Review of E-Health Activity in The States in the USA

In the last few days the Commonwealth Fund has published an interesting review of where most of the States of the US are up to with E-Health – separate from Federal and Private Sector efforts.

The Executive Summary is provided below and the full report and slide packs can be downloaded from the following URL.

http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=669309

State E-Health Activities in 2007: Findings From a State Survey

February 15, 2008 | Volume 86

Authors:

Vernon K. Smith, Kathleen Gifford, Sandy Kramer et al.

Contact:

Michelle Lim Warner, M.P.H. MWarner@NGA.org

Overview

Virtually all states now are actively engaged in e-health strategies to facilitate the use of information technology to make the health care system more effective while providing greater value and higher quality. States see e-health initiatives as high-priority; however, they and their private sector partners face significant challenges that accompany such initiatives, including the issues of cost and time required for implementation and for realizing a return on investment. Nevertheless, as reflected in the wide range of e-health activities across the states, a consensus has emerged that these policies and initiatives are significant and well worth the effort. This report is based on a 2007 survey of states and the District of Columbia conducted by the National Governors Association (NGA) in partnership with Health Management Associates (HMA) and with support from The Commonwealth Fund. The purpose of the survey was to identify current e-health initiatives, priorities, and challenges within state governments.

Executive Summary

"E-health" is a term used to describe any health care practice supported by electronic processes and communication, including health information technology (HIT) and electronic health information exchanges (HIEs). Across the nation, states have taken on the challenge of promoting e-health policies and initiatives, encouraging a wide variety of public and private sector efforts. States are motivated by their interest in improving performance, assuring quality, and obtaining greater value in their roles as health care purchasers, providers, and regulators, and as protectors of public health and catalysts for private-sector action.

Broad agreement exists that health information technology (HIT) can significantly improve health care delivery and quality and reduce its costs. Indeed, HIT has the potential to transform health care delivery and produce great improvements in efficiency and effectiveness for all the programs in which states have a role and an interest. However, states are faced with real constraints on what they can do, owing to limits on state funds and the many competing demands for those resources. As a result, important goals, including those that might lead to a "nationwide health information network," remain on the horizon, with states pursuing a variety of strategies and approaches toward their attainment.

To better understand the e-health landscape within state governments, the National Governors Association (NGA) partnered with Health Management Associates (HMA) to survey states, the District of Columbia, and the U.S. Territories. The project was also supported with funding from The Commonwealth Fund. The survey was designed to capture state HIT and electronic health information exchange (HIE) activities, challenges that states face in pursuit of these activities, emerging best practices and benefits, current directions, and future goals. Forty-one states and the District of Columbia responded to the survey (42 responses in total), providing a rich set of data and an important baseline of state e-health initiatives, activity, and progress. Key findings are outlined below.

All states now place a high priority on e-health activities. No state indicated that e-health activities were not significant, and almost 70 percent of states (29 of 42 responding) described e-health activities as very significant. States listed a wide range of initiatives as their most significant, including electronic HIE activities, adoption of HIT components, quality and transparency initiatives, registries, and efforts to resolve privacy and security issues.

According to the survey, state governors' two highest e-health priorities over the next two years were the development of electronic HIEs and of policies fostering local or state-level electronic HIEs, to assure interconnectivity among health care providers. When asked to identify the two state e-health activities they considered most significant, over three-quarters of responding states (32 of the 42) identified electronic HIE activities. Among such activities, 11 states reported forming a statewide committee, commission or board to study electronic HIE issues; 17 states reported other electronic HIE planning and monitoring activities; and seven states described either developing or implementing electronic HIEs. Also, four states (Florida, Georgia, Minnesota, and Washington) described as their significant activity providing grants, loans, or pro bono technical support to spur both HIT and electronic HIE development.

State HIT initiatives span a broad range of activities. Many states identified various HIT components (listed below) as their most significant e-health activities. These activities not only help states operate more efficiently, but also help states improve health care quality. They also provide states with opportunities to participate in e-health partnerships with private payers.

Table ES-1. HIT Activities That States Identified as Significant
HIT Component	States Indicating Activity as Significant
Telehealth	HI, NE, NM, OR, WV
E-Prescribing	AR,IL, MA, NH, PA, RI, KY
Medicaid Management Information System (MMIS) Replacement	ND
Electronic Medical Records (EMRs)	FL, HI, NM, OR, RI
Electronic Health Records (EHRs)	AR, DC, KS, MN, MO
Patient Health Records (PHRs)	OR
Decision-Support Tools, Chronic Disease Management, and Case Management	ME, MO, IN, VT
Web-Based Tools	AL, MA, UT

E-health applications are enabling states to implement quality and transparency initiatives. Five states identified significant e-health activities that focused on quality and transparency, including efforts to collect and distribute data on health outcomes, costs, utilization, and pricing and thereby increase accountability in public and private health care delivery systems.

Privacy and security remain key concerns of states and a clear focus for state action. Most states participating in the survey (31 of the 42) reported having state privacy laws and other protections in place and two-thirds (28 states) reported establishing policies and procedures to address data privacy and security breaches. Five states listed actions related to privacy and security as their most significant e-health activities.

The greatest barrier to release of health information within an electronic HIE lies in differing consent requirements, especially for services related to substance abuse, mental health, and HIV/AIDS; the second-greatest barrier identified was federal privacy requirements. In particular, most states (24 of 38 responding states) indicated that federal laws related to substance abuse services create a barrier when implementing an electronic HIE. Thirteen states reported that state and federal confidentiality and consent laws create obstacles for e-health activities and nine states reported HIPAA preemption standards as a barrier. Other barriers included the technological challenges of securing data and authentication./p>

States demonstrate interest in knowing and improving the availability of medical data to health care providers and Medicaid enrollees. One barrier for beneficiaries is lack of access to computers. One-third of states (13 of the 42 responding) had recently assessed the extent to which the Medicaid population has access to computers and the Internet. A similar number of states indicated they had initiated education efforts about e-health specifically intended to inform consumers from culturally and linguistically diverse communities. Two-thirds of states had assessed provider connectivity.

Barriers to implementing EMRs included initial and ongoing costs associated with the implementation process, lack of quantifiable return on investment (ROI), and difficulty finding an EMR application that is interoperable.

States have formed public-private consortiums to develop standardized measures of utilization and performance. Eighteen states reported working with private payers to develop statewide measures of utilization and performance.

States have adopted HIT activities across a wide variety of programs. States reported a range of e-health activities across five state-administered health care programs: Medicaid, employee health benefit plans, state-operated mental health hospitals, state prison systems, and public health. The greatest number of state e-health activities were in the area of public health, with the second-highest number within Medicaid. States reported registries as the most prevalent e-health activity. The next most frequently cited initiative was telehealth, followed by decision-support tools.

Public health has extensive experience operating registries, which will be foundational to other e-health activities. In many states, public health agencies for decades have operated electronic registries related to immunization, surveillance, disease, newborn screening, and early and periodic screening, diagnosis and treatment (EPSDT). In fact, all but one of the 42 responding states reported operating one or more of these registries. States indicated that their experience operating these registries will be foundational as they develop other HIT and electronic HIE activities. As one state official commented, a registry "is much like an RHIO with a narrow focus of information and a broad user base."

Almost all states reported e-health initiatives in Medicaid. Of the 42 responding states, a total of 37 reported e-health initiatives in Medicaid. Over half reported implementing Web-based Medicaid Management Information Systems (MMIS), telehealth, and decision-support tools. Web-based provider enrollment and certification and immunization registries were reported in about one-third of the responding states.

Obtaining funding for both implementation and long-term operations is the most significant barrier to the widespread adoption of interoperable HIT and a nationwide network of electronic HIEs. Over half of responding states identified lack of funding as the greatest barrier. Thirteen states also referred to "sustainability" or difficulty in establishing a "business case" as a barrier, e.g., building a business model in which revenues or savings from the use of HIT would be sufficient to offset its additional cost.

In addition to financial issues, other impediments observed in state survey responses included:

• Stakeholder Engagement. Almost half of responding states (20 of the 42) mentioned the challenge of obtaining the trust, buy-in, and participation of health care providers and of other stakeholders that are vital to success.
• Lack of Standards. Twelve states reported lack of defined nationwide standards for interoperability and coordination with federal standards development.
• Privacy and Security Concerns. As mentioned above, privacy and security are key concerns in state e-health initiatives. Two states also reported difficulty in coordinating with the privacy laws of neighboring states.
• Terminology. There was wide but not yet complete agreement regarding the interpretation and usage of common e-health terms. States also recommended that public health be included in the definitions for HIT and electronic HIE.
• Legal Constraints for E-Prescribing. Several states noted federal legal barriers related to e-prescribing and Schedule II prescription drugs.

States indicated that the most important "lesson learned" was the need for collaboration and stakeholder engagement. For the e-health activities that each state identified as most significant, states provided the most important lessons learned that would benefit another state undertaking the same activity. By far the most commonly cited "lesson learned" was the need to collaborate with, work with and obtain the buy-in of the full range of stakeholders. One official recommended that other states make "sure that everyone is buying in to what you want to accomplish and what the next steps will be" and "collaborate with stakeholders from the start to develop a level of trust and confidence in the information exchange."

Other lessons learned reported by states included:

• Planning. Ten states addressed the need for sufficient time and careful planning. One commented, "Proceed slowly gaining trust and fully exploring policy issues related to privacy and security, access, authorization, and authentication." Another, however, cautioned, "You don’t need all the answers today to move forward; plan broadly, implement incrementally."
• Clear and Effective Communication. Eight states stressed the need for clear and effective lines of communication and the importance of educational activities.
• Resources and Funding. Other states emphasized the need for dedicated resources and start-up funding; the need for leadership from both government and the private sector; and the importance of strong project management.
• Versatile Electronic HIE Model. One state noted that an important lesson learned was to use an electronic HIE model that did not lock out prospective participants because of its dependence on a particular vendor or service.

CONCLUSION

Virtually all states now are actively engaged in the promotion and implementation of e-health strategies intended to use information technology to provide better effectiveness, efficiency, value, safety, and quality in the health care system. Reflecting a belief that information technology can assist state and private efforts to slow the growth in health care costs and help them get greater value for their health care dollars, every state has placed significant priority on e-health. The challenges are significant, including the issues of cost and the time required for implementation and for realizing a return on investment. Nevertheless, a broad consensus has emerged, as reflected in the wide range of e-health activities across the states, that the promotion of e-health policies and initiatives is a significant undertaking that will be well worth the effort.

This report provides a benchmark of state e-health activities, showing what states have achieved and where they are going during state fiscal year 2008. States and their stakeholders can learn from their colleagues across state lines, and can leapfrog beyond what has been attained elsewhere. One state official noted, "It is powerful to learn that the majority of states share similar perspectives and plans for the future.... This report will open up lines of communication between state HIE efforts."

---- End Executive Summary.

This seems to me to have considerable relevance to Australia in that it shows a range of issues and their priority, as perceived at a State level that are likely to also be identified in a similar Australian survey. On this basis it would be interesting for such a survey to be undertaken in Australia. A survey of this sort , or something very similar, will be required as part of the process of development of the Australian National e-Health Strategy.

The full report is well worth a download and read.

David.

Who Owns Your Personal Health Data?

The team at the California Healthcare Foundation have come up with another interesting report.

http://www.chcf.org/topics/view.cfm?itemID=133577

Whose Data Is It Anyway? Expanding Consumer Control over Personal Health Information

Manatt Health Solutions

February 2008

As adoption of health information technology and the ability to exchange personal health information advance, so must the legal foundation that facilitates consumers’ access to, and control and use of, such data for their own and society’s benefit. Early technological advances offer a crucial window of opportunity to design legal parameters for appropriate consumer access and control, regardless of the information’s source or how it is used.

This policy brief explores the technological and legal landscape governing personal health information, as well as important issues that must be addressed if consumers are to have new, meaningful rights to the electronic records they entrust to an information custodian serving on their behalf. Challenges include defining "personal health information custodian" as an entity; determining the obligations of custodians, providers, and payers in an updated legal framework; providing economic incentives for clinicians to acquire the capability to electronically convey personal health information to consumers; and enforcement of applicable new laws.

The authors conclude that a modernized legal structure is necessary to ensure that consumers can maintain control over their health information. Such laws have the potential both to clearly define patients' rights and increase the level of consumer engagement in health care.

The complete issue brief is available under Document Downloads below.

Document Downloads

Whose Data Is It Anyway? Expanding Consumer Control over Personal Health Information (539K - PDF).

The Conclusion of this interesting document reads – in full:

“As adoption of health information technology and the ability to exchange personal health information advance, so should the legal foundation that facilitates access to and control of such information for consumer’s benefit. Early technological advances offer a window of opportunity to design legal parameters for appropriate consumer access and control, regardless of the information’s source or how it is used.

As a minimum new laws should give consumers an affirmative right to authorise the transmission of any standardised, electronic health information to a custodian of their choice, and ensure the custodians use such information in a manner directed by consumers. These laws would have a significant potential to engage patients in their health care by clearly defining their rights (thus winning their trust) and fostering models of information custodianship that support their needs.”

It is my view this is a real sleeper of an issue. It is going to be vital to recognise that a patient has a right to assemble their health information in a single place so they can control it and make it available to their carers (in whatever form they choose) whenever they want.

Right now, just as in the US, it does not seem this emerging need has been recognised – and I believe it should be sooner rather than later.

David.

The US Needs a New Improved National Health IT Strategy!

The US Government Accountability Office published the following on the 14^th February, 2008.

http://www.gao.gov/docsearch/abstract.php?rptno=GAO-08-499T

Health Information Technology: HHS Is Pursuing Efforts to Advance Nationwide Implementation, but Has Not Yet Completed a National Strategy

GAO-08-499T February 14, 2008

Highlights Page (PDF) Full Report (PDF, 13 pages) Accessible Text

Health information technology (IT) offers promise for improving patient safety and reducing inefficiencies. Given its role in providing health care in the United States, the federal government has been urged to take a leadership role to improve the quality and effectiveness of health care, including the adoption of IT. In April 2004, President Bush called for widespread adoption of interoperable electronic health records within 10 years and issued an executive order that established the position of the National Coordinator for Health Information Technology within the Department of Health and Human Services (HHS). The National Coordinator, appointed in May 2004, released a framework for strategic action two months later. In late 2005, HHS also awarded several contracts to address key areas of health IT. GAO has been reporting on the department's efforts toward nationwide implementation of health IT since 2005. In prior work, GAO recommended that HHS establish detailed plans and milestones for the development of a national health IT strategy and take steps to ensure that its plans are followed and milestones met. For this testimony, GAO was asked to describe HHS's efforts to advance the use of health IT. To do this, GAO reviewed prior reports and agency documents on the current status of relevant HHS activities.

HHS and the Office of the National Coordinator have been pursuing various activities in key areas associated with the President's goal for nationwide implementation of health IT. In 2005, the department established the American Health Information Community, a federal advisory committee, to help define the future direction of a national strategy for health IT and to make recommendations to the Secretary of Health and Human Services for implementing interoperable health IT. The community has made recommendations directed toward key areas of health IT, including the expansion of electronic health records, the identification of standards, the advancement of nationwide health information exchange, the protection of personal health information, and other related issues. Even though HHS is undertaking these various activities, it has not yet developed a national strategy that defines plans, milestones, and performance measures for reaching the President's goal of interoperable electronic health records by 2014. In 2006, the National Coordinator for Health Information Technology agreed with GAO's recommendation that HHS define such a strategy; however, the department has not yet done so. Without an integrated national strategy, HHS will be challenged to ensure that the outcomes of its various health IT initiatives effectively support the President's goal for widespread adoption of interoperable electronic health records.

----- End Summary.

This document provided an invaluable summary of how US Federal health IT initiatives have progressed since the 2004 Presidential Executive Order which proposed interoperable Electronic Health Records for all by approximately 2014.

Essentially what has happened is that there was developed a high level strategy and this strategy led to a number of implementation streams around EHRs, Standards, Certification and Health Information Networking. Now all these parts need to be put together and an implementation plan to get it all done over the next five years is needed.

I for one can understand just what a huge task this will be at any level of detail – which seems to be what the GAO is asking for – and if this can be done and published by mid 2008 it will be quite a feat! I must say it is a trifle unfair for the GAO to be too critical given the progress in each of the main areas that has been made. Maybe if the Congress has provided the budget support ONCHIT requested over the last few years progress would have been more rapid.

David.

SA HealthConnect – A Standing E-Health Joke.

Late last week I was pointed to the new evaluation report of the SA Care Planning Project. The document was entitled Final Evaluation Report HealthConnect SA Trial of Care Planning and Communication System. 30 November 2007. Authors were Dr Svetla Gadzhanova, Assoc Professor Elizabeth Kalucy and Professor Richard Reed of the Flinders University Department of General Practice.

The document appears to have been finalised late last year and published early in February, 2008. It is not clear why a report dated 30 November, 2007 took so long to be released.

The Executive Summary is freely available on the web and it is possible to e-mail a request for the full 56 page report.

All the links are found from this page:

http://www.healthconnectsa.org.au/Default.aspx?tabid=55

The statement positioning those involved makes interesting reading!

“The HealthConnect SA program is funded by the Australian Government and is being delivered through the South Australian Department of Health. HealthConnect is coordinated nationally by the Australian Department of Health and Ageing (DoHA) and is supported by the National e-Health Transition Authority (NEHTA), which is responsible for developing national health information management systems and information and communication technology standards and specifications.”

I wonder did NEHTA know it was “responsible for developing national health information management systems”!

The Executive Summary makes for fascinating reading.

Executive Summary

In November 2007 HealthConnect SA completed a twelve month trial of an online care planning and communication system (CPCS) for the management of chronic conditions in primary health care. One rural and two urban Divisions of General Practice in South Australia took part in the trial. The Divisions recruited, trained and supported 27 general practices, 73 general practitioners (GPs), 224 allied health professionals (AHPs), 153 patients, and other health providers in their catchment areas, in the use of the Ozdocsonline system.

The trial was evaluated prospectively in consultation with HealthConnect SA. Monthly Progress Reports and an Interim Evaluation Report were produced to maximise the value of the findings for the purpose of planning a state-wide care planning and communication system. The evaluation used data from many sources to capture the experiences and perspectives of all those involved, including patients and AHPs.

Evaluation aim 1: to test if online communication systems are an effective and acceptable method of communication within the primary health care team.

The trial demonstrated that in principle an online communication system is effective and acceptable. Overall, GPs appreciated the benefits of prompt and more efficient communication with AHPs, from which some patients benefited substantially. AHPs found the system enhanced the team approach and contributed to patients receiving the right care at the right time from the right providers. The small number of patients interviewed also found the system acceptable, and would recommend it to others. Few pharmacists and no specialists used the system.

However, GPs did not consider the benefits were sufficient to overcome specific issues of the system being trialled. The processes of completing Team Care Arrangements (TCAs) and General Practice Management Plans (GPMPs) were not quicker or easier, especially when many of the AHPs the GPs normally worked with were not registered on the system. For many GPs software limitations reduced system efficiency and increased the time taken to use it, which created substantial barriers to uptake. The software could not easily be modified to meet GPs needs, especially integration with current clinical software.

Evaluation aim 2: to test if the CPCS increases the rate in which GPs and other health care providers participate in care planning for patients with chronic conditions.

Between January and September 2007 participating GPs developed 183 new care plans using the system. Use of the system by GPs and AHPs peaked in May 2007. Some GPs used the system for most of their care plans, others reverted to previous methods, and not all users registered on the system actually used it. As the evaluators did not have access to Medicare data specifically for the GPs participating in the trial, it was not possible to determine if their rate of care planning increased; however, Medicare data for all GPs in the three Divisions showed fewer GPMPs and TCAs in the second quarter of 2007 than in the corresponding quarter of 2006.

Despite the initial assumption that GPs were already actively participating in care planning, Division liaison staff found that some GPs were not familiar with the GPMP and TCA Medicare item numbers, which they perceived as time consuming and of unproven benefit for patients. As workforce shortages increased demands on GPs, they did not see that completing GPMPs and TCAs was a high clinical priority.

Evaluation aim 3: to determine the change management techniques needed to successfully implement an online CPCS in primary health care.

Conducting the trial in three different Divisions provided an opportunity to observe some of the factors which influenced uptake, reinforcing the idea that what works for one Division may not work for another. The factors include:

• At provider level, a well tested system consistent with clinical priorities, with evidence of unambiguous benefits in terms of patient care, health providers’ work processes and/or remuneration.

• At Division level, active support for the system by senior management, clinical and IT champions within the target group

• A receptive climate for change both at practice and Division level. The high uptake of the system in the rural Division illustrated what is possible when the system is consistent with the relationships and strategic plans of the Division, in contrast to lower uptake in the two urban Divisions where the Division and practices faced competing priorities due to other initiatives and pressures.

• Flexible training and support tailored to the varying needs of users.

• Responsive support to resolve technical and other problems.

• Change management processes which address the beliefs and obstacles identified by the

target group, and overcome their resistance to unfamiliar and unproven systems.

• Appropriate incentives for trial participation at Division and at provider level. Two Divisions achieved higher participation rate by reimbursing GPs for training time or completing evaluation forms.

Findings from this evaluation suggest that successful uptake of an online CPCS at practice levelis more likely to happen if:

• GPs and practices are familiar with, and are creating, GPMPs and TCAs, and believe they are advantageous and worth the effort in both time and compensation.

• The system is compatible with existing chronic disease management processes and clinical software, facilitates secure sharing of care planning information, and is beneficial in terms of costs, time and health outcomes for patients with chronic conditions.

• There is a critical mass of AHPs and specialists with well-organized profiles on the system, with whom the GPs can share care plans.

• There is a secure broadband connection at each provider site;

• There is capacity for an extended role for practice nurses in the care planning process.

For implementation of the state-wide care planning system, the evaluation recommends the following strategies, which were outlined in the Interim Evaluation Report:

Organisational structure

• Ensure the system is consistent with the Divisions current goals and activities;

• Obtain strong ongoing support from senior clinical, IT and management staff;

• Involve Division staff with strong relationships with general practices in the promotion of the system;

• Allow time for Division staff to understand existing processes to ensure effective promotion of the new system;

• Provide Division staff with sufficient resources, time for preparation, and adequate training before the implementation of the new system.

Implementation activities

• In chronic disease management, promote e-Health widely to GPs, AHPs, specialists,

pharmacists and patients;

• If needed, educate health providers in GPMPs and TCAs.

Resources

• Provide, in electronic and printed format, information brochures and FAQs sheets suitable for all participants including patients, as well as relevant case studies demonstrating the expected outcomes;

• Ensure there is a secure broadband connection at each provider site;

• Train the GP team and AHPs at the same time to avoid time lags in getting the team onboard;

• Tailor training according to participants’ specific characteristics (prior knowledge, IT experience);

• Anticipate that additional training sessions might be required, and that time is needed to absorb training before usage.

Support structure

• Provide ongoing and timely support to users of the system, using diverse forms such as communication materials and ongoing technical support from system vendor and other organisations involved in implementation.

Participants

• Focus on specific training for practice nurses as contributors in the care planning process.

System functionality

• Implement a secure, reliable, easy to use IT care planning system which integrates well with existing chronic disease management processes and software;

• Choose a system that facilitates sharing of care plans within and between practices;

• Provide evidence of benefits in terms of costs, time and health outcomes for patients with chronic conditions.

• For information consistency, ensure a smooth transition between the trial system and the state-wide system.

---- End Executive Summary.

It is only when one looks closely at this evaluation report does one appreciate what total rubbish it, and the project were.

The statistics tell the story!

First only 183 care plans were developed in the nine months of the trial’s operation – less than one a day by my reckoning – the system was hardly likely to be overloaded!

Second the evaluation hardly provides comprehensive information on the trial as so few of those involved responded to evaluation survey requests. From the full report we see the following description of the data on which the evaluation was based. Remember 73 GPs, 200+ AHPs and 150+ patients were involved.

GP baseline survey: 8 responses (5 ACEDGP, 3 YPDGP).

GP endpoint survey: 9 responses (3 ACEDGP, 3 YPDGP, 3 SDGP)

Case studies: 3 interviews with a GP from each division

Patient interviews: 5 interviews out of 9 patients invited (3 patients from ACEDGP and 2 patients from SDGP)

AHP survey: 5 responses out of 9 AHPs invited

Third the system was hardly used!

“Use of the system peaked in May 2007 (Figure 1). Between January and September 2007 participating GPs developed 183 new care plans using the system, and made a substantial number of new planner entries and progress notes on these care plans. AHPs contributed 189 progress notes. Patients and pharmacists made negligible use of the system, and specialists none at all.”

So what we have here is a one year trial of a system essentially no one used, which was not integrated into the usual clinical workflows, and which on all the evidence available was a total and complete failure.

Worse it seems there was an interim Evaluation Report that said some change was needed that was not actioned.

Horrifyingly it seems there is still a tender on foot for procurement of what is now called the e-Health Care Planning System. The name change apparently reflects the need to identify this care planning system as an e-Health initiative! The tender closed June 12, 2007.

Much more on this farce of a tender is found at:

http://aushealthit.blogspot.com/2007/05/sa-healthconnect-opens-appalling-e.html

Amusingly the evaluation and contract was meant to be done by the end of August 2007. Seems it was done in secret or it has been canned.

One can only hope this sad chapter in Australian e-Health has been put down quietly and that those involved have been re-deployed to do something useful.

I suggest you e-mail and get the full report for yourself..it is a true collectors piece. Pity no one thought to evaluate for improved clinical outcomes and then clearly state that the system made no appreciable differences to these was thus essentially a total failure – as it truly was! This is what you get when you ask the wrong evaluation questions.

I wonder how much money was wasted on this?

David.

Useful and Interesting Health IT Links from the Last Week – 24/02/2008

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

These include first:

Google to store health records

Michael Liedtke in San Francisco | February 22, 2008

GOOGLE will begin storing the medical records of a few thousand people as it tests a long-awaited health service that's likely to raise more concerns about the volume of sensitive information entrusted to the internet search leader.

The pilot project to be announced today will involve 1500 to 10,000 patients at the Cleveland Clinic who volunteered to an electronic transfer of their personal health records so they can be retrieved through Google's new service, which won't be open to the general public.

Each health profile, including information about prescriptions, allergies and medical histories, will be protected by a password that's also required to use other Google services such as email and personalised search tools.

Google views its expansion into health records management as a logical extension because its search engine already processes millions of requests from people trying to find about more information about an injury, illness or recommended treatment.

But the health venture also will provide more fodder for privacy watchdogs who believe Google already knows too much about the interests and habits of its users as its computers log their search requests and store their email discussions.

Prodded by the criticism, Google last year introduced a new system that purges people's search records after 18 months. In a show of its privacy commitment, Google also successfully rebuffed the US Justice Department's demand to examine millions of its users' search requests in a court battle two years ago.

Continue reading here:

http://www.australianit.news.com.au/story/0,24897,23257065-16123,00.html

There have been rumours of this move for a while. They are entering a very crowded field in the US as indicated by the following list.

AHIP PHR Standards

Allscripts Patient Portal

Angel Key

Band of Life

Benefits Manager (American Airlines)

CapMed

Care Memory Band

Chart Scout

CheckUp

Dr. I-Net

E-HealthKEY (MedicAlert)

EMRy Stick

Enterprise Patient Portal

ePHR

Evolution PHR

FollowMe

FullCircle

Global Patient Record

Google (still in development)

Handymedical.com

Health Account Basic

HealthFile

HealthFrame

HealthVault (Microsoft)

iHealthRecord

Indivo (Dossia)

InfoVivo

iPHER

IQHealth

KIS Medical Records

LAXOR

LifeLedger

LifeSensor

MedCard Online/Med-Id-Card

MedCommons

MedDataNet

MedeFile

Medic Tag

Medical Passport

MedicAlert

MediCompass

mediKEEPER

MediStick

MedInfoChip

MedNOTICE

My Family Health Portrait

My Health Connection

My Health Record

My HealtheVet

My MediList

My Medical CD

MyActiveHealth PHR

MyChart (Epic)

myCIGNA

MyFamilyMD

MyHealth123.net

MyHealthAtVanderbilt

myHealthFolders

MyLife

MyMedicalRecords.com

MyMedicare.gov

myNDMA

myuhc.com

MyVitals.com

NoMoreClipboard.com

PHR4me

PatCIS

Pathway Technology

PatienTrak

Patient Power

Peoplechart

Personal Health Record (PepsiCo)

Portable Health Profile

ProfileMD

ReliefInsite.com (using Facebook)

Securamed

SGMSCorp

SynChart

Telemedical.com

The Smart PHR

Touchnetworks H.U.B.

Vital Key

Vital Records

VitalChart

Vividea (Lifetime Personal Health Software)

Waiting Room Solutions

WebMD Health & Benefit Manager

Second we have:

Are Consumers Interested in Having Online Access to Their Medical Records and Test Results?

Nearly eight out of 10 adults responding to a survey said they are interested in having online access to their medical records and test results, and 26% said they would be willing to pay extra for the service, according to a survey by Deloitte. Just 6% of respondents said they have accessed their medical records and test results online.

The survey also found that 76% of respondents are interested in communicating with physicians via e-mail, while 72% would like to schedule appointments online. Twenty-three percent of respondents said they would pay extra for e-mail access to a physician, and 18% said they would pay extra for online appointment scheduling.

Continue reading here:

http://www.ihealthbeat.org/articles/2008/2/22/Are-Consumers-Interested-in-Having-Online-Access-to-Their-Medical-Records-and-Test-Results.aspx?dp=1

This is an very interesting survey as it shows just how many people would potentially use a Person Health Record if it were available.

Third we have:

Mum in fear after CSA revealed address to ex-husband

By David Barrett and Kim Arlington

February 18, 2008 12:00am

A MOTHER of four says she has been living in fear since a government agency gave out her address to her allegedly violent ex-husband.

The woman had repeatedly moved house and fought an expensive legal battle to keep her address secret from her ex - only to find it was given to him in documents from the Child Support Agency.

The bungle is the latest in a string by government bodies, with the NSW Department of Community Services mishandling confidential case files three times in recent weeks.

The 36-year-old woman, who asked not to be named, has been involved in a dispute with her ex-husband over support payments for their two children since the couple divorced in 2002.

Her security was shattered when her details were released without her permission in July last year.

She said that just days after she and her ex-husband were sent the same paperwork by the CSA, she received an anonymous letter warning: "You can't hide anymore . . . Your (sic) history."

"I went through the paperwork and my address was listed," the woman said.

"When I realised he'd been given my address I just froze. I had goose bumps and I was in total shock."

Since then, pornography has been delivered to her home address and she believes her ex has visited her house.

In an email seen by The Daily Telegraph, her ex-husband writes: "I couldn't believe my luck when I saw your address in the CSA stuff . . . finally CSA gave me something for once".

Continue reading here:

http://www.news.com.au/dailytelegraph/story/0,22049,23229460-5001021,00.html

This is important proof of just how important it is to properly protect demographic details in electronic health systems. If it can be dangerous when a piece of mail goes astray, just how more dangerous is it to have someone of evil intent be able to access a large population demographic database.

Fourthly we have:

Gary Cohen, executive chairman and chief executive, IBA Health Group

E-HEALTH will be back on the national agenda, thanks to the Rudd Government's focus on efficiencies in healthcare, Gary Cohen says.

'E-health will be back on the national agenda,' says Gary Cohen

"The Government will want to get its head around the different health systems and the way they work in the various states, then see whether they can do something with existing systems, or whether they have to take a different tack," he says.

"I imagine we'll start seeing some initiatives come through in the second half of the year, particularly for improved connectivity between the federal and state government systems."

Local health IT organisations see the change as positive, Cohen says. "They believe investment is needed to bring out the efficiencies" that e-health can deliver.

"Trying to get an electronic patient health record system to work across the country is going to be a big task that requires funding," he says. "We're not going to achieve that through multiple pilots or small initiatives, it's going to take a bigger plan.

"We'll have to wait and see if that happens over the next six to 12 months."

This is a year of transition for IBA Health, after its acquisition of rival iSoft, along with key British contracts for the National Health Service's IT transformation.

"Obviously, our first priorities are successfully integrating the combined organisation, reigniting the sales growth, which stalled during the purchase process, and making sure we not only deliver on current commitments but also start to build trust for the future," he says.

Continue reading here:

http://www.australianit.news.com.au/story/0,24897,23234450-5013045,00.html

It is good to see there is some optimism in the health IT industry. I hope this optimism is not misplaced.

Fifth we have:

Born-again biometrics

February 19, 2008
Next
With the change in government it appears that the federal smartcard has been killed by fears of cost overruns and privacy risks. But the biometrics field is pushing on, writes Beverley Head.

HALF a decade before the twin towers fell in New York, Ted Dunstone completed his PhD exploring how computers and biometrics could be used to detect terrorists at airports.

Today he's still working out how biometrics can be harnessed to ensure the right people get access to sensitive locations, equipment and information.

Biometrics involves capturing information about something unique to an individual - their voice, face, iris, fingerprint or even the pattern of their veins. That information is stored on a database or token and when an individual wants to access a computer system, enter premises or cross a border, they speak, show their face, eye, finger or wrist. If it matches the information captured about that biometric, in they go.

This was supposed to be the year that biometrics hit its straps; the year Australia phased in a biometric access card, replacing 17 card or voucher systems. If you wanted to access government services you'd need one.

Privacy advocates were rehearsing their stump speeches, IT integrators were rubbing their hands in anticipation of a flood of consultancy and implementation dollars. The access card was the golden goose.

And it's dead. Or is it? Citing concerns about privacy and a mismatch between the cost of the project compared with the savings it might deliver, Senator Joe Ludwig, Minister for Human Services, has canned the $1.3 billion four-year program and confirmed "there are no plans to revisit the access card in the future. Spending over $1 billion on a magic card is not the solution."

Continue reading here:

http://www.smh.com.au/news/technology/bornagain-biometrics/2008/02/18/1203190738826.html

This is a useful discussion of some of the aspects of the use of biometrics and points out that at some point in the future the mechanisms by which government services are accessed – including shared EHRs – will need to be reviewed and upgraded.

Lastly we have:

Govt woes don't trouble TrakHealth

Ben Woodhead | February 20, 2008

MEDICAL software heavyweight InterSystems is eying big ticket hospital software projects in South Australia and Western Australia as it moves to capitalise on its acquisition last year of local firm TrakHealth.

But the company has acknowledged that the spectre of TrakHealth's legal battle with the Queensland Department of Health in relation to a failed patient and clinical systems initiative still looms over its meetings with other public sector organisations.

"Obviously everyone asks questions about it but moving on what's important is that we have a good product," TrakHealth chief operating officer Christine Chapman said.

Ms Chapman declined to confirm if the company was holding settlement discussions with Queensland Health over the hospital software project, which collapsed acrimoniously in late 2006.

TrakHealth subsequently said it would pursue $18.2 million in damages from Queensland Health but the health agency promptly fired back with a $21.9 million counterclaim against TrakHealth.

The matter is expected to go to trial in the Queensland Supreme Court this year if the two parties are unable to reach a settlement.

Continue reading here:

http://www.australianit.news.com.au/story/0,24897,23246200-15306,00.html

This article is worthwhile browsing as it reminds one that there are a number of hospital system vendors who are planning to try and establish a reasonable market share in the sector over the next few years with some of the planned state investments.

More information on Trakhealth also appeared in the Rust Report of the 22 Feb, 2008.

Vic health bodies take on TrakCare

Under the terms of the Victorian Government's $A360 million HealthSmart program, two community health agencies have begun implementing the TrakCare Webbased healthcare information system. TrakCare was designed in Australia by TrakHealth, which was acquired by US database developer InterSystems in 2007 (Rust Report, May 25 2007, p1).

More next week.

David.

Semantic Interoperability – The Turkish Connection!

The following important article appeared a few days ago.

Interoperability road map in development

11 Feb 2008

A Turkish research consortium is developing a road map for e-health interoperability that would eventually link up the health information systems of EU Member States in a seamless web.

Researchers at the Software Research and Development Centre, based in the Middle East Technical University (METU), have found that Europeans are more mobile than ever before, but although European health services have introduced sophisticated electronic information management systems, they are often designed to work on a local level and are often not interoperable.

With EU funding, they have developed RIDE, an interoperability solution designed to link up regional and national health information systems into a seamless European web.

RIDE is a roadmap project for interoperability of e-health systems leading to recommendations for actions and to preparatory actions at the European level.

The project’s nine partners in seven countries have already drawn up two draft versions of their e-health interoperability road map and work is in progress on the final version. This document complements the objectives of the Commission’s e-health action plan, particularly with regard to semantic interoperability.

“Two crucial principles have been identified by the RIDE project. The first is the central leadership of the European Commission in coordinating Member State activities and the second is the need for an incremental deployment process in which growing - in physical coverage - and evolving - increasing functionality - pilots are being developed across Member States,” said Asuman Dogac, a professor at the Department of Computer Engineering at METU.

Tackling the ‘interoperability challenge’ requires EU Member States to make concerted efforts to create national and Union-wide interoperability, Dogac added:

“Europeans are more mobile than ever before, moving not only around their own countries, but also across a largely borderless EU, in pursuit of leisure, education, career advancement or cultural enrichment. This enhanced mobility has brought with it challenges. What happens if a person falls sick away from home or moves to another part of the country or another country altogether?

Continue reading here:

http://ehealtheurope.net/news/3459/interoperability_road_map_in_development

The official web site for the project can be found here:

RIDE Project

The project is described in the following terms at the web site:

“RIDE is a roadmap project for interoperability of eHealth systems leading to recommendations for actions and to preparatory actions at the European level. This roadmap will prepare the ground for future actions as envisioned in the action plan of the eHealth Communication COM 356 by coordinating various efforts on eHealth interoperability in member states and the associated states. Since it is not realistic to expect to have a single universally accepted clinical data model that will be adhered to all over the Europe and that the clinical practice, terminology systems and EHR systems are all a long way from such a complete harmonization; the RIDE project will address the interoperability of eHealth systems with special emphasis on semantic interoperability. In order to create RIDE Roadmap, first the European best practices in providing semantic interoperability for eHealth domain will be assessed and the quantified requirements to create a valid roadmap will be identified. Based on these requirements, the goals, and the economical, legal, financial and technological challenges of the industry for the 21st century for achieving interoperability in eHealth solutions will be elaborated. RIDE will also focus on the limitations of the policies and strategies currently used in deploying interoperable eHealth solutions. A research portal for sharing resources addressing semantic interoperability in eHealth domain will be created and maintained; the key actors and stakeholders will be coordinated around RIDE special interest groups to create a wide consensus at the European level. Through eight RIDE workshops a shared vision for building a Europe-wide semantically interoperable eHealth infrastructure will be created. After assessing the gaps between the 'as-is' situation and the 'to-be' eHealth vision, the emerging trends and opportunities to achieve the vision statement, the required advances in the state of the art research, technology and standards will be identified.”

The seriousness of the project can be seen in the 1.15 million Euro budget (Approx $A1.9 million) and the number of organisations involved.

Most valuable are the public deliverables which can be found here:

http://www.srdc.metu.edu.tr/webpage/projects/ride/modules.php?name=Deliverables

Anyone with even the least interest in the paths to interoperation being pursued in Europe should spend an hour or two browsing here. I wonder how much NEHTA is across all this?

David.

Has Telemedicine Fallen off the Radar in OZ?

The following report prompted me to wonder just where all the remote telemedicine project and pilots had gone – it somehow seems we hear very little about it these days in Australia.

Aberdeen A+E pilots video booths

31 Jan 2008

Emergency patients in North-East Scotland can now remotely consult with a doctor through video conferencing technology.

The deveopment comes as part of a new collaboration between Cisco and the Scottish Centre for Telehealth.

The new HealthPresence booth enables patients to remotely consult with a doctor, particularly useful should they live in a remote area, without close proximity to an A+E department.

Aberdeen Royal Infirmary hospital has been running the trial since December, with the aim of seeing 300 accident and emergency patients through video conferencing.

Sitting in front of a monitor with a webcam, patients are able to have a remote consultation with a doctor via the video-teleconferencing technology.

Patients can then use a range of medical devices, including blood pressure cuffs, glucose monitors, audioscopes and stethoscopes, which upload data directly into an electronic medical record. The patients using the booths are assisted by qualified first aid professionals to help them correctly use the devices.

Cisco Internet Business Solutions Group’s global healthcare solutions director, Nick Augustinos, told EHI: “The aim of these booths is to help patients in rural areas where treatment resources are scarce, to have somewhere to go, which is an environment very similar to what they see when they visit a GP, and is able to give them an accurate diagnosis without them having to go miles away.”

The Scottish Centre for Telehealth chose the Royal Aberdeen Infirmary’s accident and emergency department, as the 877 bed hospital serves the whole of North-East Scotland, including remote areas on the coastline.

Gordon Peterkin, director of the Scottish Centre for Telehealth, told EHI: “Scotland has already been an active player in the telehealth area and we wanted to extend this for the benefit of patients. We have had an idea of an interactive booth since 2006, where we displayed a hypothetical situation to Princess Anne at our conference, looking at providing the right treatment, for the right patient at the right time.

Continue reading the article here:

http://www.ehealtheurope.net/news/3429/aberdeen_a+e_pilots_video_booths

The article also provides a link to the trial managers

Scottish Centre for Telehealth

This report got me thinking and wondering just where we are up to in Australia – especially as telemedicine is given as one of the reasons for Mr Rudd’s planned broadband rollout.

It is fascinating that if you Google “telemedicine Australia reports” you get the following first three hits

http://www.ihealthbeat.org/articles/2006/10/2/Robots-in-Australian-Childrens-Hospitals-Aid-Telemedicine.aspx?topicID=53

Robots in Australian Childrens' Hospitals Aid Telemedicine

The University of Queensland's Center for Online Health in Australia has developed robots that connect patients, physicians and other specialists through video teleconferencing, the Brisbane Courier Mail reports.

http://www.dhs.vic.gov.au/ahs/archive/telemed/index.htm

An Abridged Version of a Report for the Department of Human Services (State of Victoria)

Telemedicine

An International, Comparative Analysis of Policy, Regulatory and Medico-legal Obstacles and Solutions

Report prepared by Robert Milstein, Consultant, January 1999

And this

http://www.jma.com.au/unevendiffusion.htm

The Uneven Diffusion of Telemedicine Services In Australia

Paper presented at TeleMed 98, the sixth International Conference on Telemedicine and Telecare, Royal Society of Medicine, London, UK, 25-26 November 1998

John Mitchell & Associates, Sydney, New South Wales

If you Google “telehealth Australia reports” you get the following familiar site!

http://aushealthit.blogspot.com/2007/11/value-of-provider-to-provider.html

So we seem to have a range of reports from last century and very little apparently happening in Australia except possibly in Queensland at the Centre for Online Health.

Is it that all this stuff is so old hat and proven no one even mentions it these days or have all those pilots of years back run out of money and are now defunct?

I would love to hear from those who know. The silence seems a little ominous to me.

David.

Australia’s Northern Territory – An E-Health Leader?

The following press release appeared a week or two back from NT Health. At the same time it is announced HealthConnect is officially dead – or so it would seem – the name having been abandoned.

http://www.nt.gov.au/health/ehealthnt/documents/media2008jan18.pdf

Regional centres sign up to the Shared

Electronic Health Record

21 January 2008

Territorians are signing up to participate in an electronic system which is connecting health services under the eHealth NT program.

The eHealth NT Shared Electronic Health Record allows individuals to have their important health information stored in a secure repository, accessible from multiple health sites, with their consent. The Territory is a national leader in the implementation of the new system.

The new service is particularly valuable for individuals who change GPs, or who use multiple health services, as it helps health care providers, including hospitals, GPs and health centres, to securely access an up-to-date overview of an individual’s medical history.

Director of eHealth NT Shared Electronic Health Record, John Fletcher, said instant access to up-to-date health information can mean the difference between life and death for patients, particularly in an emergency situation.

“This service being implemented across the Territory means health consumers can be reassured that there is a secure system that allows doctors, and other health care providers, to access their health information. For a highly mobile population, as the Territory has, this system represents a major leap in patient care, especially for people who use different GPs, or a number of health services. Individuals no longer have to request copies of information from their patient records, remember medications, and other treatment information – it’s already there, and instantly accessible, if you’re signed up for the Shared Electronic Health Record.

“Electronic transfer of health information is a much quicker, more secure and streamlined process. It’s a giant leap forward in improving continuity of care, particularly for Indigenous Territorians. Implementation has only been possible because of the support of the Major Aboriginal Medical Services and their representative bodies, AMSANT and KRAHRS, Northern Territory Public Hospitals and Private GP Practices.” Mr Fletcher said.

Katherine Region registrations are largely completed and registration teams are currently targeting the areas of Batchelor, Adelaide River, Acacia, and Borroloola, Daly River, Nguiu, Darwin as well as residents living in the Tennant Creek / Barkly areas where a significant number of Territorians have registered and in Central Australia at communities including Ali Curung, Amatjere, Willora and Tara.

Opportunities for registration will also be available at the Imparja Cup in Alice Springs between February 11 and February 16.

To date more than 15,000 Territorians have registered to participate in the SEHR and over 900 professionals are registered participants.

The eHealth NT Shared Electronic Health Record is a joint Australian and NT Government initiative. It stores patients’ summaries electronically in a secure repository which provides rapid access for participating providers, and eliminates the need for paper records to be faxed or mailed, or for multiple telephone calls between providers.

The Shared Electronic Health Record was first trialled in Katherine after research had shown that communications barriers between different providers of health care for Indigenous Territorians were resulting in hospital re-admissions, service duplications, and self-discharges – all having a potential for adverse health outcomes.

Release Ends.

Obviously to discover more was irresistible – had nirvana arrived I wondered.

The initiative has a web site and this can be found here:

http://www.nt.gov.au/health/ehealthnt/index.html

A later press release also makes some pretty big claims

eHealth in first place at the Imparja Cup

Wednesday 30 January 2008

eHealthNT’s Shared Electronic Health Record is delighted to be a major sponsor of the 2008 Imparja Cup, the pinnacle of Indigenous cricket.

The Shared Electronic Health Record (SEHR) is a dramatic advance in health care delivery, allowing patients to have their health records stored in a secure repository, accessible from multiple health sites, with patient consent. The Territory is a national leader in the implementation of the new system.

John Fletcher, Director of the eHealthNT SEHR, said that instant access to accurate health information can be the difference between life and death, particularly in emergency situations.

“The new service means patients can be reassured that there is a safe system allowing doctors, and other health carers, to access their health information. For a highly mobile population, as the Territory has, this system represents a quantum leap in patient care, especially for people who use different GPs, or a number of health centres. Patients no longer have to request file material, or recall prescriptions, and other treatment information – it’s already there, and accessible, if you’re signed up for the SEHR.”

Read more at site

http://www.nt.gov.au/health/ehealthnt/documents/media2008jan30.pdf

What is really being done here is made clear when the following page is browsed:

http://www.nt.gov.au/health/ehealthnt/sehrs/technical.html

In summary what is happening here is that the secure messaging system Argus is being used to transfer discrete records, with patient consent, to a repository. The repository is arrange by patient record number. The server / repository has a record viewer that can display these records.

All this is, as NT claims, way ahead, in a conceptual sense of what is happening elsewhere in Australia – and for that it deserves the strongest commendation and encouragement but there are some issues.

On the positive side it is great that a rational and appropriate approach is being adopted to patient consent and patient control – although it would be good if in a later release the consumer could access and review their record with the doctor possibly explain what it all means.

The problems I see with the architecture approaches being deployed are:

1. A possible lack of scalability of this architecture beyond 2-3 times the present number of users without a range of issues emerging.

2. The rather lump like nature of the data being captured. A newer version might use some of the recognised data and information standards for health summaries.

3. The potential lack of robustness of the document identification numbers with some attendant risks for document mix up.

4.The possibility of a lack of granularity as to just what records a particular provider may access. The risk of abuse of such a system rises exponentially with the number of users who have access to the database.

It is worth noting that the Argus e-mail technology is also being used to enable secure doctor to doctor messaging and the e-prescribing pilots.

I look forward to some evaluation of all this work so the appropriate lessons can be learnt and adjustments made to make it all work more successfully and safely than now.

Well done to the team and I hope they can continue for forge ahead. Their site is well worth a browse to understand what is happening in the Top End. However, that this would be seen as progress really shows just how behind Australia is compared with places like NZ, Denmark, Holland the UK and so on.

In passing I note that the NT web site provides official confirmation of the death of the Australian HealthConnect program – even the name has now been abandoned! I wonder what will become of the SA, NSW, Qld and Tasmanian manifestations of this totally discredited and shockingly managed waste of public money – no wonder NT was keen to see the name go! The silence from all these has been informative. I note the Tasmanian program now says it is in its final stages and SA HealthConnect is changing project names and saying it is out of funds in August 2008 – unless renewed!

David.