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."

Friday, September 30, 2011

Here Is Something We Should Be Thinking About For Australia Over Time. It Will Be A Five Year Journey At Least!

The American Medical Information Association seems to have achieved something of a coup!
This was announced a few days ago

Clinical informatics to be certified subspecialty

Posted: September 23, 2011 - 11:45 am ET
For the first time, physicians will have the opportunity to become board-certified in the subspecialty of clinical informatics, the American Medical Informatics Association announced.
The American Board of Preventive Medicine will administer a clinical informatics examination for physicians seeking certification in the subspecialty, which the American Board of Medical Specialties recently voted to recognize. Physicians who have primary specialty certification through the ABMS will have the opportunity to sit for the exam.

The target timeline is to have the exam available by fall 2012 and the first certificates awarded in early 2013, according to an AMIA news release. The association will develop materials for online and in-person courses for physicians wanting to prep for the exam, the release noted, adding that materials should be available next spring.

"Establishment of the clinical informatics medical subspecialty is consistent with the current emphasis on broadening and professionalizing the health information technology workforce," AMIA President and CEO Dr. Edward Shortliffe said in the release. "With the need over the next decade for 50,000 informatics professionals in the health sector with various levels of expertise, this focus on physician expertise in clinical informatics is clearly a step in the right direction."

More here:
There is also a blog on the same topic from the same author here:
By Joseph Conn

Professional medicine officially embraces IT

The big news in healthcare information technology last week was the announcement by the American Medical Informatics Association that "official medicine" is finally climbing aboard the IT train.
By late 2012, for the first time, physician informaticists will be able to sit for an exam and gain board certification in the subspecialty of clinical informatics.
The American Board of Preventive Medicine will administer the exam, which the American Board of Medical Specialties has voted to recognize. Certificates should be issued by early 2013—matching a timeline published in March 2010 by former AMIA President and CEO Dr. Don Detmer.
AMIA has been working toward certification in clinical informatics since 2005. The AMIA board received a 2007 grant from the Robert Wood Johnson Foundation to develop the content and requirements.
Under the plan, practicing physician informaticists who have been university-trained in medical informatics or informally educated can take the board exam for the first five years.
More here:
Additionally there is coverage here:

Clinical informatics becomes a board-certified medical subspecialty

September 23, 2011 | Diana Manos, Senior Editor
WASHINGTON – The American Board of Medical Specialties (ABMS) has now recognized clinical informatics as a subspecialty, according to the American Medical Informatics Association (AMIA).
AMIA officials announced the news Thursday following what they called “a multi-year initiative” to elevate clinical informatics to an ABMS subspecialty.
According to AMIA, the certification will be available to physicians who have primary specialty certification through ABMS.
Clinical informatics (CI) certification will be based on “a rigorous set of core competencies,” developed by AMIA and its members. AMIA said many of its members have pioneered the field and supported CI’s new status as an ABMS-recognized area of clinical expertise.
AMIA anticipates the first CI board exam to be available next fall, with the first certificates awarded early in 2013. To prepare physicians who wish to sit for this examination, AMIA is developing preparatory materials both as online and in-person courses starting in spring 2012.
“It is entirely appropriate and timely to certify clinical informatics as a specialized area of training and expertise in an era when more and more clinicians are turning to data-driven, computer-assisted clinical decision support to provide care for their patients,” said AMIA’s Board of Directors Chair Nancy M. Lorenzi, of Vanderbilt University Medical Center. “Clinical informatics blends medical and informatics knowledge to support and optimize healthcare delivery.”
More here:
AMIA provides a link to a page which explains just what is covered, what the speciality is and what those in the profession add to clinical care.
See here:
At present it seems that informatics is to be seen as a sub-speciality for someone who already holds specialist certification but the president of AMIA has also said that other paths to certification are being considered actively. This quote shows the forward plans:
“A press release on the subject (of certification) was distributed last week (see “AMIA in the News” on AMIA.org) and the feedback and interest have been remarkably positive.  Meanwhile, recognizing that many individuals who wish to obtain clinical informatics certification will not be eligible for the ABMS examination, AMIA’s Academic Forum is working with the association’s leadership to develop additional certification options.  A special task force is considering various ways in which AMIA can work to assure that clinical informatics certification is available to everyone, regardless of whether the person is a board-certified physician.
AMIA has also started development of board review courses that will assist members and other physicians who wish to take the ABMS/ABPM exam.  The boards will not be offered until at least the autumn of 2012, but there is much to do in the meantime to develop the review courses while the ABPM is developing the examination itself.”
Given the diverse skill sets and origins of people who wish to be involved professionally in Health Informatics (computing, engineering, medicine, nursing and others) this seem very sensible and pragmatic.
To me the most important thing is to have both professional recognition and real career paths for people interested in the area. Both are needed to encourage people with the right skill mixes to join in!
This is a step the Australasian College of Health Informatics should be working towards over time.

Draft PCEHR Legislation Out for Consultation Until The End Of October, 2011.

The following press release came out today:

Release of draft eHealth Legislation

Minister for Health and Ageing, Nicola Roxon, released the draft eHealth records legislation for public consultation.
30 September 2011
Today the Minister for Health and Ageing, Nicola Roxon, released the draft eHealth records legislation for public consultation.
“Electronic health records have the potential to save lives, time and money and make the health system more efficient,” Minister Roxon said.
“The draft legislation outlines the process by which consumers, health care organisations and data repositories will register to be part of the eHealth system.
“It also will establish a new independent advisory council to advise the Government on the operation of the system.”
This legislation will underpin the strict security regime being established to protect the privacy of patients using the eHealth system. A benefit of eHealth is making medical information much more secure and private than paper based records.
“Using a combination of legislation, security and technology, backed by strict penalties for infringements, we will give patients peace of mind that their sensitive medical information is safe and secure,” Minister Roxon said.
“For the first time patients will have control over who accesses their information – and further they will know who has accessed their medical records, and the exact time that record was accessed.
“This system will be a first for Australia. Patients will not only be able to access their own eHealth record but, will also be able to view who has accessed their record.
The legislation includes strong penalties of up to $66,000 for a record being inappropriately accessed. If more than one record is accessed without authorisation then the penalty multiplies by the number of records.
There will also be proactive monitoring of the system to detect suspicious or inappropriate behaviour, ensuring that records are only accessed when there is a need to do so.
“Patients can upgrade their privacy settings to suit their needs, for example, giving their GP access to their entire records, but more limited access to their dentist,” Minister Roxon said.
“Doctors, or other health professionals, will be the only people allowed to create medical notes on the file. Patients can add their own notes about their general health but cannot make medical notes.
eHealth system is a critical part of national health reform. All Australians will be able to register for a personally controlled eHealth record from July 2012.
Comments on the legislation will be open until Friday 28 October. The release of this draft legislation follows a previous round of consultation on a Legislative Issues Paper. Final legislation will be introduced into Parliament later this year.
To read the draft legislation and make a comment visit: www.yourhealth.gov.au
----- End Release.
Something to download and read for the weekend - between the football!

Thursday, September 29, 2011

Some Useful Thoughts About Managing The Privacy and Security of Health Information. It Seems It Is The Insiders Who Should Be Blamed!

The following reports of a PwC Report appeared a few days ago.
There is coverage here:

Theft of Digital Health Data More Often Inside Job, Report Finds

September 22, 2011, 12:16 AM EDT
By Carol Eisenberg
Sept. 22 (Bloomberg) -- Electronic health data breaches are increasingly carried out by “knowledgeable insiders” bent on identity theft or access to prescription drugs, according to a report from PricewaterhouseCoopers LLP.
More than 11 million consumers have had medical data stolen or inappropriately disclosed since September 2009, and the privacy breaches are expected to rise as more health information is put online, according to the report released today by the New York-based accounting firm’s health research institute. The most frequently reported issue was the improper use of protected information by an “internal party,” the study found.
The report underscores the need to strengthen privacy and security controls as health records are more frequently stored online and accessed by portable devices, said James Koenig, co- lead of PwC’s Health Information Privacy and Security Practice. Consumer concerns that personal medical information may be vulnerable to disclosure are likely to increase as the Obama administration spurs the adoption of digital records.
“Going forward, there needs to be the vigilant focus not just on improvements to health care, but also making sure privacy and security keep pace so that confidence in these new uses can be enabled,” Koenig said in an interview.
Survey of Executives
The report analyzed data from a survey of 600 executives from U.S. hospitals and physician groups, insurers and pharmaceutical and life sciences companies. More than half of the organizations reported a privacy or security-related issue related to health data over the last two years, Koenig said.
Theft accounted for 66 percent of publicly reported breaches, including stolen laptops, smart phones and other electronic devices, misuse of patient data to submit fraudulent claims and people seeking care in someone else’s name.
More details are here:
There is also some coverage here:

Health industry lacks patient data safeguards: poll

Thu, Sep 22 2011
By Alina Selyukh
(Reuters) - New technologies are flooding into the healthcare world, but the industry is not adequately prepared to protect patients from data breaches, according to a report published on Thursday.
A vast majority of hospitals, doctors, pharmacies and insurers are eager to adapt to increasingly digital patient data. However, less than half are addressing implications for privacy and security, a survey of healthcare industry executives by PricewaterhouseCoopers LLP found.
PwC's Health Research Institute interviewed 600 executives in the spring of this year and also found that less than half of their companies have addressed issues related to the use of mobile devices. Less than a quarter have addressed implications of social media.
"The health IT and new uses of health information are changing quickly and the privacy and security sometimes may not be moving in step," said Jim Koenig, a PwC director who is among the contributors to the report.
More here:
There is very comprehensive coverage here with a link to the actual report.

PwC: Health industry under-prepared to protect privacy

September 22, 2011 | Mike Miliard, Managing Editor
NEW YORK – Most health organizations are under-prepared to protect patient privacy and secure personal health information as new uses for digital health data emerge and access to confidential patient information expands, according to a new report from PwC's Health Research Institute.
Old privacy and security controls no longer suffice to comply with existing privacy laws and patient consent agreements, say to PwC officials – who emphasize that health organizations need to update practices and adopt a more integrated approach to ensure that patient information doesn't fall into the wrong hands.
The report, titled "Old data learns new tricks: Managing patient privacy and security on a new data-sharing playground," shows how existing privacy and security controls have not kept pace with new realities in healthcare: increased access to information in electronic health records; greater data collaboration with external partners and business associations; the emergence of new uses for digital health information to improve the quality and cost of care; and the rise of social media and mobile technology to better and more efficiently manage patient health.
A recent nationwide PwC Health Research Institute survey of 600 executives from US hospitals and physician organizations, health insurers, and pharmaceutical and life sciences companies found:
  • Theft accounted for 66 percent of total reported health data breaches over the past two years. Also, medical identity theft appears to be on the rise. Over one third (36 percent) of provider organizations (hospitals and physician groups) confirmed that they have experienced patients seeking services using somebody else's name and identification.
  • More than half (55 percent) of health organizations surveyed have not addressed privacy and security issues associated with the use of mobile devices, and less than one-quarter have addressed privacy and security implications of social media.
  • More than half (54 percent) of health organizations surveyed reported at least one issue with information privacy and security over the past two years.
  • The most frequently reported issue among providers was the improper use of protected health information by an internal party. Over the past two years, 40 percent of providers reported an incident of improper internal use of protected health information.
  • The most frequently reported issue among health insurers and pharmaceutical and life science companies was the improper transfer of files containing personal health information to unauthorized parties. Over the past two years, one in five (21 percent) pharmaceutical and life sciences companies and one in four (25 percent) of health insurers improperly transferred files containing protected health information.
"Although paper-based health information breaches must now be disclosed under the breach notification provision under the HITECH Act, electronic data breaches occur three times more frequently and affect 25 times more people when they occur," said James Koenig, director and co-leader, Health Information Privacy and Security Practice, PwC. "Most breaches are not the result of IT hackers, but rather reflect the increase in the risks of the knowledgeable insider related to identity theft and simple human error - loss of a computer or device, lack of knowledge or unintended unauthorized disclosure."
A full copy of PwC's report can be found here .(After registration)
Much more here:
The full report - or at least the summaries linked here are important reading.
Just as you though it was all easy we have a slightly contrarian view put here:

Jay Cline: Are medical-data breaches overreported?

Healthcare organizations should make better use of the 'significant risk of harm' exemption in the federal law

Jay Cline
September 20, 2011 (Computerworld)
The Eli Lilly employee whose programming glitch exposed the e-mail addresses of almost 700 Prozac users to each other didn't know he was making history. Since that day in June 2001, hundreds more US healthcare organizations have reported medical-data breaches. As a result of those reports, federal and state health agencies have dealt out millions of dollars in fines, and the U.S. Department of Health and Human Services has launched a round of 150 audits. Meanwhile, a cottage industry of breach-notification service providers has arisen, and healthcare organizations can't find enough privacy talent to batten down the hatches.
But is this obsessiveness over health-data privacy warranted? Do medical-data breaches harm people, and does notifying them of the incidents help them?
The answer to these questions might seem like a resounding yes. The thought of our medical records ending up on websites or in criminals' hands makes us nervous. We want to know about these incidents if they happen, even though few of us take any action as a result of being notified.
This large and growing allocation of healthcare resources in an era of cost containment, however, deserves a closer look.
The phenomenon of data-breach notification started in California the same year as the Eli Lilly incident. State legislators Steve Peace and Jim Simitian drafted what became SB 1386, the first data-breach notification act in the world. Passed in 2002, this law remained an outlier until the infamous ChoicePoint breach of 2005. Nearly every U.S. state passed a breach-notification law in its aftermath, and many other countries are following suit. Most of these laws notably did not include personal medical records in their scope of concern.
That all changed in 2009. In April of that year, Congress passed the HITECH Act as part of the economic-stimulus package. Included in that act were instructions for the U.S. Department of Health and Human Services (HHS) to issue a series of new rules about improving the protection of personal health information. In August 2009, HHS released its first installment -- an "interim final rule" on notification of health-data breaches. By the end of 2011, HHS is expected to divulge its "final final rule" on medical-data breach notification.
The landmark feature of the interim final rule is a mandate to immediately notify HHS of any data breaches affecting 500 or more people. The rule also requires an annual notification to the department of incidents affecting fewer people. The department posts the notices for the large breaches on its infamous "wall of shame."
Lots more here:
Jay Cline does go on to propose a sensible framework for assessment of health information breaches but I have to say that I do think at the very least those whose identifiable information leaks out or is exposed are entitled to know about it. After that Jay is right that a ‘horses for courses’ approach makes sense looking at the risk, possible damage and so on.
Better still might be to look hard at the PwC report and see where improvements can be made. You can be sure once the national PCEHR is commenced the pressure for breach notification will skyrocket!

This Is A Really Important Reason To Make Sure EHRs Are Fully Implemented And Then Properly Exploited!

I was reminded by a series of articles this week that there was more to the push for deployment of clinician used EHRs that just assisting individual care directly.
These three article brought the point home pretty clearly!
First we had:
Monday, September 19, 2011

Mining Data for Better Medicine

The health battles of millions, recorded digitally, open a world of virtual research.
The antidepressant Paxil was approved for sale in 1992, the cholesterol-lowering drug Pravachol in 1996. Company studies proved that each drug, on its own, works and is safe. But what about when they are taken together?
By mining tens of thousands of electronic patient records, researchers at Stanford University quickly discovered an unexpected answer: people who take both drugs have higher blood glucose levels. The effect was even greater in diabetics, for whom excess blood sugar is a health danger.
The research is an example of the increasing ease with which scientists now scour digitized medical results, like glucose tests and drug prescriptions, to find hidden patterns. "You're not constrained by the need to actually get patients lined up in a clinical trial that would be incredibly expensive," says Russ Altman, director of Stanford's Biomedical Informatics Training Program, whose group published the Paxil/Pravachol result in the journal Clinical Pharmacology and Therapeutics this July. "We had most of this paper done probably in a month."
The spread of electronic patient records, with their computer-readable entries, is opening new possibilities for medical data mining. Instead of being limited to carefully planned studies on volunteers, scientists can increasingly carry out research virtually by sifting through troves of data collected from the unplanned experiments of real life, as preserved in medical records from scores of hospitals.
Such techniques are allowing researchers to ask questions never envisioned at the time of a drug's approval, such as how a medicine might affect particular ethnicities. They are also being used to uncover evidence of economic problems, such as overbilling and unnecessary procedures. Mining of health records "is going to build advancements in research, but also efficiencies in the health delivery system," says Margaret Anderson, executive director of FasterCures, a think tank in Washington, D.C.
Some large hospital systems that use electronic records now employ full-time database research teams. Laurence Meyer, associate chief of staff for research at the Salt Lake City Veterans Administration Medical Center, says he knows of more than 100 research projects using electronic records from the VA's six million patients, who are seen at 152 hospitals and 804 outpatient clinics across the country.
"If you're looking at a single hospital's cases of, say, hypertrophic cardiomyopathy, you might have 20 or 30 over 10 years, whereas all of a sudden we're looking at thousands of cases," says Meyer.
Large numbers of patient records are critical to these efforts, researchers say. In 2002, in the best-known case of a medical discovery to emerge from a database, researchers with the California managed-care provider Kaiser Permanente helped show that the $2.5 billion pain drug Vioxx was killing people by causing heart attacks. The effect became apparent only after Kaiser combed the records of its eight million patients. Vioxx was subsequently pulled from the market.
Lots more here:
Then we had this

How Penn Medicine Mines E-Records For Clinical Trial Prospects

It shows a hospital wringing value out of an electronic record system that took years to implement. One in a series of profiles of InformationWeek 500 innovators.
By Marianne Kolbasuk McGee,  InformationWeek
September 14, 2011
When recruiting patients for clinical trials, medical researchers still typically get word out with billboards and newspaper ads. Some have tried Facebook lately. But those methods generally don't attract enough of the right patients, delaying research and sometimes leading to trial cancellations.
Penn Medicine, part of the University of Pennsylvania Health System, is trying something new: using the trove of data in electronic medical records to find clinical trial candidates and then alert those patients' doctors.
It's an example of how healthcare IT teams are working to wring value from the electronic record systems they've often spent years implementing. Earlier this year Penn Medicine completed a five-year project to roll out Epic e-records to its 1,800 employed physicians. "You often need an army to install EMR systems," says Michael Restuccia, CIO of the University of Pennsylvania Health System. "But once you finally have these systems in place, the amount of effort to get added value out of them with programs like this is comparatively little."
The provider's new clinical trial application, called Penn Research Trial Advisory, took several months to develop. It has piloted the app in its ob-gyn department, helping recruit 200 patients for infertility clinical trials. The test brought an 87% increase in the number of physician-referred patients for trials compared with the prior four-month period.
"The key is the much more targeted, available information sitting in the EMR that's now turned into a tremendous asset," says Brian Wells, Penn Medicine's associate CIO. Other departments plan to use the app for their own clinical trials.
In general, 85% to 95% of patient care is provided by ambulatory care clinicians--doctors in their offices or other locations outside in-patient hospital settings. Because they tend to have a more ongoing, trusting relationship with their patients, those docs are best positioned to recruit patients for clinical trials, Restuccia says. It's more likely than an ad to produce the right conditions, as well.
How it works here:
Last we have this:

How EHRs Feed The Clinical Research Pipeline

Natural language processing programs can now data mine e-records to help locate the best candidates for clinical trials. Several major healthcare organizations have taken notice.
By Paul Cerrato,  InformationWeek
September 16, 2011
As healthcare moves gradually from a fee-for-service to a pay-for performance model, it will be judged on how closely clinicians adhere to evidence-based guidelines. The best evidence comes from controlled clinical trials, but since so few treatment protocols are supported by these trials, the movers and shakers in clinical medicine are looking to fill the void by recruiting large groups of subjects willing to enroll in them. Not an easy task.
What has surprised many IT managers and clinicians is how valuable EHRs are proving to be in fueling that research effort.
The Mayo Clinic, for instance, has been mining its EHR data for several years to find subjects for clinical trials. When choosing patients to enroll in such experiments, one of the challenges is to find those who meet predetermined clinical criteria. Sifting through paper files is a nightmare, and even having clinicians manually search e-records for eligible candidates takes far too long.
With that in mind, Mayo Clinic has employed natural language processing (NLP) to speed things along. In one project, it needed to locate patients with heart failure to enroll in a study. The NLP-enabled algorithm was engineered to search through EHRs--including free-text clinician notes--to locate patients with cardiomyopathy, congestive heart failure, pulmonary edema, and a variety of other relevant conditions.
But the system didn't stop there. It automatically searched for synonyms in a database of 16 million problem list entries--all of which were written in unstructured natural language. The same algorithm was capable of weeding out patients with "negation indicators"--patients whose records said something like "patient denies symptoms of heart failure."
More examples here:
So, really in just the space of a week we see three different and beneficial ways of exploiting the EHR infrastructure once it is in place.
Any national infrastructure should ensure all these benefits can be readily obtained! I am not convinced the PCEHR offers much in this regard - with the personal control and so on.
Maybe a major opportunity missed?

Wednesday, September 28, 2011

Is This An Workable Approach To Thinking About the PCEHR? Different National Approaches Are All Over the Place!

The following editorial appeared a few days ago - and as the PCEHR was mentioned I thought it was worth a careful read.

Solving the right health IT problem

September 20, 2011 | William Yasnoff, MD, PhD, President, Health Record Banking Alliance
Twenty years have passed since the Institute of Medicine identified electronic health records (EHRs) as "an essential technology for patient care." However, despite much activity, and some progress, comprehensive electronic patient records are still not available to providers of care.
Most of our efforts thus far have been focused on automating our current record retrieval process: When a patient presents for care and has records elsewhere, a manual request is made to the outside provider and the records, if available, are typically faxed to where they are needed. We have mistakenly believed that if we could just automate this process with electronic health information exchange (HIE), all would be well. This provider-centric approach addresses the wrong problem. Each provider’s records, even if electronic, are not complete patient records.
Treating the symptoms of missing records by automating our current manual "fetch the records" process will not fix this. The locations of all the records for a given patient are not generally known or recorded. Every provider must have an EHR system able to respond immediately to a record request from any other provider (a combinatorial explosion of potential connections). Provider sharing of records is totally voluntary. Records from multiple sources must be correctly identified and integrated in real time. Protecting privacy is very difficult since patient information is located in many different systems. The scattered patient records cannot be feasibly searched for public health, public policy or medical research purposes, eliminating our opportunities to use this information to detect patterns and improve care. Finally, there is no clear business model for sustainability.
Last year's report from the President’s Council of Advisors on Science and Technology concluded that current HIE efforts through the states "will not solve the fundamental need for data to be universally accessed, integrated, and understood while also being protected." Findings of a recent survey of HIEs "call into question whether RHIOs [Regional Health Information Organizations] in their current form can be self-sustaining and effective."
The right problem is ensuring the availability of comprehensive electronic patient records. Solving it requires a patient-centric approach. Imagine each patient having their own secure and private electronic "checking account" for their medical records.
William Yasnoff, MD, PhD, FACMI, is a health IT consultant and President of the Health Record Banking Alliance.  His prior work at HHS resulted in the creation of ONC in 2004.  He is the author of the Health Information Infrastructure chapter in the textbook Biomedical Informatics (Shortliffe & Cimino, eds.). This post appeared at NHINWatch.com.
Read the full article here:
The following paragraph provides some links to some examples.
“This approach, known as a health record bank (HRB) or "patient-controlled EHR" (PCEHR) is already in use in Singapore and Denmark, and is being implemented in the Netherlands. Australia just awarded a large contract to build a PCEHR system by mid-2012. Aided by seed funding from Washington State starting in 2009, several small HRBs are now operational there.”
Here is the announcement from Singapore:

Accenture Implements Nationwide Electronic Health Record System in Singapore

June 20, 2011
Accenture Implements Nationwide Electronic Health Record System in Singapore
Phase One Launch Provides Single Patient Record for Healthcare Professionals
SINGAPORE; June, 21 2011 - Accenture (NYSE: ACN) and MOH Holdings Singapore have launched one of the world’s first national electronic health record (NEHR) systems. Aligned to Singapore’s “one patient, one record” vision, the NEHR enables a single patient health record for clinicians to access across the healthcare continuum. 
As patients visit providers – including primary care clinics, acute and community hospitals – healthcare professionals will be able to access a single patient record for medical information. The NEHR captures medical data, including patient demographics, diagnosis, medications, tests, procedures and discharge summaries, for exchange among clinicians. 
“Our goal is for all Singapore health organizations to have real-time clinical information for treating patients,” said Dr. Sarah Muttitt, Chief Information Officer, MOH Holdings. “This milestone represents a significant step towards achieving our vision.”
“The NEHR will enable insight driven health through the timely access to holistic patient information,” said John Vidas, who leads Accenture’s health business in Asia Pacific.  “Singapore’s vision, leadership and innovation will establish standards and best practices for other regions to follow.”
The Singapore NEHR go-live is the first phase of the effort and was deployed in 10 months.
Full release here:
From Denmark we see a really interesting approach.

Widespread Adoption of Information Technology in Primary Care Physician Offices in Denmark: A Case Study

March 11, 2010
Authors: Denis Protti and Ib Johansen


Denmark is one of the world's leading countries in the use of health care technology. Virtually all primary care physicians have electronic medical records with full clinical functionality. Their systems are also connected to a national network, which allows them to electronically send and receive clinical data to and from consultant specialists, hospitals, pharmacies, and other health care providers. Under the auspices of a nonprofit organization called MedCom, over 5 million clinical messages are transferred monthly. One of the most important innovations has been the "one-letter solution," which allows one electronic form to be used for all types of letters to and from primary care physicians; it is used in over 5,000 health institutions with 50 different technology vendor systems.


D. Protti and I. Johansen, Widespread Adoption of Information Technology in Primary Care Physician Offices in Denmark: A Case Study, The Commonwealth Fund, March 2010.
Full text of issue brief is found here:
I can’t vouch for the third link but it seems to rather double Dutch to me!
Go here if you read the language:
My take is that the guts of the Health Bank concept has some merit. The implementations in the US look nice and simple and are obviously reasonably practical:
See here:
and of course here:
What is happening in Denmark looks like a clever way to skin the Health Information Exchange approach and the Singapore model is still emerging.
Had our powers that be decided to go with Danish simplicity and elements of the Singapore and US approaches we might have had a workable system without all the issues to suit those patients who wanted one and still have been able to enhance our present clinical systems.
I still struggle to know how any of these concepts can make complex long term collections of information easily accessible and useable - so there does seem to be a role for curation of a health summary if a sensible balance between patient desire and clinician time and effort can be struck.
I have to say having a look at what is going on elsewhere is really worthwhile. Comments welcome.

Texas Health Information Exchange Interoperation Guidance. A Really Interesting Set of Documents With Some Relevance To OZ!

I was alerted to this press release over the last weekend.

Accenture Completes Assessment for Texas Health Services Authority

September 07, 2011
Accenture Completes Assessment for Texas Health Services Authority
Project to Support Health Information Exchange and Interoperability
 AUSTIN, TX; September 07, 2011 – Accenture (NYSE: ACN) has completed an assessment and plan to support implementation and interoperability standards for a state-wide health information exchange (HIE) for the Texas Health Services Authority (THSA).
Accenture identified the technology standards, architecture, and strategy to ensure consistency with state and federal requirements. The strategy will support interoperable health information management and exchange among unaffiliated organizations. Accenture also developed an enterprise architecture blueprint (EAB) for state-level HIE services and a plan to manage the EAB lifecycle to help ensure compatibility as standards evolve.
“Accenture is proud to partner with the Texas Health Services Authority to help realize the statewide Health Information Exchange vision for Texas,” said Rick Ratliff, global connected health managing director, Accenture Health.  “This initiative is a significant step toward improving healthcare quality and enabling an insight driven health system.”
Accenture also produced a technical implementation specification document for local and regional HIEs as a reference guide for healthcare IT implementation.  Additional information on Texas’ HIE Interoperability Guidance is available from the Texas Health Services Authority.
About Texas Health Services Authority
The Texas Health Services Authority (THSA) was created by the Texas Legislature through House Bill 1066 in 2007 as a public private partnership, legally structured as a nonprofit corporation, to support improvement of the Texas health care system by promoting and coordinating health information exchange (HIE) and health information technology throughout the state. The THSA is working under contract with the Texas Health and Human Services Commission (HHSC) to implement HIE strategic and operational plans for the State of Texas.
Here is a the main page from the THSA.

Texas HIE Interoperability Guidance

Wednesday, August 24, 2011
Texas HIE Interoperability Guidance
In order to facilitate statewide Health Information Exchange (HIE), the Texas HIE Strategic and Operational Plan provides that the Texas Health Services Authority (THSA) will develop technology standards, including reference guides and policies, to support vendor neutrality and ensure statewide and federal program interoperability.
The THSA, with input from stakeholders, has developed the following documents to serve as HIE interoperability guidance for organizations supporting HIE in Texas.
· Technical Standards Landscape Review - This document contains information gathered during an assessment of the State of Texas, Federal Government, and industry Healthcare IT landscapes to identify the relevant architecture, interoperability, and security standards being used or proposed to be used to support the secure exchange of health information among unaffiliated and (technically) heterogeneous organizations.  Texas HIEs can use this document as a reference tool to understand the overall technical standards landscape within the U.S.
· Enterprise Architecture Blueprint - This Enterprise Architecture Blueprint (EAB) document describes the architecture vision for the Texas HIE space for the next six years, divided into three two-year increments.  The EAB includes a set of high-level use cases chosen to reflect the Texas HIE vision and desired capabilities for the next two years (years 1-2).  It also includes planning considerations for years 3-4, and very high-level strategic direction for years 5-6.
· EAB Lifecycle Management Plan - This document is based upon information gathered during the development of the EAB and the Technical Standards Landscape Review, and is intended to identify the processes for managing the lifecycle of the enterprise architecture. This includes identifying the appropriate parties to implement change management, such as monitoring and updating as appropriate the standards used to establish interoperability between the local, regional and state level HIEs, as well as the standards utilized for the identified use cases in order to facilitate the continued support of Texas HIE and its connecting organizations.
· Technical Implementation Specifications - This implementation specification document is intended to serve as a technical reference guide for local and regional HIEs to use in implementing their networks.  The intent of the document is to define a high-level solution that HIEs and Health Information Service Providers can implement to meet the desired capabilities of Texas HIE as defined by THSA.  Technical standards have been identified and documented for each functional component defined in this specification.  Standards and profiles are also documented for the messaging and data flows required for communication between components.
----- End Extract
The same site also has some other interesting material - examples are here

Implementing Privacy and Security Standards in Electronic Health Information Exchange

Wednesday, August 24, 2011
The University of Houston Health Law & Policy Institute, under contract with the Texas Health and Human Services Commission, prepared a white paper on Implementing Privacy and Security Standards in Electronic Health Information Exchange.  The white paper discusses privacy and security policies necessary to support secure interoperable health information exchange, including authentication, consent, audit, breach, and patient engagement policies.
and here:

Recommendations for Texas Health Information Trust Agreements

Wednesday, August 24, 2011
The University of Houston Health Law & Policy Institute, under contract with the Texas Health and Human Services Commission, prepared a white paper on Recommendations for Texas Health Information Trust Agreements.  The white paper discusses the use of trust agreements to support exchange of health information and for establishing and ensuring privacy, security, and trust within a health information exchange.
First note that this plan and associated documentation covers a population of over 25 million people and is about establishing a state-wide Health Information Exchange that draws from at least 14 separate more local exchanges
Second note that the program has a implementation plan and approach that encompasses a sensible time frame - with implementation running over six or so years.
Third the Standards that are to be used are already nailed for national and other constituencies so that the rules are pretty clear from the outset and will evolve in a predictable way.
Fourth it seems clear from the documentation that consultation with stakeholders was not an after- thought - rather it was baked in from the start!
In a similar light we had the following interview reported last week:

Working Towards an Integrated System

Interview with GE Healthcare’s Vice President of eHealth Solutions, Blair Butterfield.

GE Healthcare announced to launch its eHealth Information Exchange in Australia this week which is seen will make an impact on eHealth in Australia. As current aspirations and concerns about the development of eHealth in Australia continue to unveil, Blair Butterfield shares his experience working on eHealth projects internationally and how Australia could learn and benefit from this.
Interview conducted by Rebecca Merrett
By far the best part of the interview was this question and answer:
What would be some key learnings that you think could help foster the success of eHealth and information sharing in Australia?
I would say the key learnings that we have shared with those that ask on this topic would be:
  • Define standards early
  • Involve the physicians as much as possible in the process because they are the users and custodians of the data
  • Ensure that privacy and consent issues are managed very well to avoid consumer backlash
  • Start small and build incrementally because there will be several iterations to get to the full implementation
  • Be open to learning from other countries successes and failures
If you do all those things right then I think the chances of success go way up.
----- End Extract.
I leave it as an exercise for the reader to see how close the NEHTA / DoHA team have come to doing things properly. (Hint 1 out of 5 at best is my score). Accenture and Texas are doing a good deal better!

Tuesday, September 27, 2011

The AMA and Others Are Stiffening Its Opposition to the PCEHR. Minister Roxon Should Be Really Worried.

A little while ago I pointed out in a blog that the PCEHR was going to go very badly unless the medical profession was on side.
See here:
Earlier this week we had this appear following Ms Roxon’s suggestion the AMA should just stop complaining and ‘get on board’!
Now we have a response from the AMA - a day later!

Dangers of de-medicalising the PCEHR

Guest editorial by Dr Steve Hambleton
The Federal Government has released the final version of the Concept of Operations for the Personally Controlled Electronic Health Record (PCEHR) system — a document that is very similar to the draft version. The AMA is extremely disappointed in both versions.
For a health record that is being promoted as revolutionary for patients and health professionals, including doctors, it is sadly bereft of sufficient medical input to its design and intended purpose.
It appears that the personally controlled e-health record has effectively been ‘de-medicalised’. It appears that consultation has been merely conversation. Medical input has been ignored, while the government has caved in to noisy minority consumer groups.
Everybody in health wants e-health and the personally controlled e-health record to succeed. The AMA has been one of the strongest supporters of the government’s e-health initiatives. If it works properly, it will certainly save lives.
But we cannot support aspects of a system that do not improve on what we have now.
Nor can we support something that potentially creates risks to patient health.
Unfortunately, that is where we find ourselves with the release of the Concept of Operations. Under the proposed arrangements, people will be able to alter their health record without consultation with their doctor. Patients could entirely remove from their record clinical documents they had previously considered worth sharing with healthcare providers.
The personally controlled e-health record will no doubt give patients greater involvement in and responsibility for their healthcare.
We are all for giving patients greater control, but not total control that excludes medical moderation. This is reckless and dangerous. It could undermine all the potential benefits of an electronic health record.
If this goes ahead, we will have a system that doctors want to support but can’t because their patients may not give them access to their records or parts of their records.
The AMA had hoped that the personally controlled e-health record would have contained a shared electronic medical record that sat within it. The medical component would contain reliable and relevant medical information about individuals that had been posted by doctors.
Consumers with serious concerns about privacy, or an objection to their medical and health information being shared, could actively make the choice not to participate in an opt-out system.
Dr Hambleton is president of the AMA.
More here
This article is blazingly clear. Ms Roxon you want help having this work there are some major changes we will insist on. No change, no deal is how I see it.
Of course all this could have been avoided if NEHTA bothered to listen to those who responded to their request for submissions.
We even now have the RACGP seemingly being a bit more concerned about workflow and time impacts:
“Dr John Bennett, chair of the RACGP’s national e-health standing committee, said: “I don’t think the government has any clear idea of what the workload implications are going to be. I think for a small proportion of patients — those with multiple diagnoses on multiple medications, those in aged care — there will need to be more time spent gathering information and updating records.
“No doctor loves spending time doing that work but I think if they see real benefits for patients, that this system works, that will be something they are willing to do.”
Dr Bennett said that despite the safety concerns raised by the AMA, the system would be a “vast improvement” on the fragmented information doctors currently relied on to care for patients.”
Full article here:
Interestingly a small poll from Medical Observer is suggesting that of a sample of 30+ GPs on 12% would not bill for PCEHR maintenance (12% didn’t know and 76% would bill).
This whole thing will run off the rails unless some rapid work is done to fix the basics!
I will leave it as an exercise for the reader to see how many of the Australasian College of Health Informatics suggestions were addressed (see page 4) of their submission which is found here:
“However, there are a number of areas where substantial improvements for the next release of the Concept of Operations can be achieved:
  • Provide clarification if the PCEHR is part of a total EHR and what the specific goals of the PCEHR are
  • Provide more detailed information on the business case for the PCEHR
  • Include recommended implementation approaches and criteria
  • Include "Build on and strengthen the patient‐doctor relationship" in the PCEHR Principles
  •   Include more rationale how practitioners' will use electronic systems vs paper‐based systems
  •  Add features to increase the trust of patients (particularly "opt out" patients) and practitioners
  • Make the access arrangements more implementable and simpler for the majority of users
  • Include more details on a simple and complete audit trail access by consumers
  • Provide more details on PCEHR data retention/archival and access for secondary use of data
  •  Give priority to a small number of useful "low hanging fruit" functions to ensure fast adoption
  •  Combine the approach to Referrals and Discharge Summaries and add hospital dispensing systems
  • Include more details on which interfaces and interface standards are to be used for which function
  • Ensure the 12 first and second wave projects are able to seamlessly interoperate and share data
  • Include specific design guidelines how the clinical quality of unstructured data can be assured
  • Review the value and data quality of consumer‐entered information
  • Include a long‐term implementation timeline with clearly defined major milestones
  • Include consideration of the e‐Health Workforce limitations
  • Include a section on how the PCEHR will compete with and leverage new technologies
It is a pretty long list and not much was addressed! As the AMA etc. say - really just not listening!