Quote Of The Year

Timeless Quotes - Sadly The Late Paul Shetler - "Its not Your Health Record it's a Government Record Of Your Health Information"


H. L. Mencken - "For every complex problem there is an answer that is clear, simple, and wrong."

Thursday, June 10, 2010

All Their Own Work - Senate Estimates June 3, 2010 – Selected, As It Happened, Highlights.

The full transcript can be found here. The fun stuff starts at Page 65.


Here are the ‘must not miss’ parts. Read closely and see how many evasions and porkies you can spot. I certainly found a few.

The key players are:

Senators in attendance: Senators Abetz, Adams, Back, Boyce, Brandis, Carol Brown, Fierravanti-Wells, Fisher, Furner, Humphries, Ludlam, Lundy, Milne, Moore, Parry, Ryan, Siewert and Xenophon

Government Representative – Senator Joe Ludwig.

DoHA Representatives.

Ms Jane Halton, Secretary

Primary and Ambulatory Care Division

Ms Raelene Thompson, First Assistant Secretary

Mr Lou Andreatta, Principal Adviser, Office of Rural Health

Mr Rob Cameron, Assistant Secretary, Rural Health Services and Policy

Ms Liz Forman, Assistant Secretary, eHealth Branch

Mr Mark Booth, Assistant Secretary, Workforce Distribution Branch

Mr David Dennis, Assistant Secretary, Policy Development Branch

Ms Tuija Harms, Assistant Secretary, Practice Support

Ms Sharon McCarter, Assistant Secretary, eHealth Systems Branch


Italics are mine

Page 65.

CHAIR—We will move to 10.2, which is e-health.

Senator BOYCE—Ms Thompson, I am not quite sure who to direct questions to, but I am sure you will tell me if I have not got it right. The funding for e-health in the last budget was $467 million over two years, which is much less than was anticipated by the industry. Given the low amount of funding and some terminology used during the budget and consequently by Minister Roxon, there appears to be quite a lot of confusion in the market. I will go through and ask you to explain some of the terms that seem to be being used at the moment.

‘Personally controlled identifier’, or ‘electric health records systems’, is a term that is being used by both the Treasurer and the health minister. This has been interpreted in some areas to mean that people would be required to keep these records on a USB and take it with them wherever they went. Could you explain to me exactly what is meant by a ‘personally controlled electronic health record system’?

Ms Thompson—Yes. The concept of a personally controlled electronic health record is about the fact that only people who wish to use it will use it into the future. What goes into that record and who is allowed to access it, in terms of other health providers that they may be involved with, will be within their control. That is the concept. There is certainly no expectation that people will carry around their health records on a USB stick.

Senator BOYCE—Where will I go to decide that I want to have an electronic health record if I am a consumer of health services in Australia, which is pretty much everyone? How will that be accessed by me or by others?

Ms Thompson—The concept is that, if you have chosen to establish a health record, once the enablers are in place for you to do that you will actually be able to access it on a portal, similar to what you do with internet access for other information systems.

Senator BOYCE—Who else will be able to access it?

Ms Thompson—If you have chosen to be part of the system then it will be those people you have authorised to access it—so, health providers.

Senator BOYCE—Can I do this from my home computer?

Ms Thompson—Potentially, yes.

Senator BOYCE—What do you mean by ‘potentially’?

Ms Thompson—We have not yet built it all.

Senator BOYCE—Would the intention be that I would be able to do this from my home computer or from a computer in a library—or whatever else?

Ms Thompson—Yes.


Page 66.

Senator BOYCE—We are coming to that. We are assuming at the moment that the system is (a) going to be passed and (b) going to happen, which are probably some pretty big assumptions to make—but never mind. So the number is given, but whether I use that identifier number will be entirely up to me.

Ms Thompson—Whether you use it to attach a health record will be completely up to you as an individual.

Senator BOYCE—Who else will use it if I do not?

Ms Thompson—Use the number?

Senator BOYCE—Yes.

Ms Thompson—The number will potentially be used by health providers in terms of your individual records with those providers, but the electronic health record that we are talking about is about the ability to connect information from various health providers.

Senator BOYCE—But, irrespective of whether I have chosen to create a collated health record for myself, other health providers, who also have different identifier numbers, will be able to use my number to put in their information about what their dealings with me may have been. Is that correct?

Ms Thompson—That is right, in a similar way to the fact that they identify patients at the moment through perhaps an individual set of numbers. The concept is that there will be one health identifier, which will ensure over time that the potential for mistakes in exchanging health information will be reduced because you will have a unique identifier number.


Senator BOYCE—You are not. I could perhaps give you a copy of this. It appeared in the Australian on 12 May and the title of the article is: ‘Will e-health records be outsourced to Google, Microsoft?’

Ms Thompson—Yes, I am aware of that article; thank you.

Senator BOYCE—You are aware of that article.

Ms Thompson—I was not sure about what you were referring to. I think that is the issue that you raised earlier about how you would access your record. The whole way forward here is about building the infrastructure that will ensure that the portals that are used to go in and get a record, attach information to it and are used over time are secure. In fact there is certainly no intention for the record to be free for anyone to use. That is not part of the architecture at all.

Senator BOYCE—So we will not have Facebook identifiers in the health area?

Ms Thompson—No, absolutely not.

Senator BOYCE—That is good to hear because there was some confusion. When you look at the article, it says: Will it be the private sector, Medicare, or some other government body— running the proposed electronic health records system? You are confirming that Medicare will develop the system.

Ms Thompson—No: I confirmed that Medicare would develop the number, and we are in the early stages of the next phase of implementation, so we have to think through all those next steps. Obviously we have done some thinking already, but in terms of how we build the infrastructure that is still being mapped out.


Page 67.

Senator Ludwig—we are optimistic in having it introduced into the Senate in the next sitting week and of course calling on the opposition, minor parties and Independents to support what is a very good initiative from this government to build a new health system. I am sure we can garner your support, Senator Boyce.

Senator BOYCE—Indeed. Does the legislation need to passed for the system to function?


Senator CAROL BROWN—Are you able to give me some information about the introduction of personally controlled electronic health records?

Mr Thompson—Yes, they are very related issues. The health identifier is an enabler of the next stage of the development of the personally controlled electronic health records system. The identifier in itself is a number that will attach to people’s records and will allow for unique identification so that we reduce the risk of error relating to information not being available because you cannot backtrack and find the right person’s records. In addition to that, the personally controlled electronic health record is about what you might attach to that record in an electronic space. So you might attach immunisation records, and you might attach allergies and medications—things like that—over time. That is what we are seeking to develop as the next stage in the electronic health strategy.

Senator CAROL BROWN—Thank you.


Page 68.

Senator BOYCE—Can we look at the budget allocation for this and how it is to be spent? What happens on 1 July, presuming the legislation is passed?

Ms Thompson—I might deal with the second question first, if that is all right. Presuming that it passes, we will then be authorising Medicare Australia to implement the system that they have built. In the first instance that is an allocation of numbers. I might ask Ms Forman to give you some detail around that.

Senator BOYCE—Is the system built?

Ms Thompson—Yes.

Senator BOYCE—And operational?

Ms Thompson—It is not operational until it is authorised, but it is ready to go.

Senator BOYCE—We have talked in the past about doing tests, have we not, and they were—I forget the term—virtual tests or something. Can you tell us where you are up to now, Ms Forman?

Ms Forman—As you know, the system has been built by Medicare Australia. They are under contract to NEHTA to build that system. The build is substantially advanced. I think we discussed that testing at this stage could only be on non-live data, so there would need to be live testing of data following the legislation coming in. The capacity of the system from 1 July would be that it would be able to issue healthcare provider individual numbers and those would actually be issued as part of the national registration process for providers that are registered under the AHPRA legislation. The internal allocation of healthcare identifier numbers to individuals would actually happen within Medicare itself to all those individuals who currently have a Medicare number or a DVA number.


Page 69.

Senator BOYCE—Assuming the legislation is passed within the next two weeks, then Medicare will do some live trials. Is that right?

Ms Forman—The regulations would also need to go through their process, which I think would not be until the end of June.

Senator BOYCE—So the time to do some live trials between when the regulations pass and when the button gets pressed on 1 July is what?

Ms Forman—I am confident that Medicare Australia will not press the button to allocate those numbers until they are confident that the results will be accurate, safe and secure.

Senator BOYCE—In which case the rollout is highly unlikely to start on 1 July. Is that the situation?

Ms Forman—I would have to take advice from Medicare Australia on that.

Senator BOYCE—Has the department—or the government; I am not sure who the signatory would be— signed the contract to provide the system with Medicare?

Ms Forman—The contract to provide the system is between NEHTA and Medicare Australia. NEHTA is actually funded by COAG to build and operate the healthcare identifier service.

Senator BOYCE—Is it signed?

Ms Forman—The contact for the ongoing operation following the legislation will not actually be signed until the legislation is passed. But there is a contract currently in place until 30 June.

Senator BOYCE—I presume there is an unsigned contract somewhere—

Ms Forman—That is my understanding.


Page 70.

Ms Forman—Medicare Australia has been working closely with the industry and making available specifications for the system. We have also been working quite closely with the industry around the regulations, how they work and technical options that will be available for vendors to meet all the various ways that they deliver services to healthcare providers.

Senator BOYCE—Plenty of medical systems information system organisations have said that with a new rollout like this they would expect maybe six months of live testing to make sure the system is debugged properly and that it is functioning properly. There has been no live testing with this and yet it is due to come in in about three weeks time. Are there concerns about how it can integrate with the large number of management systems that are used by health providers already and that there have been no coordinating programs or software developed in that space up to date, how could all this happen on 1 July? That is the ongoing concern.

Ms Thompson—Senator, perhaps I could add something. In March this year, Medicare Australia made access available to the HI service IT test environment—

Senator BOYCE—That was after last estimates—

Ms Thompson—Yes—which allows clinical IT and software providers to test their interoperability. They have to sign a developers agreement in order to start that process. To date we understand that three have signed.

Senator BOYCE—Three out of how many potentials?

Ms Thompson—I could not answer the potential number, I am sorry. But the fact is that there is a process in place for the software industry to engage in the development of this project. We understand that Medicare has been very keen to engage with the industry to ensure that they do understand what their concerns might be.


Page 70.

Senator FIERRAVANTI-WELLS—How much has been spent—and I think you will have to take this on notice—in total by the Commonwealth since 1993 on e-health initiatives? I think it was referred to in the hearing but I do not think we got an exact figure.

Ms Thompson—I think we will have to take that on notice.

Senator FIERRAVANTI-WELLS—I appreciate that. Could you also take on notice how much has been spent by the state and territory governments since 1993 on e-health?

Ms Halton—No, Senator, we cannot take that on notice. We cannot answer questions on behalf of the state governments.

Senator FIERRAVANTI-WELLS—All right. If you do have any information that refers to state and territory government spending on e-health, could you provide that on notice? Can you provide a breakdown of the expenditure year by year?

Ms Thompson—Since 1993?

Senator FIERRAVANTI-WELLS—Yes, since 1993, year by year—thank you. How much did NEHTA ask for in their business case for patient controlled e-health records?

Ms Thompson—There is no NEHTA business case for patient controlled e-health records.

Senator FIERRAVANTI-WELLS—Has the government estimated how much will be required for the promotion of health identifiers if the legislation does go through?

Ms Forman—I would have to take that on notice.

Senator FIERRAVANTI-WELLS—Have you done any preparatory work in terms of any communication or moneys expended in communication and, if so, when the approval, if you have gone through—

Ms Halton—No—

Senator FIERRAVANTI-WELLS—Yesterday we went through that process.

Ms Halton—No, there is no campaign or anything of that sort in this area.

Senator FIERRAVANTI-WELLS—There is nothing like that?

Ms Halton—No.

Ms Huxtable—On the HI service there is an implementation and communication plan which NEHTA has just posted on their website. I think that went up yesterday. But it is not—

Senator FIERRAVANTI-WELLS—No, yesterday we went through the committee that you have to go through.


Senator FIERRAVANTI-WELLS—Okay. On the $466 million under COAG provided over two years to establish the national components for a secure national system as part of the plan, what will that be spent on?

There is only a global figure of $466.7 million. Can you break that down to separate line items or will it be paid in total to NEHTA?

Ms Huxtable—On page 126 there is a year-by-year breakdown, but that probably does not go as far as you would like.

Senator FIERRAVANTI-WELLS—No, I do not think we are going to be successful by looking at that. I do not have that one flagged.

Ms Thompson—With regard to the government’s announcement of $466.7 million, I cannot give that to you line by line. We certainly have ideas about how it needs to be broken up in terms of governance, infrastructure and funding for different elements of it such as the tools that might need to be deployed and the lead implementation sites that may need to be contracted to trial the infrastructure and architecture that we are going to design. The detail of that I would have to take on notice.


Page 72.

Senator FURNER—I am getting to that. Back in March 2005, Tony Abbott said that NEHTA would identify the various steps necessary to get us to an integrated IT based national health information system.

Furthermore, he went on to say, this was important because he believed upwards of 3,000 people a year died prematurely because of inadequate information and record keeping. We could avoid quite a few of these unnecessary deaths if we have an integrated record system. Can you identify whether you concur with both the figures in the report I have handed up and the comments that I have just indicated from Mr Abbott? Is that a savings figure for deaths and our health systems?

CHAIR—It is difficult for the officers to respond to your question when they have just got a copy of the report.

Ms Thompson—I can respond generally. This report and many others recognised the importance of ehealth. It is internationally recognised that an electronically connected health record does mitigate many of the issues that you have spoken about. There is no doubt that the clinics and the professions believe that this is essential. They believe it because they can see the history of errors that happen across the health sector in its various forms in both the acute sector and primary care. So there is no doubt that there is pretty universal understanding and the view that electronic health is the way forward in terms of really mitigating some of these adverse events.

Ms Halton—I can confirm that this report did indicate that if it extrapolated the RAND study, for example, by 2020 you could expect to avoid 10,418 deaths. That is the one figure I can find in here which I can confirm.

I also found $7.6 billion.


Senator FURNER—What is happening in other countries with respect to the issue of e-health? What are we seeing in other progressive countries?

Ms Thompson—There are certainly a number of countries that are progressing their e-health systems. We know of several, such as Denmark and the UK, that are advanced in this regard, but all around the world countries are looking at e-health as a way of creating not only better and safer health but also efficiencies in the dollars that the health sector costs.

Senator FURNER—What, therefore, would be the case if there were any threats of not implementing the e-health system as it stands?

Ms Thompson—I think the feedback from the professions is probably the most relevant here. The announcement about the next stage of the personally controlled electronic health record was universally welcomed by the professions. Everyone sees it as the next step forward because of the understanding of how important it is for the future of the provision of a health system that is built for this century. I believe there would be great disappointment in the sector if we did not proceed with this.

Senator FURNER—Would it be fair to suggest that the issues associated with deaths, underreporting, overreporting and all those sorts of things that we have identified would continue as a result of opposing the introduction of an e-health system.

Ms Thompson—I know there are many factors to that issue, but not proceeding with a system that connects the health sector and ensures that people’s records are accurate and available when they are needed would certainly be a detriment to the health system altogether.


This is almost as good as having been there!




Jim Cocks said...

Profoundly depressing...

Anonymous said...

DOHA still don't know what they are talking about.

There are two possible implementations of what they are describing (if you can call what they are doing description):

First is a Microsoft/Google PHR.

Second is an IHE Registry/Repository type solution with a patient portal.

The problem for both of these solutions is where to get the content. $466.7 million may build the patient portal part, but it will not cover the cost of getting the information into that portal.

Dr David G More MB PhD said...

Exactly, as I have been saying!


Anonymous said...

Presumably the federal money is to create the IEHR infrastructure. The cost of a connecting a feeder system like a state hospital EHR or a divisional EHR would be met by the owners of the feeder system, perhaps with some incentives to make them get a move on. Clearly the jurisdictions are going to have to put in more $ to connect their bits to the national system, over and above the federal comment.

Dr David G More MB PhD said...

That leaves out GPs and Path / Radiology practices. Hard to see them stumping up without some funds..


Andrew Patterson said...

I think someone has sold them on the IHE registry/repository vision (XDS etc). They've even started using IHE words like 'tiger team' etc (not that there is anything wrong with IHE - just saying that I would bet this is the way they are heading).

Anonymous and David makes the right point though.. you need to convince GP/path/rad vendors to be XDS document sources (and to register their documents with the index).

Once you've overcome that hurdle, then you'll get to the even more interesting questions..

a) how do we make the document content standardised/computable
b) how do we organise the content to be more than a filing cabinet of 'documents' - does the patient organise things, or does a GP do it? I might have 100 documents of medical history, but a curated subset of that (subsets of documents, and subsets of content from documents) is what is 'interesting' to my health providers.

However, if they got the GP/rad/path/hospitals to generate some content and have it indexed, at least that would be a start? Or do people think it's going down the wrong track entirely?

Anonymous said...

If we can have source information indexed, and available in 'native' form elsewhere(as opposed to being rendered in a common format), then that is a great leap forward on its own, and probably within the bounds of achievabilty.

Get that done, say over the next 3-5 years, and we can move to more aggressively encouraging document standardisation and semantic interoperabilty. To expect the whole kit and kaboodle (never spelt that before - nice word) to be up and running day 1 is infeasible. As they say 'the great is the enemy of the good'.

Here's to getting the information moving around the system, and then in time, to it moving around intelligently.

Anonymous said...

The whole idea of sending around information in its "native" form and then moving to standards is wrong. We still have many systems only supporting PIT years after having HL7 standards in place. If we make this mistake again its learning nothing from history.

Its fine to have simple forms of standards based data which can evolve to semantically rich data but to create a eHealth landscape of pdfs and word documents will set us back to BEFORE PIT was introduced!

Anonymous said...

Well Saturday June 12, if it is so 'wrong' are you instead advocating ripping out all the existing systems that are not 'standards compliant'? That worked a treat in England, didn't it?

Moving to standards compliance takes time, lots of time, and money, lots of money. The idea is to set up a trajectory for compliance that makes the change needed inevitable, and not joining in the changes unsustainable. And that means one day 1, like it or not, most systems will not be compliant.

Andrew McIntyre said...

Standards compliance is the only safe way to allow eHealth as sending data in native formats that may or may not be understood at the other end is unacceptable. There is no way you know the document has been received or understood and even formats such as rtf as not interoperable as the rtf viewers in many pms systems cannot reliably display complex rtf.

All we need is some requirement to be standards compliant to actually motivate vendors to work towards it. There is no motivation now and in fact there are perverse incentives to not be standards compliant to encourage users into a vertical closed market.

All of the messaging vendors understand this but it seems that people with no experience moving data around know better?

The native transfer of non standard data is a recipe for disaster and misadventure on a grand scale.

Anonymous said...

Many hospitals are investigating or installing scanned record systems. We are already heading back "to BEFORE PIT was introduced!"

Even worse, these scanned record systems will not be supporting CDA (which allows a document to be both human and machine readable).