazy.

Shared EHR’s have been very problematic in large countries with success seemingly being confined to the smaller states such as Denmark etc.

Before I conclude I need to say I would really like a Shared EHR to proceed in a planned strategically rational fashion – just not in the unsound and ill considered way proposed by NEHTA which I feel is doomed. I know how hard this will actually be and I fear NEHTA does not have a clue.

If NEHTA goes ahead with its present plans, and COAG is silly enough to approve the request, I am convinced it will be an un-remitting fiasco some 2-3 years out and there will be blame and blood-shed everywhere.

See if I am not right.

David.

Tuesday, December 18, 2007

Link Between Hospital IT and Patient Safety Becoming Stronger

An interesting paper appeared in the Journal of Healthcare Management recently.

It is reported in iHealthBeat.

Research Builds Case for Hospital IT Adoption To Boost Safety

by Kate Ackerman, iHealthBeat Associate Editor

Despite mounting evidence that IT can help boost patient safety, many hospitals have been reluctant to invest in technology like electronic health records and computerized physician order entry systems.

Only about 11% of hospitals that responded to an American Hospital Association survey released in February reported having a fully implemented EHR system. This reluctance is likely tied to financial, cultural and workflow barriers. In addition, there are several well-publicized instances in which IT actually added to problems at hospitals -- information that clearly supports hospital officials' resistance.

Experts believe that as the volume of research supporting the benefits of health IT increases and as the results of those studies are able to be generalized to hospitals nationwide, health care leaders' resistance to investing in IT will dwindle.

Jon White, director of Health IT at the Agency for Healthcare Research and Quality, said, "There is a good amount [of research] under our belt, but we also have a good amount more to go." He added that as research continues, "providers -- at least those [who] understand the literature and the evidence -- will kind of say you know, 'I deliver better care when I use these tools in this way; therefore, I have kind of a moral responsibility to do that.'"

Mounting Evidence

A study in the current issue of the Journal of Healthcare Management builds on existing research on IT and patient safety at hospitals.

"The evidence that IT when properly implemented can yield positive organizational benefits is beginning to be well known," but most studies on the topic "are conducted in very limited settings -- academic medical centers or other specialized institutions where information generated there may not necessarily translate to the average community hospital," Nir Menachemi, author of the study and associate professor at Florida State University's College of Medicine, said. He added, "So trying to begin filling in more pieces of the puzzle in terms of how IT affects care, we looked at this project so that the information could be generalized to the typical hospital."

The study, called "Hospital Adoption of Information Technologies and Improved Patient Safety," examined the relationship between IT adoption and AHRQ's patient safety indicators at 98 hospitals in Florida. The study found that eight patient safety indicators were related to at least one measure of IT adoption -- a finding the study's authors say hospital leaders should consider when making decisions about IT adoption.

…..

MORE ON THE WEB

  • AHA health IT survey
  • AHRQ
  • "Cedars-Sinai Suspends CPOE Use," iHealthBeat, 1/22/03
  • "Study: CPOE System Linked With Increased Patient Mortality," iHealthBeat, 12/8/2005

Read the full article on the web

http://www.ihealthbeat.org/articles/2007/12/12/Research-Builds-Case-for-Hospital-IT-Adoption-To-Boost-Safety.aspx?a=1

Interestingly the full article – without charts – is also available:

Hospital adoption of information technologies and improved patient safety: a study of 98 hospitals in Florida.

by Menachemi, Nir Saunders, Charles Chukmaitov, Askar Matthews, Michael C. Brooks, Robert G.

Journal of Healthcare Management • Nov-Dec, 2007 •

EXECUTIVE SUMMARY

Most of the studies linking the use of information technology (IT) to improved patient safety have been conducted in academic medical centers or have focused on a single institution or IT application. Our study explored the relationship between overall IT adoption and patient safety performance across hospitals in Florida. Primary data on hospital IT adoption were combined with secondary hospital discharge data. Regression analyses were used to examine the relationship between measures of IT adoption and the Patient Safety Indicators (PSIs) of the Agency for Healthcare Research and Quality.

We found that eight PSIs were related to at least one measure of IT adoption. Compared with administrative IT adoption, clinical IT adoption was related to more patient safety outcome measures. Hospitals with the most sophisticated and mature IT infrastructures performed significantly better on the largest number of PSIs. Adoption of IT is associated with desirable performance on many important measures of hospital patient safety. Hospital leaders and other decision makers who are examining IT systems should consider the impact of IT on patient safety.

This really is quite an important article as the iHealthBeat editor makes clear. By showing the relationship between clinical IT infrastructure and improved clinical outcomes the study adds a very significant brick in the wall in the case for further adoption of Clinical Health IT in Hospitals!

Great stuff.

David.