Thursday, October 01, 2009

Who Else is Watching the e-Prescribing Stoush with Amazement and Confusion?

It seems the e-Prescribing wars are staging another battle!

The latest round seems to have been triggered by this reported statement.

MediSecure causing concerns over patient safety

29 September 2009 | by Mark Gertskis

There are fears that a lack of integration between e-script platform MediSecure and a popular doctors' prescribing software could lead to possible infiltration by unauthorised operators and threaten patient safety.

HCN chief executive John Frost has warned that MediSecure was not supported by its widely-used Medical Director software and was accessing records without proper authority.

"We have taken this unprecedented step as we have grave concerns around patient safety," Mr Frost said.

"To date, information regarding the apparent integration of MediSecure with Medical Director 3 has not been forthcoming from the relevant parties and, hence, HCN is not aware of how MediSecure accesses prescription data from Medical Director 3.

"Our concern is due to the significant patient safety risk associated with potentially using incorrect data for e-prescribing through unsupported and hence, by definition, potentially risky access methods."

More here:


This is followed by comments from the Pharmacy Guild that the Medisecure approach is unsafe because HCN does not really know how it is being done.

We then, of course, have the inevitable response:

MediSecure dismisses HCN claims on patient safety

In response to claims from Medical Director vendor HCN yesterday that its electronic script technology may compromise patient safety the MediSecure company issued a statement overnight denying this.

MediSecure Chairman John Cunningham said that the HCN assertion is unsupported by any facts and that MediSecure takes patient safety issues very seriously.

More here (registration required):


and here:

MediSecure defends patient safety accusation

30 September 2009 | by Mark Gertskis

The MediSecure e-script platform has vigorously rejected accusations that it could threaten patient safety because it was not supported by a popular doctors' prescribing software.

Pharmacy News yesterday reported on concerns by John Frost, the chief executive of HCN, that records from its Medical Director 3 (MD3) software were being accessed by MediSecure without proper authority, putting patients at risk.

"HCN asserts that MediSecure compromises patient safety," MediSecure chief executive Phillip Shepherd said.

"They need to explain precisely how this is supposed to happen. We suggest that the Royal Australian College of General Practitioners (RACGP) is in fact the professional body that is best placed to comment on patient safety issues.

"RACGP has not raised any issue with us, simply because they have looked at the e-prescription process and understand the professional checks and balances that are in place to ensure the best patient and health system outcomes arise from the MediSecure process."

More here:


Now I am an outsider but what it seems is going on here is an attempt on the part of the Guild to use the market share of Medical Director to drive their dominance of the prescription transmission space.

I for one would love to be a fly on the wall for the GP 09 Conference which is being held for 4 days in Perth starting on the First of October.

Here we find that Medisecure (which is associated with the RACGP who are also organising the Conference) is a Principal Sponsor and two grades lower as a Supporting Sponsor we have eRx!

See here:


There might be a few frosty exchanges of looks across the exhibition space!

Of course, as regular readers will know, I am firmly of the view that the prescription exchange infrastructure should be Government managed, have a Board that represents all stakeholders in charge, be open for use by all client systems who conform to the appropriate standards and cost no more than a cost recovery price (if anything at all).

All the finger pointing gets the wider e-Health agenda nowhere fast and just makes it hard for those who would like to get going. NEHTA and DoHA where on earth are you when you are actually needed?

David.

19 comments:

Anonymous said...

Champaign comedy:

"RACGP has not raised any issue with us, simply because they have looked at the e-prescription process and understand the professional checks and balances that are in place to ensure the best patient and health system outcomes arise from the MediSecure process."

The reality is:

"The RACGP has not raised any issue with us, cause we hoodwinked them into picking us as a 'winner' in support of our own commercial aspirations. All we had to do to get this endorsement was rabbit on about standards for a bit - which btw are incomplete and don't work. They'd look pretty stupid accusing us of jeopardizing patient safety now, despite the fact that we are extracting data from clinical systems using undocumented methods."

Anonymous said...

It is patently unfair to make an accusation without providing specific corroborating evidence about HOW patient safety is being compromised. I sense egg on face to follow. Come on, do we honestly believe a company would be stupid enough to try selling a solution that is obviously not to be trusted? Not likely, IMO

Anonymous said...

"HCN chief executive John Frost has warned that MediSecure was not supported by its widely-used Medical Director software and was accessing records without proper authority."

I guess this means that MD had to be in some way reverse engineered to allow the 2 systems to be integrated? If MediSecure is using available public specifications of how MD data is stored, then it probably is scare mongering on HCN's part.

If MediSecure is taking an educated guess at MD's inards, then I can see the risks involved, and I look forward to a full disclosure of their test regimes and safety cases, which I would expect from any medical software developer (but we dont ever see).

The thing is, now that HCN has made this accusation, MediSecure is a hostage to fortune. Should anything go wrong with the system, and should a patient be in some way harmed, they are on a hiding to nothing, and maybe even staring down a class action. Tricky manoeuvring to come. Kind of fascinating to watch.

And of course for HCN, the risk is also that they make patient safety of e-health systems a public issue, with the same risks to them, as the public and lawyers now twig to this as an avenue for litigation. Maybe they believe they are on safe ground here with a tried and tested system?

Who said e-health safety issues were an academic distraction? Its now grist to the marketplace mill.

Anonymous said...

Good question. Most of our Division is watching and we are none too happy. Most of us use MD, probably more than 80% of our Division. But we are seriously wondering -why? Why should we use it when there are plenty of good alternative solutions available? It doesn’t make sense to hand over control of e.prescriptions to the Pharmacy Guild when we have an equally good, if not better option, available to choose from that has the backing of the College.

Why has John Frost turned his back on us after all these years? It just doesn’t make sense. Has he hit his head?

It is clear MD and HCN don’t want to work with the College on e.scripts and they don’t want to collaborate with MediSecure either. But instead they want us all to get under the doona with the Pharmacy Guild and its eRx prescription exchange. Remember what happened to Troy? Remember the Trojan Horse?

There are plenty of good alternative systems out there to choose from so as far as we are concerned they’ve made their bed and they can lie in it. We have decided that as they don’t want to work with us, we don’t want to work with them. So, all our prescriptions will be going to MediSecure and the pharmacies that want to dispense them can link into MediSecure too.

Anonymous said...

As usual, there are two sides to this story - and both should share the blame for what is a half-baked solution.

MediSecure is just one of many health appplications that have developed "integration" with GP desktop systems by "hacking" destop systems' (including MD's) databases. The result is interfaces that are NOT supported by the GP desktop vendors and which ARE therefore at risk of generating erroneous information if and when the databases change (which they often do).

GP desktop vendors (MD included), however, have been woefully slow to implement standard's based interfaces so that they CAN interact reliably with third party systems - in most cases because they are trying maintain a commercial advantage and control or dominate their market segment. This has had the effect of forcing the hands of those trying their best to provide better eHealth services to healthcare providers.

The inevitable outcome is that everybody is a loser!

Anonymous said...

This chitter chatter about standards and patient safety is just that; distracting chitter chatter. I don’t say it isn’t important, it is, but it is irrelevant as far as the core issue is concerned at this moment in time.

There is no way either vendor, the Guild controlled eRx solution or the RACGP backed MediSecure solution is compromising either patient safety or security at this stage in their products’ development. This is because the paper prescription is the only dispensing source which the pharmacist has to work from.

All either of these vendors are doing is adding a unique, secure, bar code identifier to the paper script, so that when the paper script is presented at the pharmacy by the ‘patient’ (consumer) the pharmacist can scan the bar code and pull down [from the eRx or from the MediSecure ‘holding bay’]the electronic version of the paper script which replicates exactly what has been printed on the paper script by the doctor’s computer. Neither of these vendors is fiddling with or changing the information in any way.

The pharmacist’s job is to look at and check the information on the paper script, to confirm that it is identical to the information that has been ‘pulled down’ using the unique, secure, bar code identifier from the ‘holding bay’ and then, if it is correct, push the button to file the information in his pharmacy computer ready for dispensing. This saves him time re-keying the information and eliminates the possibility he will re-key it inaccurately. In essence this method is therefore ‘safer’ than before. Only then can the pharmacist dispense the medications which have been prescribed.

So, let me repeat, There is no way either vendor, eRx or MediSecure is compromising patient safety or security at this stage in the development of either product.

HCN’s Chief Executive, Mr Frost, has gone of half-cocked. He is employing a hoary old sales technique in a desperate and ill-conceived attempt to undermine a far-sighted, responsible, politically astute and courageous initiative by the RACGP-MEDISECURE initiative.

He has resorted to sowing the seeds of FUD - FEAR, UNCERTAINTY and DOUBT - shame on him.

There is no room, none whatsoever, for such appalling shenanigans, and most certainly not in the public arena, in such a sensitive, delicate, difficult, vitally important area of ehealth which Government, for whatever reasons, has left to the private sector to demonstrate appropriate leadership.

Anonymous said...

"All either of these vendors are doing is adding a unique, secure, bar code identifier to the paper script, so that when the paper script is presented at the pharmacy by the ‘patient’ (consumer) the pharmacist can scan the bar code and pull down [from the eRx or from the MediSecure ‘holding bay’]the electronic version of the paper script which replicates exactly what has been printed on the paper script by the doctor’s computer."

Sounds fool proof, no? And as long as both sources are in agreement all should go well.

Except errors could occur when there is disagreement between the two. What happens when the paper and the electronic version do not agree? Well, sometimes the right script gets dispensed, and in a proportion, statistically speaking, we would get the wrong thing done.

The question is, to what degree have the e-escript systems tested their ability to accurately retrieve information? And most crucially, what is their strategy to deal with the likely but unannounced situation when the home system eg MD, changes?

The scenario that is scary is that MD changes its database, even modestly, and that it does not tell anyone (why should it - its proprietary), and then an e-script system ceases to work. We get either a few random mismatches, or a whole cascade of them. And that's when mistakes would happen.

Its not that simple - safety never is.

Anonymous said...

Ahh the evil 'P' word - "proprietary".

"The scenario that is scary is that MD changes its database, even modestly, and that it does not tell anyone (why should it - its proprietary)".

There is also a good 'P' word it's:

P for Progress
P for Productivity
P for Professionalism
P for Patients
P for Propitious
P for Propriety
P for Permitted

Only the good should Probably be Permitted to Prevail.

Anonymous said...

How about P for Perpetuate.

Reverse engineering or not - it is no longer acceptable that Medical Director, HCN, or for that mater any other health IT vendor, be permitted to perpetuate the insanity of ‘closed systems’.

For far too long Government and the Peak health bodies have ‘perpetuated’ the situation where they have allowed themselves to be held hostage by software proprietors eager to exploit commercial opportunities, whilst enforcing their perceived IP rights, by restricting access to health information stored on the database which their systems’ use.

What makes a mockery of this totally inexcusable situation is that nearly all these developers have been, all too often, the most vociferous in agitating for interoperability between all health software systems.

On the one hand they want access, whilst on the other they act to impede progress by blocking access to their own system. HCN is not alone in this but its track record to-date is not favourable. It is time to put an end to this unhealthy practice. It is a ludicrous situation which should be permitted no longer.

It is not helpful to government, to practicing health professionals, or to the patients whom they serve. It is also debilitating to the entire health system and perhaps the greatest barrier to achieving meaningful reform of the health system in primary care.

What should be done?

By all means government could take a stand but that will inevitably require legislation and mandating to force all vendors to ‘OPEN UP’ their systems to others; dare I say it - to their competitors. This will then force them all to improve the quality of their systems and compete on a different playing field with an emphasis on functionality, price and level of service.

But history demonstrates that if one waits for government or the likes of NEHTA nothing will happen and the constraints imposed by the proprietary handcuffs will be perpetuated for many years.

So it is up to those who set the Professional Standards of clinical practice to take the initiative and lead the way. But they need not do it alone, for the consumer too can help by demanding that practicing health professionals use clinical record systems which are interoperable one with another. This means that the peak professional bodies like the AMA, PSA, and RACGP, should become the initiators - enforcing implementation and compliance with such standards as they deem necessary to achieve the goals of interoperability between systems.

Anonymous said...

"Good question. Most of our Division is watching and we are none too happy. Most of us use MD, probably more than 80% of our Division. But we are seriously wondering -why?"

Well your Division's IT staff probably helped to entrench the monopoly by giving years of government funded support to practices using Medical Director, making it very difficult for the other players to compete.

"It doesn’t make sense to hand over control of e.prescriptions to the Pharmacy Guild when we have an equally good, if not better option, available to choose from that has the backing of the College."

The Medisecure implementation is convoluted at best, with potentially 5! software products/companies being required to move a script through their system.

eRx, which has in place both technical and contractual arrangements with both the prescribing and dispensing system at each end, effectively take end to end responsibility for the transport, something that Medisecure can simply not do (especially if they are resorting to hacks to gain attention in the space).

What makes you think Medisecure is technically equal or better than eRx?

What are you basing your faith in the college on? When was the last time they did anything innovative with ehealth? GP computing stalled around 10 years ago as far as I can tell.

Last time I checked it was entirely up to the GP to decide whether they sent scripts electronically. As such, pharmacy can in no way control e-prescribing - not now or ever. Remembering that there is nothing except increased legal liability in it for GPs, if they don't like what is on offer, they can and will vote with their feet. Hopefully their decisions will be based on more than college-backed propaganda.

"Why has John Frost turned his back on us after all these years? It just doesn’t make sense. Has he hit his head?"

Keep in mind that John Frost is actually turning down a potentially lucrative revenue stream from Medisecure - like eRx, they pay the software vendors for each script. When commercial entities turn down money, closer examination and respect for their justification is warranted.

"It is clear MD and HCN don’t want to work with the College on e.scripts and they don’t want to collaborate with MediSecure either."

I don't think it's clear at all that HCN doesn't want to work with the College. However the College made the flawed decision to pick a "winner" as suggested by a previous poster. By doing so they have created artificial barriers to competition, innovation, and standards development and adoption. Had they said "These are the standards - we advise you to use a provider that implements them", then the playing field would have been open to all and devoid of this unhelpful RACGP vs Guild banter.

It's also incorrect to say that HCN don't want to work with Medisecure - in fact they have said the opposite publicly. If HCN want to give eRx a first mover advantage (as Best Practice and others have done before them), then Medisecure would be better served by playing nice instead of antagonising its future partner.

Anonymous said...

“However the College made the flawed decision to pick a "winner"

Oh. …. and what sort of ‘decision’ did the Pharmacy Guild make?

If John Frost understood the importance of risk containment he would have done the same as some other vendors - straddle the fence and align with both; very, very important for him to do so because the doctors are his constituents.

Oh …….. and whilst you’ve mentioned it ………. going just with one provider eliminates competition in favour of a monopoly. One has to assume you are in favour of the Pharmacy Guild being a (the) monopoly supplier in the electronic transmission of prescriptions. Hello.

Anonymous said...

As you said "GPs, if they don't like what is on offer, they can and will vote with their feet." .......... but hey, if you have your way there would be only one system so their 'vote' would be useless. If there are two systems the GP can choose ("vote with their feet").

Anonymous said...

"GP computing stalled around 10 years ago as far as I can tell." Indeed it did. You obviously had a bad experience and so did the College. The College was doing quite well until the Gov'mint cum along and did them in. Yep, they pulled they pulled the plug on the RACGP's noble efforts at supporting IT and GPCG and forced it over under AMA control. So don't point your finger at the College without fist getting your facts right.

Juanita said...

The Australian eHealth incompetence is mind boggling- volunteers are exhausted trying to provide feedback on every single aspect of the debacle.

Anonymous said...

In March last year with lots of fanfare HCN joined the Guild's ScriptX project. A few months later it pulled out and the project folded.

In November last year with the Guild's support FredHealth established its eRx system. Now HCN wants back in the game. Will it pull the plug again? Maybe.

The best insurance we have is to encourage other prescribing and dispensing software vendors into the market. HCN claims to be the leader with 85% market share. The sooner that drops to 50% the better off we will all be.

HCN should do two things; the first is to provide the interface specs to its system to help advance interoperability and if it can't do that it should get booted off the Standards Australia and NEHTA committees and stakeholder working parties until it does; the second is that it should engage with MediSecure, as it has with eRx, so as to give us all the maximum opportunity to decide as doctors which exchange service we want to use, and if it can't do that we should all go out and find another vendor who will. It is in our interests as doctors to demand a competitive environment. For too long we have been hostage to one major player and this has impeded the emergence of new competitors. Complacency is the enemy of progress.

Anonymous said...

Given that others are now planning to interface with MD, and that there are patient safety risks if that interface changes and people are not told, there is a case to argue that HCN/MD cannot adopt a 'not our problem' or 'we told you so' approach.

It could be easily argued that if something went wrong in another system because of a change in MD, that MD *did* have some culpability. How? Well I'm no lawyer but, MD will know ahead of time that other systems depend upon its feed, and that if that feed changes, patients might be harmed (we know the latter because they have told us so in public).

So, they are kind of stuck too now, as anytime they make a change, they will need to at least notify the systems feeding off them in some defensible way, of the changes. Not to do so would wilfully put patients at risk. In a class action patients would sue the lot of them!

They may even be required to provide the interface to their system at some point, simply on the basis for protecting patient safety. Gets weird when the lawyers get into it, no?

Lucky we have so many standards now in operation after $213 million investment in NEHTA, to protect us!,

Anonymous said...

Referring to Saturday, October 03, 2009 8:43:00 PM I thought "Great idea".

But what about the legal liability in all its dimensions - where and with ho will that lie? So perhaps we need to ask / answer the question(s) - who exactly do you have in mind? Is it the doctor? Is it the software vendor accessing the database? Is it HCN? Is it the patient? Who is it? Is it all of them?

Anonymous said...

It’s pretty basic really if common sense is allowed to prevail. In essence it comes down to what is responsible and what is reasonable.

The database has been designed by HCN. So HCN must ask itself is it reasonable that we withhold information needed by others to safely interface with our system? It must also ask itself are we being responsible and to whom are we being responsible in whatever decision we come to on this issue?

On the other hand the clinician, the patient and those software developers seeking access to the patient’s and the doctor’s clinical information held in HCN’s systems also need to ask - is HCN being reasonable and responsible by not permitting access to the information?

Judging by the standards ‘today’ of ‘the reasonable person’ it could be argued that withholding access via a reliable open published interface to such important information is unreasonable. It is unreasonable because it could threaten the life and well being of the patient. It is unreasonable because those who depend on the clinical information which is held in electronic form require it to be available for others to share and interoperate with. Is it reasonable for health professionals, patients and consumers to expect HCN to facilitate interface access? I think so but maybe HCN will want to put that to the test by a jury of reasonable people. In fact it is reasonable to suggest that by not facilitating such access HCN is not only being unreasonable it is also being irresponsible.

The legal ramifications for HCN continuing to be obstructive and uncooperative are formidable. The world has advanced and attitudes have changed since the bad old days of closed proprietary systems being used to secure the customer’s loyalty and to make it difficult to go elsewhere.

NEHTA and Government have had years to address this problem. They have studiously avoided it, nothing less. That too is unreasonable and irresponsible.

Anonymous said...

Interestingly, I think a similar scenario played out in the US with 2 different e-prescription consortia vying for the market. I understand that in the end they were forced to come together, for sanity's sake. Does anyone know more about what happened there?