Could NEHTA Have Been Done Better and Cheaper?

The following article appeared last week.

HITSP works on communication, inside and out

By: Joseph Conn / HITS staff writer

Story posted: June 25, 2008 - 5:59 am EDT

The federally supported Healthcare Information Technology Standards Panel (HITSP) has come up with a plan to improve its own internal communications as well as to educate members of the broader healthcare community about its work to promote healthcare IT interoperability.

The 43-page plan was presented and accepted Monday during a meeting of the HITSP by its education, communication and outreach committee. The HITSP was created in 2005 by the American National Standards Institute under a $3.3 million contract with HHS to develop a process to select and recommend appropriate healthcare IT standards.

"The measure of our success is not just harmonizing the standards, it's actual implementation," said HITSP Chairman John Halamka in a telephone interview after the meeting. "You want all systems to be plug and play. You want e-prescribing to be universal."

To do that, Halamka said, will require educating everyone in the healthcare community about HITSP and the availability of the HITSP-vetted standards. And in doing that, "You can't overcommunicate," he said.

Work on the education, communication and outreach plan in February, said its chairman, Walter Suarez, president and chief executive officer of the Institute for HIPAA/HIT Education and Research, Alexandria, Va. According to the plan, the committee "anticipated building a multidimensional package of tools and recognizes that significant maintenance will be required to keep these resources up-to-date."

The tools will include one- and two-page fact sheets on the HITSP process and interoperability specifications, slightly longer issue briefs, lists of frequently asked questions that will be kept current and amended in response to reader input, all of which will be published online. The plan also calls for the issuing of news releases as needed and the writing of articles and, possibly, columns for industry publications. The group also contemplates creating a speakers bureau and library of PowerPoint presentations on specific topics such as the use of HITSP harmonized standards in medication management.

In addition, the plan calls for the development of various case studies of interoperability success stories presented either in print, audio or video format and maintaining "a significant presence" at industry events such as trade shows and annual meetings of member organizations.

One key order of business, the plan's authors recognized, will be overcoming the incomprehensibility of the patois of standards development organizations for many people in segments of the plan's target audience who are not IT geeks, particularly patients, government officials and healthcare organization leaders outside of IT. "The single biggest challenge is the need to translate what we do from what we call 'HITSP speak' to a description and a presentation that is simplified and is provided at a level of language that can be understood by nontechnical people," Suarez said. "If I'm a CEO, HITSP speak is not going to cut it for me. It really requires a translation from the technical world to the nontechnical audience, because the nontechnical people are the ones that make the decisions of either creating the products that are HITSP-compatible or compliant and buying those products.

More here

http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20080625/REG/528301340/1029/FREE

A visit to the HITSP Web site is very worthwhile.

It can be found at www.hitsp.org

Before commenting it is sensible to provide a description of what HITSP does. To quote:

HITSP Background

In the fall of 2005, the U.S. Department of Health and Human Services' Office of the National Coordinator for Health Information Technology (ONC) awarded multiple contracts to advance President Bush's vision for widespread adoption of interoperable electronic health records (EHRs) within ten (10) years. The contracts targeted the creation of processes to harmonize standards, certify EHR applications, develop nationwide health information network prototypes and recommend necessary changes to standardized diverse security and privacy policies.

The American National Standards Institute (ANSI), in cooperation with strategic partners HIMSS, Booz Allen Hamilton, and Advanced Technology Institute, was selected to administer the standards harmonization initiative. The resulting collaborative, known as the Healthcare Information Technology Standards Panel (HITSP), brings together experts from across the healthcare community - from consumers to doctors, nurses, and hospitals; from those who develop healthcare IT products to those who use them; and from the government agencies who monitor the U.S. healthcare system to those organizations who actually write the standards.

The Panel's objectives are to:

• serve and establish a cooperative partnership between the public and private sectors to achieve a widely accepted and useful set of standards that will enable and support widespread interoperability among healthcare software applications in a Nationwide Health Information Network for the United States.
• harmonize relevant standards in the healthcare industry to enable and advance interoperability of healthcare applications, and the interchange of healthcare data, to assure accurate use, access, privacy and security, both for supporting the delivery of care and public health.

Most telling is this FAQ response:

“Who can join the HITSP?

The HITSP reaches across the stakeholder community and facilitates the broadest possible participation of all affected parties. Membership on the Panel is open to groups within any of four major categories: standards development organizations (SDOs), non-SDO stakeholder organizations, government bodies and consumer groups.”

Two other facts are useful to be aware of. First the HITSP has its priorities set by the American Health Information Community which is the peak HIT advisory body chaired by the equivalent of the Federal Health Minister and having a wide variety of government, industry, health informatics and consumer representation.

The membership is found here:

http://www.dhhs.gov/healthit/community/members/

It includes all sorts of heavy hitters including the Chairman of Intel and the Vice-Chairman of Wal Mart!

Second the CCHIT (often mentioned in this blog) works with HITSP to ensure products are certified to meets HITSP standards.

Now, while HITSP has not had a totally criticism free of successful run over the last three years much has been achieved and it seems that the internal mid course review will only make what is a good effort even better.

The emphasis, from the get go, on full and broad consultation and involvement makes a refreshing contrast to the situation in OZ.

HITSP is doing much of what NEHTA is doing and more in some ways. Maybe NEHTA 2 (which must come soon) could look a little more like HITSP. It could really help I think!

David.

Useful and Interesting Health IT Links from the Last Week – 29/06/2008

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

These include first:

Urgent Survey Response Needed!

In a comment on the blog this week I had the following comment:

“The Deloitte eHealth strategy is available online. Perhaps you should ensure that they receive a good response.

https://www.deloittedtermine.com/SPSSMR/ImageCache/ImageCache.aspx?project=NESAUDEL001&file=default.htm”

What is actually on line is a short questionnaire. I suggest all those who read the blog quickly make their contribution to the survey. This is despite the fact that I find the survey both very constrained, quite confusing and lacking any apparent discussion of the drivers of the new e-Health Strategy. There are a range of ‘strategic choice’ questions the survey could and should have addressed.

Second we have:

Behind the Curtain

Epic's unwavering commitment to its unique values has created an unusual recipe for success. What's behind Epic's gains in the clinical IT sphere?

by Mark Hagland

When readers of HCI were asked what vendor they most wanted to read about, respondents picked one company by a wide margin (see graphic on page 28). The results weren't surprising, as one clinical information systems vendor has a truly unusual profile, and its very unusualness has given it a certain cachet. What's more, that company is different not just in one way, but in many. It has a unique operating methodology, sales approach, market strategy, history, and culture. It's even been described by some over the years as a “cult.” That company? The Madison, Wis.-based Epic Systems Corporation.

Of course, there are ways in which Epic does resemble its competitors. It sells corporately designed clinical systems software, which it implements in patient care organizations; it has a team of internal software developers and a team of implementers; and it competes with other core-clinical companies for the same essential base of customers, in both the inpatient and outpatient spheres (though Epic started in the outpatient sphere and moved into the hospital, while most have done the opposite). And it makes money — lots of money ($500 million in annual revenues as of late 2007 — see Epic's entry in the HCI 100, page 52).

Very much more here:

http://www.healthcare-informatics.com/ME2/dirmod.asp?sid=&nm=&type=Publishing&mod=Publications%3A%3AArticle&mid=8F3A7027421841978F18BE895F87F791&tier=4&id=125CB9E22CE6403F9A68D87839295283

This is a fascinating review of the mysterious Epic – which is the provider of core clinical system for organisations such as Kaiser Permanente. They are being amazingly successful and there are lessons in how they go about their work that should be carefully reviewed and discussed.

Third we have:

IBA's Lorenzo health system in tests

Karen Dearne | June 27, 2008

THE long-awaited Lorenzo clinical software suite by IBA Health will be launched in Australia within three to four months and will be available for general release in early 2009.

Despite continuing political sniping over missed deadlines, Lorenzo has been installed in three British National Health Service hospital trusts - Morecambe Bay, Bradford and South Birmingham, and are undergoing final testing ahead of go-live next month, Gary Cohen, IBA Health Group executive chairman said.

Two early adopter sites, in Germany and Holland, have already proven Lorenzo's real-world capabilities and reliability.

"We're starting with these three trusts with Lorenzo release one, and after three to four months' actual operation it will be rolled out to a larger number of hospitals," Mr Cohen said. "The intention is to use these as a staggered and stepped approach, so it will probably take two years to roll it out to all trusts in the three regions.

"So a delay of a few weeks in going live is nothing. The reality is, significant progress has been made in the past 12 months, there are no major issues and we're just getting on with delivering."

More here:

http://www.australianit.news.com.au/story/0,24897,23930668-15306,00.html

Another report is found here:

IBA Health set for Lorenzo release

June 26, 2008 - 1:15PM

IBA Health Group Ltd says it is on track to meet its 2008 financial year earnings guidance and has revealed it will release its flagship software, Lorenzo, in Australia in coming months.

Australia's largest health-care information technology company said it remains on track to meet its earnings before interest, tax, depreciation and amortisation (EBITDA) guidance of between $85 million and $95 million.

The company delivered EBITDA of $32.27 million in 2006/07, up 70 per cent from 2005/06.

IBA Health said its revenue was being impacted by the surging Australian dollar against the British pound.

More here:

http://news.smh.com.au/business/iba-health-set-for-lorenzo-release-20080626-2x87.html

Clearly IBA Health is now getting close to the ‘put up or shut up’ time with Lorenzo. If we don’t see real delivery in the next few months confidence in the company’s capability is likely to be severely eroded. (The usual disclaimer that I own a few IBA shares applies) .

Fourth we have:

IT waste a 'major challenge' to human health: UNEP

June 26, 2008 - 10:29PM

Millions of discarded mobile phones and computers are posing a "major challenge" to human health, the chief of the United Nations Environment Programme said Thursday.

Achim Steiner told a UN conference on waste management on the Indonesian resort island of Bali that 20 million mobile phones were thrown away each year in China.

Meanwhile, the global number of personal computers was expected to double to two billion by 2015.

"The rapid growth and rapid redundancy of all this equipment ... represents a major challenge to the international community in terms of human health and the environment," he said.

He said 20 to 50 million tonnes of electronics waste was produced every year -- enough to load a train that would stretch around the world.

More here

http://news.smh.com.au/world/it-waste-a-major-challenge-to-human-health-unep-20080626-2xkp.html

This is a reminder of a major downside to all the gadgets and computers. There are some really nasty metals and toxins locked up in this stuff that really should be addressed more systematically.

Fifth we have:

Mobiles and internet link to help the mentally ill

Louise Hall Health Reporter
June 29, 2008

MOBILE phones and the internet will be used to help up to 2 million Australians manage their mental health problems.

People can use the technology to track their wellbeing on a day-to-day basis by recording their mood, sleep, activities, medication, physical activity and drug and alcohol use.

The $1.88 million system is being developed by Sydney's Black Dog Institute as part of a growing move towards "e-therapy" as a way to cope with the chronic shortage of services for the mentally ill.

Using secure messaging via the internet or SMS on their mobile phone, patients report their condition daily. Information is fed back on their condition and alerts are sent to their phones or computers when things aren't going well, along with links to appropriate self-help tools.

Black Dog's senior research fellow Judy Proudfoot said the system would assist those at risk of depression, anxiety or stress to recognise symptoms and seek support, as well as help existing sufferers manage their illness.

More here:

http://www.smh.com.au/news/technology/mobiles-and-internet-link-to-help-the-mentally-ill/2008/06/28/1214472837799.html

I also came across this press release in the last few days.

http://www.swinburne.edu.au/corporate/marketing/mediacentre/core/releases_article.php?releaseid=1142

Internet therapy helps treat panic disorder

Online psychological treatment (etherapy) can be as effective as face-to-face therapy for treating mental health disorders, according to a new study by Swinburne researchers.

Published in the Journal of Medical Internet Research, the study found that therapist assisted etherapy is highly effective for the treatment of panic and panic-related symptoms.

It revealed that when online treatment programs are supported by health professionals they can achieve patient outcomes comparable to best-practice face-to-face therapy.

“Mental illness is a growing problem worldwide,” said lead author and psychologist Kerrie Shandley. “In Australia, it accounts for 13 per cent of health problems and one in 10 adults report that they suffer from a long-term mental or behavioural problem.”

“The management of anxiety and depression generally falls to family doctors who may lack the time and resources to deliver appropriate psychological treatment to their patients, so other methods for delivering effective therapy need to be developed.”

The study found that when panic disorder sufferers used the etherapy program ’Panic Online’ in conjunction with support from a general practitioner, their panic disorder and panic-related symptoms were reduced with around 30 per cent losing their symptoms altogether.

The study followed 96 people with a primary diagnosis of panic disorder who completed the Panic Online program over 12 weeks. Fifty-three of the participants had face-to-face assistance from their GP, who had received specialist training in cognitive behavioural therapy, and 43 had assistance from a clinical psychologist via email.

The participants completed a telephone interview conducted by a psychologist and a series of online questionnaires to assess panic-related symptoms over the course of the treatment and at a six-month follow-up.

“Both groups were shown to significantly improve over time”, Shandley said. “There were no noticeable differences between the participants who had assistance from their GP and those who had assistance from a clinical psychologist.”

----- End Release.

I also understand that “Internet based mental health therapy (has) received a boost thanks to a $.1.5m Federal Government grant to establish the National e-Therapy Centre for Anxiety Disorders (NeTCAD).

The service, based in Swinburne, will offer internet based clinical treatment programs for anxiety disorders, train postgraduate psychology students in the science and practice of e-therapy and develop online treatment programs for other psychological problems.”

This is all really good news to see studies that are showing such techniques can work – but even better that these services are certainly very accessible as well as being cost effective.

Sixth we have:

Backflip over OneSchool online student database

James O'Loan | June 23, 2008

THE controversial OneSchool online student database is being watered down after a public backlash against its instigator, Education Queensland.

School principals are leading the erosion, with one northside Brisbane primary school principal writing to parents advising them that photos of students do not need to be posted on their profiles.

The photos were, according to Education Queensland, to be posted along with students' academic performance, career aspirations and extra curricular activities.

The move follows Education Minister Rod Welford's defence of OneSchool when he dismissed the idea that hackers would target the database of nearly half-a-million students as "ridiculous, extreme and hypothetical".

Eatons Hill State School principal Clyde Campbell's letter to parents stated OneSchool was a "fundamental component of the Government's Smart Classrooms strategy".

He said the decision to omit photos was "a decision taken by the school" and reassured parents the new centralised system would be even more secure than the individual student management system it used previously.

More here:

http://www.australianit.news.com.au/story/0,24897,23907719-16123,00.html

Well it seems there has been the outbreak of just a little common sense here. It is clear Education Queensland needs a student management system..the issue is really about how much information is needed in that system and what protections are in place to prevent abuse. I hardly see how recording extra-curricular activities and career aspirations should be compulsory! If people volunteer such information fine..compulsion is just silly!

Last we have out slightly technical note for the week:

Third of IT admins admit snooping with privileged passwords

Power and anonymity equals risky business, says password management vendor.

Gregg Keizer 23/06/2008 08:36:30

One in three IT administrators say they or one of their colleagues have used top-level admin passwords to pry into confidential or sensitive information at their workplace, according to a survey by a password-management vendor.

Nearly half also confessed that they have poked around systems for information not relevant to their jobs.

"We asked these questions last year, too," said Adam Bosnian, vice president of product strategy and sales for Cyber-Ark, a Newton, Mass.-based maker of password file security management software. "And we got similar results. So on one hand, the results weren't surprising. What was surprising initially -- and this time around, too -- is that people admit to it."

Last month, Cyber-Ark polled approximately 300 senior IT professionals at a London security conference and trade show, asking them a dozen questions about their password practices. The majority of those surveyed said they work for companies with more than 1,000 employees.

The fact that a third acknowledged they had abused an admin password to access out-of-bounds information shouldn't surprise anyone, said Bosnian. "Everyone thinks that IT administrators are the trusted ones, and it's all the rest that we need to worry about. But admin passwords not only give administrators a lot of power, they also provide a lot of anonymity."

More here:

http://www.computerworld.com.au/index.php?id=1907566447&eid=-255

This is a worry, but not unexpected. What it tells me is that we need to have systems that foster the maintenance of security while at the same time making sure all those who have such roles understand (through education etc) the trust and responsibility they carry – to keep all the things they discover in the course of their work to themselves. This should be backed up by regular review of audit trails to detect bad behaviour and a clear and transparent penalty process for abuse.

More next week.

David.

E-Health and the Terrible Floods in the US MidWest.

The follow press release appeared a day or two ago.

FSSA Announces Indiana Flood Victims eHealth Support Center

INDIANAPOLIS--(BUSINESS WIRE)--Today, the Indiana Family and Social Services Administration (FSSA) announced the creation of the Indiana Flood Victims eHealth Support Center (1-877-788-5888) as a part of the relief effort for disaster victims across the state. This support center will provide doctors with medical information of flood victims, to the extent obtainable, for treatment purposes. FSSA is leading the effort between the Regenstrief Institute, Indiana Health Information Exchange (IHIE), who is handling the calls, and Electronic Data Systems (EDS).

“Governor Daniels called upon state government to assist the disaster victims in any and all ways possible. The support center is just one of several initiatives taking place to help Hoosiers get back on their feet,” said FSSA Secretary Mitch Roob. “With the eHealth Support Center, we will be able to give providers all the information we have available in a timely manner, resulting in a higher quality of care for patients.”

Medical information is being made available through the Indiana Network for Patient Care (INPC). The INPC is a secure clinical data repository that is populated with healthcare information in collaboration with central Indiana hospitals, outpatient centers, pharmacies, imaging centers, laboratories, public health departments and insurance providers.

“We are pleased to be able to support flood evacuees and their doctors in this time of need,” said Dr. J. Marc Overhage, Director of Medical Informatics at the Regenstrief Institute, Inc. and President/CEO of the Indiana Health Information Exchange. “The ability to provide medical information that would otherwise be lost or inaccessible is going to make a difference in the care of many Hoosiers. We applaud FSSA in making this collaboration a reality.”

Calls will be taken 24 hours a day, seven days a week. Requests that are made to the Indiana Flood Victims eHealth Support Center (1-877-788-5888) during business hours (7:00am – 5:00 pm EST) will be processed within one hour. Calls made after hours will be processed the next business day.

For additional information about the eHealth Support Center, patients and physicians should visit: www.ihie.com/indianaflood. For more information on disaster relief efforts visit: www.emergency.in.gov .For more information about FSSA, visit: www.fssa.in.gov. For more information about EDS, visit: www.eds.com . Additional information about the Indiana Health Information Exchange may be found at: www.ihie.com. Information about the Regenstrief Institute is available at: www.regenstrief.org.

URL for release:

http://www.businesswire.com/portal/site/google/?ndmViewId=news_view&newsId=20080620005411&newsLang=en

This is really a good thing to see the infrastructure be quickly brought into action to support those who have been displaced and possibly separated from their usual services and carers. This is, of course, what did not happen with Cyclone Katrina.

One can only hope planning to deliver such services is part of the disaster planning that is undertaken in Australia – given the bad run we have had with cyclones and the like recently.

David.

The New England Journal of Medicine Assesses the Real EHR Use in the USA

The following abstract is from a full article published in last week’s NEJM.

Electronic Health Records in Ambulatory Care — A National Survey of Physicians

Catherine M. DesRoches, Dr.P.H., Eric G. Campbell, Ph.D., Sowmya R. Rao, Ph.D., Karen Donelan, Sc.D., Timothy G. Ferris, M.D., M.P.H., Ashish Jha, M.D., M.P.H., Rainu Kaushal, M.D., M.P.H., Douglas E. Levy, Ph.D., Sara Rosenbaum, J.D., Alexandra E. Shields, Ph.D., and David Blumenthal, M.D., M.P.P.

ABSTRACT

Background Electronic health records have the potential to improve the delivery of health care services. However, in the United States, physicians have been slow to adopt such systems. This study assessed physicians' adoption of outpatient electronic health records, their satisfaction with such systems, the perceived effect of the systems on the quality of care, and the perceived barriers to adoption.

Methods In late 2007 and early 2008, we conducted a national survey of 2758 physicians, which represented a response rate of 62%. Using a definition for electronic health records that was based on expert consensus, we determined the proportion of physicians who were using such records in an office setting and the relationship between adoption and the characteristics of individual physicians and their practices.

Results Four percent of physicians reported having an extensive, fully functional electronic-records system, and 13% reported having a basic system. In multivariate analyses, primary care physicians and those practicing in large groups, in hospitals or medical centers, and in the western region of the United States were more likely to use electronic health records. Physicians reported positive effects of these systems on several dimensions of quality of care and high levels of satisfaction. Financial barriers were viewed as having the greatest effect on decisions about the adoption of electronic health records.

Conclusions Physicians who use electronic health records believe such systems improve the quality of care and are generally satisfied with the systems. However, as of early 2008, electronic systems had been adopted by only a small minority of U.S. physicians, who may differ from later adopters of these systems.

The Full Text is available (for free) at the URL below.

http://content.nejm.org/cgi/content/full/NEJMsa0802005?query=TOC

The study has been warmly received by a number of commentators.

The following long article provides a lot of detail.

EHR access sparse in ambulatory-care environment

By: Joseph Conn / HITS staff writer

Story posted: June 19, 2008 - 5:59 am EDT

The summary report on a comprehensive survey, funded by government and private organizations, of physician adoption of electronic health-record systems finds that after more than four years of federal ballyhoo of health information technology, only 17% of physicians in the ambulatory-care environment have access to an EHR.

Just 4% of physicians in ambulatory care have available a “fully functional” EHR system, including patient-safety features such as drug-drug and drug-allergy alerts and full electronic prescribing.

Anticipating just such a low adoption rate, researchers graded on a curve, giving partial credit to physicians who have something less than the best EHR system in their offices. Another 13% of physicians surveyed have such “basic” EHRs with a minimum set of functions.

Given that 83% of ambulatory-care physicians don’t have an EHR, “the U.S. healthcare system faces major challenges in taking full advantage of EHRs to realize its health goals,” according to an executive summary of the published survey in the June 19 issue of the New England Journal of Medicine. A copy of the full report should be released July 2.

The survey was conducted between September 2007 and March 2008 by the Institute for Health Policy at Massachusetts General Hospital, Boston, the Harvard School of Public Health, George Washington University and RTI International, working under a contract with the Office of the National Coordinator for Health Information Technology at HHS. The initial contract was awarded in 2005 to develop a standardized methodology to measure the rate of adoption of EHRs among physicians and hospitals.
More here:

http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20080619/REG/785336712/1029/FREE

There is additional Coverage here:

'Full function' EHRs may not get full CMS incentives

By: Joseph Conn / HITS staff writer

Story posted: June 20, 2008 - 5:59 am EDT

Only 4% of U.S. physicians in ambulatory care have access to an advanced, "fully functional" electronic health-record system, but even those top-tier systems may not be fully featured enough to qualify for maximum payments under the new CMS pilot program to boost EHR adoption.

Still, most healthcare information technology experts contacted for this story reacted favorably to the release of the executive summary of what may be the most authoritative and methodologically solid study of EHR use to date.

The summary was published in the New England Journal of Medicine. The survey work was conducted under two $600,000 grants from the Robert Wood Johnson Foundation and another $3.6 million grant from the Office of the National Coordinator for Health Information Technology at HHS, the latter of which paid for both the ambulatory-care EHR survey and a separate hospital IT survey that is yet to be completed. A final report on the ambulatory survey is due July 2.

The survey of 2,758 physicians was conducted between September 2007 and March 2008 by the Institute for Health Policy at 902-bed Massachusetts General Hospital, Boston, the Harvard School of Public Health, George Washington University and RTI International.

See full article here:

http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20080620/REG/739079971/1029/FREE

The New York Times also covered the report.

See:

http://www.nytimes.com/2008/06/19/technology/19patient.html?_r=1&oref=slogin

Most Doctors Aren’t Using Electronic Health Records

A very important aspect of these studies is that a methodology has been developed that really assesses the quality and depth of the EHR being used. This is clear recognition of the fact that it is only when the more advanced forms of functionality are not only present, but actually used, will the hoped for benefits and improvements in care quality be achieved.

It would be invaluable if such a detailed study were carried out in Australia.

I look forward to the full paper on July 2.

David.

Health Information Exchange – Some Really Sound Thoughts and Why NEHTA might be Off Course.

The following post appeared on the e-CareManagement blog a day or two ago.

Untangling the Electronic Health Data Exchange

Posted by Vince Kuraitis on June 19, 2008

by David C. Kibbe MD, MBA

The purpose of this post is to help a non-technical audience untangle some of the confusion regarding health data exchange standards, and particularly come to a better understanding of the similarities and differences between the Continuity of Care Record (CCR) standard and the CDA Continuity of Care Document (CCD). But what I’m most interested in is getting beyond the technical, political, or economic positions and interests of the proponents of any particular standard to arrive at some principles that demonstrate in plain language what we are trying to achieve by using such standards in the first place.

Frankly, I don’t give a hoot about what standardized XML format for capturing clinical data and information about a person becomes the norm in the health care industry over the next several years. I do care that the decision is made by the people, institutions, and companies who use the standards, and not made by a quasi-governmental panel or a group of “industry experts” whose economic or political interests are served by the outcome, and dominated by a particular standards development organization with whom they are very cozy.

In other words, I do want free and open market forces to be able to operate freely and openly as health information exchange evolves, in part because I believe market forces will work in the direction of continuously improving health IT, whereas in my experience top-down efforts are often protective of established interests and discouraging to innovation.

Herein lies the problem, in my opinion, with the standards adoption process that the Office of the National Coordinator of HIT (ONC) and HITSP have overseen during the past four years.

It is the epitome of a top-down, large established player-controlled, and anti-competitive juggernaut in which a “one size fits all” paradigm has been promoted and lobbied for. In this case, HITSP has “selected” the CCD and not the CCR standard, despite the market forces that seem to be continuing the use of the CCR standard. This is simply stupid and likely will turn out to be futile.

I am one of the many volunteer co-developers of the Continuity of Care Record standard, which has been developed under the auspices of ASTM International, a not-for-profit organization that develops standards for many industries, including avionics, petroleum, and air and water quality. The CCR is sponsored by the American Academy of Family Physicians and numerous other physician groups. I am also the 2008-2010 chair of the E31 Technical Committee on Healthcare Informatics, the leadership group within ASTM that is working with Google Health and many other individuals and organizations on the implementation and use of the CCR standard in this country and abroad.

Much more here:

http://e-caremanagement.com/untangling-the-electronic-health-data-exchange/

It needs to be said that while there is a risk of some sort of partisanship in all this David Kibbe is a man who knows what he is talking about. Some of the points he makes I find really compelling – especially in the light of some of the choices NEHTA is making in the same domain at present.

Of special importance is the last paragraph of the blog.

“Which brings me to the finale of this post, namely, to state in plain language that interoperability can only be approached in incremental stages when so much health data and information exists in non-structured formats. The principle to uphold is the encouragement of any and all efforts to innovate in the direction of computability and interoperability, even if some of these appear less than perfect or even piece-meal. One size will not fit all uses or use-cases, and what is good for consumers’ PHRs may not be the same thing that works in a very large medical enterprises. Control over standards by large enterprises and/or their vendors is spurious, anti-competitive, and probably won’t be effective. The standards are supposed to make our lives simpler, not more complicated.”

What Dr Kibbe is saying you is you have to start simple and grow – not do a NEHTA and come up with untested – and probably unusable – 100+ page documents defining how to do a discharge summary or referral.

He also clearly recognises the inapplicability of the top down ‘we will instruct and you will comply’ approach, so beloved of NEHTA, in the e-Health domain.

A great read. Certainly a blog to subscribe to notifications of updates!

David.

Just Why are NEHTA’s Plans for the Shared EHR a Secret?

The following is adapted from the NEHTA web site (captured 22/06/2008)

http://www.nehta.gov.au/index.php?option=com_docman&task=cat_view&gid=130&Itemid=139

Shared Electronic Health Record

NEHTA is working to develop specifications and requirements for a national approach to shared electronic health records. These records will enable authorised healthcare professionals to access an individual's healthcare history, directly sourced from clinical information such as test results, prescriptions and clinician notes. The shared electronic health record will also be able to be accessed by individuals who have received healthcare services.

Specifically, NEHTA will focus on developing:

• Operating concepts for a national approach to establishing and maintaining shared electronic health records;
• Policies, requirements, architecture and standards for a national approach to shared electronic health records; and
• A business case to substantiate and validate the proposed approach.

For the health system within Australia to reap the full benefits from the IT, governments and healthcare providers need to make the case for undertaking further investment including the development of a national system of shared electronic health records. The case for the required level of investment depends on the credible quantification of the costs and benefits of providing such.

Contact

Dr Andrew Goodchild - Shared Electronic Health Record Design

Fact Sheets

Shared Electronic Health Record Fact Sheet 19/08/2006

Context and Strategic Direction

Standards for E-Health Interoperability v1.0 - 08/05/2007

Review of Shared Electronic Health Records Standards v1.0 - 21/02/2006

What this shows us is that it is over 14 months since NEHTA has published anything on the Shared EHR.

However we have had Dr Haikerwal running around the country spruiking the plans for having a new electronic record implemented over the next few years – following the receipt of funding from Council of Australian Governments which is to meet in October this year.

See:

http://www.misaustralia.com/viewer.aspx?EDP://20080620000020806080&magsection=news-headlines-list&portal=_misnews&section=news&title=Electronic+health+system+on+the+mend&source=/_xmlfeeds/mis/news/feed.xml

It seems, from the reports I have received, NEHTA has been conducting briefings about such a plan to a collection of clinical and consumer peak bodies. (The last one was on June 18 in Canberra).

The obvious concern is just what they are telling these audiences and what commitments are being made that have not been subjected to any technical scrutiny other than the NEHTA staff. The situation we have here is that NEHTA (a publicly funded organisation) is providing private briefings on topics where it has by no means the monopoly on expertise trying to get very substantial ($billions I would not be surprised) funding to keep itself in existence while having been reviewed by the Boston Consulting Group recently as a failed organisation – especially in the area of Shared EHRs (now somehow renamed Individual EHRs).

In the meantime we also have the following:

3 years away">Surprise, surprise - e-health records >3 years away

17 June 2008

The Australian Doctor website reports today that Australia “is at least three years away from introducing shared e-health records for every patient — despite $150 million being sunk into e-health programs over the past eight years.”

Federal Health Minister Nicola Roxon, when interviewed by the Australian Financial Review last week, refused to commit to a 2012 deadline for a national e-health record system.Clinical leader of the National e-Health Transition Authority (NEHTA) and ex-AMA president Dr Mukesh Haikerwal told Australian Doctor, “There is no element of the reform agenda that can succeed unless we have a decent underpinning by a robust e-health system.”NEHTA is believed to be looking initially at a minimum-quality data set - limited to information such as allergies, hospital history and medical conditions to ensure there is enough information “to treat the patient safely”.

For more see:

http://wellingdigital.com.au/

Worse we have a National E-Health Strategy being developed by Deloittes which NEHTA is clearly making bets on the outcome of. This is a governance and management farce. Either NEHTA or Deloittes are setting the direction for the future of e-Health. I know which is should be and it isn’t NEHTA!

Deloittes need to be allowed to finish their work – have it made public for consideration by all relevant stakeholders - and at this point NEHTA should be invited to consider how it can actualise whatever is recommended.

I believe both Ms Roxon and Mr Hockey (the Opposition spokesman) should be asking some hard questions of NEHTA right now as to just what they are up to and how they justify it. At the very least the public (and not just a select few) is entitled to know what they have in mind!

David.

Useful and Interesting Health IT Links from the Last Week – 22/06/2008

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

These include first:

CBO director stands by criticized IT report

By: Joseph Conn / HITS staff writer

Story posted: June 17, 2008 - 5:59 am EDT

The director of the Congressional Budget Office has rallied to the defense of his troops, one current and one former CBO researcher, who in a report last month criticized two older and oft-cited studies touting the macroeconomic benefits of widespread, national deployment of healthcare information technology systems.

Peter Orszag, director of the congressional watchdog agency, took to his blog earlier this month to answer criticisms of the CBO report sent to him in a letter and an attachment from officials at the RAND Corp.

To paraphrase, the RAND folks wrote to the CBO people saying, "You done us wrong," and the CBO boss blogged back, answering, "We stand by our men."

"Nothing in the RAND letter would cause us to modify our previous conclusions," Orszag wrote on his blog.

"The RAND study estimated potential savings of approximately $80 billion per year from health IT if it were widely adopted," Orszag continued. As the "CBO concluded in its recent report, however, that $80 billion figure is not an appropriate guide to the effects of legislative proposals aimed at increasing the use of health IT for several reasons. For example, the RAND study attempted to measure the potential impact of the widespread adoption of health IT—assuming the occurrence of 'appropriate changes in healthcare'—rather than the likely impact, which would take account of factors that might impede its effective use.

More here:

http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20080617/REG/247135062/1029/FREE

This and the article following show just how hard it can be to draw firm conclusions in the absence of real life implementation. Sadly, if done well, the implementation process always changes things in such a way that pre / post comparisons are very difficult if not impossible. It seems unlikely we will ever have a randomised controlled trial of health IT – so we need to look for other indicators to show health IT makes a difference. I would suggest measures that reflect the quality and safety of treatment before and after would be a good place to start.

Second we have:

Health IT Might Not Produce Immediate Savings, But It Could Improve Quality of Care, Reduce Health Disparities, According to Analysts

[Jun 16, 2008]

Health IT Now! Coalition on Friday at a Capitol Hill briefing asked lawmakers to pass legislation that would subsidize health care providers for the adoption of electronic health records, ensure interoperability among health care information technology platforms and address privacy concerns, CongressDaily reports (CongressDaily, 6/13).

At the briefing, RAND researcher Richard Hillestad cited a study he led that found implementation of an interoperable health care IT system by 90% of the U.S. health care system would save $80 billion annually after 15 years. He added that preventive care and chronic disease management efforts that use health care IT could prevent 400,000 deaths and add 40 million workdays annually (Wyckoff, CQ HealthBeat, 6/13). Hillestad also said that use of health care IT could prevent more than 2.2 million adverse events related to medications annually (CongressDaily, 6/13).

More here:

http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=52757

This is an important briefing that makes it clear the objective of Health IT is better and safer care and not savings in the short term.

Third we have:

N.Y. Medicaid ups the ante

By refusing to pay for 14 ‘never events,’ the nation’s biggest Medicaid program could propel other states into action

By: Jean DerGurahian

Story posted: June 16, 2008 - 5:59 am EDT

In a relatively short period for the healthcare industry, several insurers and hospital associations have adopted positions of not paying for certain medical errors; now, with the New York state Medicaid program establishing its own policy, the stage is set for an even faster growth in the trend, industry experts say.

New York, with the nation’s largest Medicaid budget at $47 billion, stands to garner attention as to how it structures its policy, which was announced earlier this month. New York’s approach is noteworthy and has been met with approval by hospitals because they prefer a list of “never events” instead of the more complex hospital-acquired conditions that constitute Medicare’s nonreimbursement policy. The state is not the first to jump on the nonpayment bandwagon and its list of events is not as lengthy as lists of other groups with similar policies.

More here:

http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20080616/REG/564730725

This is a very interesting article where it is explained that the US Health Insurance system will now refuse to pay for the management of complications in treatment that should never happen – e.g. wrong side surgery, lost sponges inside the patient, development of pressure ulcers and so on.

Seems like this could certainly be applied in Australia to make sure there is focus in Hospitals on preventing complications that should not happen.

Fourthly we have:

Telemedicine In Emergency Departments - Medical Journal Of Australia

16 Jun 2008

The use of telemedicine in emergency departments (EDs) is most effective for moderate trauma patients, according to a research paper published in the latest issue of the Medical Journal of Australia.

Professor Johanna Westbrook, from the Health Informatics Research and Evaluation Unit at the University of Sydney, and her co-authors evaluated whether the introduction of an emergency department telemedicine system changed patient management and outcome indicators. The study looked at the use of the Virtual Critical Care Unit (ViCCU), a telemedicine system that allows real-time, broadcast-quality, low-latency audiovisual communications between ED clinicians at different sites.

The study was conducted in the EDs of an 85-bed district hospital and a 420-bed metropolitan tertiary hospital - for one year before and 18 months after the introduction of the ViCCU.

At the end of the study, doctor and nurse clinicians were interviewed on their perceptions of how the ViCCU system impacted on the care provided and their work.

More here:

http://www.medicalnewstoday.com/articles/111404.php

This is an interesting study.

The full paper is found here and is well worth a browse.

http://www.mja.com.au/public/issues/188_12_160608/wes11019_fm.html

Fifth we have:

Vic's Eastern Health moves from legacy to leader

Virtualisation, VoIP, wireless networks, electronic documents all overhauled as part of massive upgrade.

Darren Pauli (Computerworld) 19 June, 2008 10:37:36

A four-year IT modernisation overhaul of Victorian health provider Eastern Health will spell the end of server sprawl, expensive Private Automatic Branch Exchanges (PABXs), and soaring printing costs.

The government organisation has 8000 staff spread across more than 60 sites including hospitals, aged care facilities and rehabilitation clinics, making it the second largest in the state and among the biggest in the country.

So it is no surprise that inefficiencies in IT have inflated top end operating costs and damaged the role of technology as a business enabler.

But like all IT trailblazers, Eastern Health CIO Mark Gardiner has focused the renovation cross-hairs on improving efficiency rather than frugality.

"Healthcare is not just a people-business, it's an information business that relies on the right information to get to the right place at the right time. And IT is key to helping us operate more efficiently, effectively and provide better care to patients," Gardiner said.

The project, which kicked off in 2006, is part of the Victorian government's $360 million six-year HealthSmart initiative to spruce-up IT operations across the public health sector. Gardiner headed-up the project.

More here:

http://www.cio.com.au/index.php?id=1066434940&eid=-601

This sort of report really makes me sad. The best that can be said about progress in health IT in this area (Eastern Health) is that issues like network infrastructure should have been addressed years ago. The lack of discussion about application upgrades I find very revealing indeed. To describe getting decent infrastructure in place as trailblazing really is just hopeless.

Sixth we have:

Pedophile fears as student profiles go on net

Article from Courier Mail.

James O'Loan and Melanie Christiansen

June 16, 2008 12:00am

A PHOTO of every state school student will be posted online by the Government, sparking fears pedophiles could use the database.

The intranet database, dubbed OneSchool, will profile each of the state's 480,000 public school students enrolled from Prep to Year 12.

Photographs, personal details, career aspirations, off-campus activities and student performance records are being collected from all 1251 state schools.

Education Queensland said details of 180,000 students from 637 schools already were online and the database would be completed by December.

About 80,000 students are expected to be added to the internal education department database each year.

The site already has been labelled a likely target for computer hackers.

"The social fabric of hackers is such that this database (OneSchool) is going to be a fair target," Queensland University of Technology deputy dean of Information Technology professor Mark Looi said.

More here:

http://www.news.com.au/couriermail/story/0,23739,23868131-952,00.html

Most worrying is this quote from the Minister

“Education Minister Rod Welford has warned the state-wide rollout of the OneSchool database is "non-negotiable" and students could be refused an education if they don't divulge required information.

He also said he understood some people might have concerns about the security of online databases but OneSchool was designed to be more secure than the current system.

"If they don't want to have any of their information recorded ... how else does one record a student's results," he said.”

Now while I am sure this will all be managed sensibly – with all teachers having access to the whole database one really has to wonder just how long it will take for one ‘bad egg’ to abuse the information for some reason or other. Also to not permit individuals to opt-out if they have some concern – perhaps about bullying, family violence etc is just plain wrong in my view.

I suspect the Minister is just a bit too arrogant for his own good by not showing some reasonable level of flexibility in all this.

More on this here:

http://www.news.com.au/couriermail/story/0,23739,23875371-3102,00.html

Government secrecy 'favours the state, not individual'

Last we have out slightly technical note for the week:

Test Center review: Firefox 3 comes out sizzling

After an eight-month beta phase, Firefox's major update scores big with unprecedented ease, snappier performance, and sensible security features.

Paul Venezia (InfoWorld) 18/06/2008 17:22:03

As the window to the Internet, the Web browser is arguably the most important application ever developed, and it will only become more important in the coming years, as applications continue their retreat from the local system and into Web frameworks built on Apache, IIS, Python, PHP, Perl, Ruby, and countless other languages and tools. Against this backdrop, today's official introduction of Firefox 3 may in fact be a watershed event in the history of computing.

It's no secret that Firefox isn't the most popular browser. Internet Explorer, for better or for worse, enjoys a significant advantage in market share, but data gathered from all corners of the Internet show this advantage eroding. Judging by the traffic at a Web site that handles more than 100,000 unique visitors a day, Firefox gained almost 8 per cent over Internet Explorer for the month of May, year over year, moving from just over 26 per cent of all visitors to 33 per cent. Internet Explorer lost a total of 9 per cent to other browsers in that time frame.

Oddly, the difference seems to have been taken up by Apple's Safari, which gained almost 3 percent. These numbers will differ depending on the site — for instance, sites focused on technology will have higher numbers for Firefox, since most tech-savvy users prefer Firefox over Internet Explorer — but the general trend shows that Firefox is making significant inroads all over the globe. Judging by the advances in Firefox 3, this is likely to accelerate.

Continue reading here:

http://www.computerworld.com.au/index.php?id=1922793285&eid=-255

All I can say is I use it and the features it has, and the speed, make it great fun to use! Go get it from www.mozilla.com if you are not already a user. You will not regret it!

This article is also fun.

Stupid user tricks: IT admin follies

IT heroes toil away unsung in miserable conditions -- unsung, that is, until they make a colossally stupid mistake

Andrew Brandt (InfoWorld) 17/06/2008 09:05:55

Go here:

http://www.computerworld.com.au/index.php?id=692810722&eid=-6787

More next week.

David.

Issue No 2 of [Pulse+IT] eNews Available

Pulse+IT eNews

Edition 2: 20th June, 2008

Click here to download this edition

Contents

- Simon James - 1800-Skype: Free phone calls for all.

- Dr David More - What is Big Blue up to in E-Health in Oz?

- Dr Sam Heard - Guest commentary: Why is it taking so long?

- In other news...

Events calendar

Edition Sponsors

- GPA Accreditation Plus

- eVisit

Enjoy!

David.

The USA Plans to Prove Ambulatory EHRs Really Make a Difference!

The following release appeared a few days ago:

http://www.hhs.gov/news/press/2008pres/06/20080610a.html

HHS Secretary Announces 12 Communities Selected to Advance Use of Electronic Health Records in First Ever National Demonstration

FOR IMMEDIATE RELEASE
Tuesday, June 10, 2008

HHS Secretary Mike Leavitt today named 12 communities that will participate in a national Medicare demonstration project that provides incentive payments to physicians for using certified electronic health records (EHR) to improve the quality of patient care. The five-year, first-of-its-kind project is expected to improve the quality of care provided to an estimated 3.6 million Americans.

“The use of electronic health records, and of health information technology as a whole, has the ability to transform the way health care is delivered in our nation,” Secretary Leavitt said. “We believe that EHRs can help physicians deliver better, more efficient care for their patients, in part by reducing medical errors. This project is designed to demonstrate these benefits and help increase the use of this technology in practices where adoption has been the slowest – at the individual physician and small practice level.”

The communities selected to work with the Centers for Medicare & Medicaid Services (CMS) on the EHR demonstration project range from county- and state- level to multi-state collaborations. They include:

• Alabama
• Delaware
• Jacksonville, FL (multi-county)
• Georgia
• Maine
• Louisiana
• Maryland/Washington, DC
• Oklahoma
• Pittsburgh, PA (multi-county)
• South Dakota (multi-state)
• Virginia
• Madison, WI (multi-county)

These 12 communities were selected through a competitive process from a field of more than 30 applicants. They demonstrated active collaboration among stakeholders, including physicians and other providers, health plans, employers, government and consumers; existing or planned private sector initiatives related to health information technology and quality reporting; and adequate size to recruit a sufficient number of primary care physician practices. They also demonstrated close ties to the medical community and ability to work closely with CMS to recruit physician practices to participate in the demonstration.

In letters sent to communities not selected for the demonstration, Secretary Leavitt urged them to consider pursuing EHR incentive projects of their own, based on the work they have already done.

“A tremendous opportunity exists for communities to impact and improve health care delivery starting at the local level,” Secretary Leavitt said. “While the number of sites selected was limited to 12, we are greatly encouraged by the substantial multi-stakeholder initiatives ongoing across the nation. It is my hope that those communities not selected and others that were not yet prepared to apply will continue working together to improve health care – and consider creating their own incentive-based projects to advance the use of EHRs.”

“Broad adoption of EHRs has the potential to transform health care and the way medicine is practiced in our nation,” said Acting CMS Administrator Kerry Weems. “Medicare has chosen the communities whose proposals will work best for this demonstration project. But other communities can still build on the outstanding work they have done and consider designing and carrying out their own incentive-based projects. In a community where health care providers and payers have already achieved significant coordination in applying for the Medicare demonstration, it may be possible to design independent incentive programs even without Medicare’s participation.”

Over the five-year demonstration project, financial incentives will be provided to as many as 1,200 primary care physician practices in the selected communities that use certified EHRs to improve quality as measured by their performance on specific clinical quality measures. In addition to the incentive payments, bonus payments may be awarded based on a standardized survey measuring the number of EHR functionalities a physician group has incorporated into its practice. Total payments under the demonstration for all five years may be up to $58,000 per physician or $290,000 per practice.

Findings from the demonstration will help determine the role of EHRs in delivering high-quality care and reducing errors. The demonstration will also assess the role of incentive payments in encouraging adoption and use of EHRs.

The project will be implemented in two phases. CMS will begin working with partners in four Phase I communities over the coming months to develop site-specific recruitment strategies, and recruitment of physician practices will start in the fall. For Phase II sites, these activities will begin in 2009.

The EHR demonstration project is an important step toward President Bush’s goal of most Americans having a secure, interoperable electronic health record by 2014. For more information on the project, visit http://www.cms.hhs.gov/DemoProjectsEvalRpts/downloads/2008_Electronic_Health_Records_Demonstration.pdf.

This initiative is also part of HHS’ bold vision for health care reform built on the four cornerstones of value-driven health care. These include: adopting interoperable health information technology; measuring and publishing quality information to enable consumers to make better decisions about their providers and treatment options; measuring and publishing price information to give consumers information they need to make decisions on purchasing health care; and promoting incentives for high-quality, efficient delivery of care.

To learn more about Connecting to Better Health Care, please visit www.hhs.gov/secretary/connecthealthcare.

• Fact Sheet: Electronic Health Records Advancing 21st Century Medicine

Many more details are available here:

http://www.cms.hhs.gov/DemoProjectsEvalRpts/MD/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=3&sortOrder=descending&itemID=CMS1204776&intNumPerPage=10

The bottom line is that ambulatory EHRs of known and certified capability are going to be compared with that status quo (paper records) to see how much improvement is quality, safety etc can be achieved.

The aim is to have 1,200 physicians use certified systems (that could involve up to 3 million patients) and to demonstrate they provide improved care.

I sure would not want to be a patient whose doctor was part of the control group! Indeed this very problem has raised concerns with some

EHR study raises docs' concerns

By: Matthew DoBias / HITS staff writer

Story posted: June 13, 2008 - 5:59 am EDT

Some physicians have expressed concern over a new federal electronic health-record demonstration project that could divide volunteers into the haves and the have nots.

The project, announced by HHS in February, aims to scientifically determine whether the use of EHRs in physician practices will live up to its promise of improved, higher-quality care at lower costs. Medicare, private payers and many providers say they already know the answer to that question, and the CMS is betting $150 million that its new study will spotlight the benefits of health IT.

But to do so, the CMS must first divide participating doctors into separate study and control groups. Those in the study group will be given incentive payments to help defray the cost of buying and implementing an EHR system, while those in the control group will continue to eschew computers for paper.

Not surprisingly, it's the latter group that has raised preliminary concerns by some physician groups.

More here (free registration required)

http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20080613/REG/411266165/1029/FREE

All in all this is a great study and I hope I am still about to hear the outcomes. It really is wonderful the US is attempting a proper trail.

David.