Quote Of The Year

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

Monday, November 02, 2009

Electronic Prescription Transfer – Talk About NEHTA Under Delivering Again!

As mentioned a day or so ago, NEHTA have just released their first attempt at ETP (Electronic Transfer of Prescriptions) documentation.

These can be found here:

http://www.nehta.gov.au/e-communications-in-practice/emedication-management

The summary release document has the file name:

NEHTA_0544_2009 Electronic Transfer of Prescription Draft Release 1 0 - Release Notification v0 6

And the most interesting document I find is the one named:

ETP Concept of Operations_Release_1_v1 Draft

Some of the more interesting things found in this document are the following:

“NEHTA’s e-Medication Management program has been tasked to develop key specifications required for software vendors, GPs and Pharmacists to establish a national environment for standardised electronic prescription exchange, one where prescriptions can be sent securely and reliably to community pharmacists, while maintaining the consumer's right to their own choice of pharmacy.”

Release Notification Page 1.

What this actually says is that we are working on a system that won’t allow the patient to direct the prescription to where they want (as is done elsewhere). We want to create a central infrastructure where all prescription data will flow through. Of course this will also be where we (the Pharmacy Guild) can collect a fee for each prescription that flows through.

The proposed design also responds to the paranoia held by community pharmacy regarding doctors being able to suggest one pharmacist in preference to another – something pharmacists have always been able to do regarding doctors.

At present is fails also to note how consumers would also like to be able to arrange delivery of their medicine from their doctors surgery and other even more consumer friendly ideas (Thanks Heather Grain for pointing this out)

Of course point to point transmission can be made simpler and more secure but we won’t do that – we are going for a complex SOA based store and forward approach.

Next we have:

“The following will be released shortly:

• e-Prescribing Structured Document Template

• Dispensing Record Structured Document Template

• Secure Messaging End Point Specification “

Release Notification Page 2.

Opps! We have not quite worked out the structure of the prescriptions we plan to send or their content!. One would think that was pretty basic!

Actually it seems to be worse than even that.

Page 19 of the Concept of Operations Document we find.

“The components of the goal-state architecture are:

Prescription Exchange Service (PES): The PES may require additional interfaces, beyond those specified in ETP Release 1, in order to support integration with potential national IEHR repositories, research repositories and (possibly) Medicare Australia systems. The interfaces used by an Electronic Prescribing System or an Electronic Dispensing System to manage the prescribing-dispensing processes, however, will not require any changes.

Electronic Prescribing Systems (EPS): ETP Release 1 supports the optional use of national standard clinical terminologies including SNOMED-CT and the Australian Medications Terminology (AMT) in e- Prescriptions. The goal-state is, however, to make the use of standard clinical terminologies mandatory.

Electronic Dispensing Systems (EDS): ETP Release 1 supports the optional use of national standard clinical terminologies including SNOMED-CT and the Australian Medications Terminology (AMT) in Dispense Records. The goal-state is, however, to make the use of standard clinical terminologies mandatory.”

Translated the Australian Medicines Terminology and SNOMED are, and will be for a while, optional. Just how long have we been waiting – only to be now told:

Page 18 of Information Model

ePrescriptionItem.MedicationItem

- MedicationItem

This class is the entry point that contains a detailed description of a single, unique good that is listed as an item within an ePrescription.

MedicationItem.Description

The description of the prescribed item as defined by the prescriber. This text representation encapsulates all relevant concepts associated with describing an item, i.e. brand/trade or generic name, strength, form, etc.

When prescribers are describing a medication, they may do so at differing levels of specificity, depending upon the clinical context, the healthcare setting, the type of medication being prescribed, their knowledge of specific drugs, the functionality of their prescribing system and other factors.”

So the guts of NEHTA’s ETP system is the sharing of free text. Just amazing and symptomatic of the leadership we are getting from NEHTA.

More interesting is the scope of what these 5 documents are about (Page 9 of Concept document):

“NEHTA has identified five distinct capabilities for comprehensive eMM:

1. Exchange of electronic prescribing and dispensing messages:

this capability is concerned with the generation and exchange of electronic records that represent prescriptions and their associated dispensing records.

2. Adherence monitoring: this capability supports the ability to inform authorised healthcare providers and individuals when deviations from the expected sequence of dispensing events are detected. Adherence monitoring requires records of an individual’s prescribed and dispensed medications – it will make use of the electronic prescribing and dispensing records described in the previous paragraph.

3. Current Medication Lists: this capability supports the storage of medication reviews that are performed by healthcare providers. The documents produced by these medications reviews are referred to as “current medication lists” (CMLs). CMLs are either stored in dedicated CML repositories or are stored, along with other types of individual electronic healthcare records, in general purpose IEHR repositories. In either case the repositories make CMLs available to the individual, their authorised representatives and to authorised healthcare providers.

4. Medication History Lists: this capability supports the storage of a chronological record of an individual’s prescribed and dispensed medications. These records comprise a Medication History List (MHL) for each individual. MHLs are either stored in dedicated MHL repositories or are stored, along with other types of individual electronic healthcare records, in general purpose IEHR repositories. In either case the repositories make MHLs available to the individual and their authorised representatives and to the healthcare providers who require this information to service the individual and are authorised to do so by the individual.

5. Medication Decision Support and Secondary Uses: It is intended that medications management processes are supported by prescribing and dispensing decision support tools (integrated into prescribing dispensing and administration applications) that implement best practices based on evidence. This capability therefore includes the collection, storage and analysis of more complete and more detailed consumer medications data than is currently possible and the use of this data to derive appropriate rules for decision support tools.

The above five capabilities reflect various stages in the evolution of eMM and are not to be taken directly as a roadmap for national implementation across all the various different healthcare communities. Different communities will evolve to support these capabilities at different rates depending on the rate at which they can implement changes to existing policies and practices and on the rate at which the necessary underpinning e-health foundation services become available to them.”

NEHTA then goes on to say it is only point 1 they are addressing for now, the rest needs a whole heap of other things to happen and they haven’t yet.

Equally amazing is that if you look at ETP Context Diagram you find Decision Support is the last thing to be concerned with, where this is what a lot of the E-Prescribing Business Case is built on.

Second last I note this (Page 13)

“NEHTA has focused to date on specifying an ETP service that is targeted at adoption in the primary care community, and, with the expectations of this community in mind, Release 1 of the ETP service will continue to support the existing paper based processes. The goal-state of the ETP service is, however, for paperless processes to be widely available nationally.”

The detail is that what this is actually all about is basically adding a barcode to printed prescriptions to that the prescription text can be pulled down from some third party ‘cloud’ to a dispensing computer. This is just as is being already being done by eRX.

Last we have this (Page 16):

3.1 Governance and Privacy

A Governance and Privacy Management Framework will underpin the operations of the eMM services (including ETP) within the Australian healthcare sector.

This framework will be supported by legislation, participation agreements, security controls, audit and secondary uses. There are three levels of governance required:

Strategic governance is required to provide oversight of the operation of the future directions of the eMM services (e.g. Ministerial council)

Program management is required to provide oversight of the day to day activities of the eMM services (until an operational e-health entity is more formally established, NEHTA will provide overall program management with program management for specific implementation projects being the responsibility of the project principal).

Regulatory oversight is required to provide legal authority, ensure privacy compliance and regulate operations in terms of complaints handling, dispute resolution and enforcement functions (e.g. Privacy Commissioner/s and jurisdictional health regulators).

ETP Release 1 has been restricted in scope in order for it to comply with the governance and privacy management framework that is already in place for community prescribing and dispensing. Similarly it is expected that implementations of the Current Medications List service within specific communities (e.g. Aged Care) can also be constrained to comply with existing governance and privacy management frameworks.

It is expected that Commonwealth Department of Health and Ageing will determine the preferred governance and privacy model for subsequent implementation initiatives. Interim arrangements for pilot projects will likely be required – these will be tailored to address specific local constraints.”

It is important to pay attention here as what we are told that we need governance we don’t have and an operational e-Health entity Minister Roxon (and Ms Halton) is not planning to pay for.

Talk about pie in the sky!

David.

11 comments:

Anonymous said...

I bet there is no reference to or acknowledgment of the two private sector initiatives currently being promoted. What use would this NEHTA documentation be to them? In its current form zilch.

Andrew Patterson said...

David, I think you're being a bit harsh - if someone wants to have a political battle with the Guild over "choice of pharmacy" policy etc, then you (or them) need to have that battle in the political sphere - ring the Minister, write editorials etc.

You can't blame the tech guys at NEHTA for not including innovative pharmacy delivery models in their specs, when they already have an uphill battle coming up with technical plans that will fit in with the existing commercial players.

I reckon they have a tough road convincing eRx etal to move over to some sort of standardised system - throw some innovative thinking like "Lets let the customer pick up their script from Coles" and I can assure you that the possibility of change happening goes down to 0 very quickly.

With regards this being "still paper" - every national prescribing program starts off this way. The NHS only have pilot programs for paperless, and they've been doing it for a fair bit longer (they also don't have the same consumer choice requirements). I believe Canada are only just getting to paperless in limited geographical areas (ala NT project).

I am actually quite optimistic about this first step.

Dr David More MB, PhD, FACHI said...

Andrew,

So your view is let's continue with a provider centric health system rather than a consumer centric one because it is too hard to do the latter.

Sorry, these systems last a long time once established and this one, giving in totally to the Guild, is going the wrong way in my view.

David.

Andrew Patterson said...

Well, I'd have to be informed what a 'consumer centric' health system actually means beyond the obvious buzz words.

Irrespective of that, surely you agree that declaring war on the Guild is a decision that is above the pay grade of technical staff working at NEHTA? That that perhaps is a decision for their political masters?

I just think that blaming NEHTA for not correcting what you perceive as the broader flaws in the Australian health care system is venting your anger at completely the wrong target. A technical body is never going to be allowed to make those sort of 'bold' decisions.

Anonymous said...

You are right about longevity of systems David. Few people understand, although the vendors do, that particularly in the health sector, once a system has been implemented it will remain in place for 10 to 15 years; not just a few years until some nice new sparkling alternative system comes along. This is usually not the case in other industries. There are many reasons why systems, once entrenched, remain in place in health sector for a very very long time; politics, organisational and professional cultures, scarcity of resources and funding, the devil you know is .... , and many more. So it is important to get the strategic pathway well into the future clearly delineated up front because one you bite the bullet you will be biting it for a very long time.

Dr David More MB, PhD, FACHI said...

Andrew,

NEHTA's role is to work in the national interest, they are after all paid by the public purse, and being party to setting up things in a way that generates cash flow for the Guild I oppose. As I have said many times on this blog I believe the Prescription Exchange should be Government Controlled and choice be at the client to the that exchange level to provide competition. (Assuming you even have an exchange - remember the US does way more real EPT than the rest of the world put together and does not go down that sort of route)

The public good is not served by what NEHTA is doing here I believe but sadly their political masters are out to lunch as they even say in their documentation.

Believe me or not, I believe we will all regret going down this path.

David.

Anonymous said...

Well, Andrew Patterson has a point when he says that "a technical body is never going to be allowed to make those sort of 'bold' decisions". Unfortunately, the way these bodies are structured you have a chain of events where the blind lead the blind who lead the blind ad infinitum.

The technical body is directed by the political body which turns to the technical body for advice and guidance and so the cycle repeats itself. Within that mix of young inexperienced enthusiastic bureaucrats and technocrats with limited experience at the healthIT coalface you have a recipe for a very expensive disaster.

Anonymous said...

Consumer choice is incompatible with paperless prescriptions unless there is some way for the pharmacy to discover the ePrescription. This is a difficult problem. Expecting a solution now is unreasonable.

Dr David More MB, PhD, FACHI said...

Who said the goal was paperless prescriptions. The goal is accurate, secure movement of prescription information from prescriber to dispenser.

Handing people a token (e.g. a printed prescription with a barcode to facilitate retrieval is one way. Another is to use the patient's IHI to look up current undispensed scripts - could be paperless).

Goal met either way and consumer choice preserved.

David.

Andrew Patterson said...

Now I'm confused

"Handing people a token (e.g. a printed prescription with a barcode to facilitate retrieval is one way.)"

That's exactly what the NEHTA proposal suggests
(and what eRx currently does) - is it a bad idea when they suggest it but a good idea when you suggest it?

Dr David More MB, PhD, FACHI said...

Andrew,

First I am quite happy with use of a bit of paper or a token for prescription identification - I even suggested that to DoHA in 1996!

My point about this work from NEHTA is that it is half baked replicating the status quo, does not deploy anything other than a text description of the medications (why develop SNOMED and AMT if it is to be optional and merely a goal?), does not prioritize decision support and merely replicates what is already happening with both eRx and Medisecure essentially.

It also assumes private store and forward networks which I simply do not agree with - as I want a level properly governed playing field for all prescribers and dispensers.

David.