Quote Of The Year

Quotes Of The Year - 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, August 30, 2012

Is cdmNet Setting Up To Compete or Coexist with the NEHRS? Hard To Tell Just Yet.

The following appeared a few days ago.

Chronic disease care goes online

21 August, 2012 Michael Woodhead
An online support site has been launched to help GPs caring for patients with chronic diseases such as diabetes.
Chronic Disease Management-Net (cdmNet), enables patients, GPs and allied healthcare professionals to develop care plans, share medical histories, test results, updates on patients’ conditions, send referrals, and set appointment reminders, says Professor Leon Piterman of Monash University.
 “What cdmNet has done is provide an efficient clinical information system that makes health records available and accessible electronically,” Professor Piterman said.
“This supports the GP’s decision making. It also provides a delivery system for information sharing and feedback with the care team. It ensures the team is working cohesively.”
More here:
We also had coverage here:

Victoria takes e-health national

A Victorian government-funded electronic health service will be offered to every Australian with a chronic illness
A Victorian government-funded electronic health service will be offered to people with chronic illnesses across Australia, following the announcement that 10,000 patients had signed up for the service.
Victorian health minister David Davis announced that the Collaborative Care Cluster Australia (CCCA) is now a national program that “empowers patients to work collaboratively with their GPs, specialists, pharmacists and other healthcare professionals to manage their own health issues using a new online capability.”
Davis was referring to the CCCA’s Chronic Disease Management Network (cdmNET), an online system that links patients with their own care plan and helps an entire healthcare team share information.
More here:
Here is the full media release:

The Hon David Davis MLC

Minister for Health
Minister for Ageing

Media release

Friday, 17 August 2012

Government provides big win for patients with chronic disease

Ten thousand patients are now taking back control of their lives with the help of a Victorian Government funded program that is transforming management of chronic diseases like diabetes, asthma and arthritis.
Health Minister David Davis today launched the Victorian-based Collaborative Care Cluster Australia (CCCA) as a national program that empowers patients to work collaboratively with their GPs, specialists, pharmacists and other healthcare professionals to manage their own health issues, using a new online capability.
“Currently over 10,000 patients, 1,000 GPs and nearly 3,000 allied health professionals have already signed up, the project is running successfully—and now this Victorian initiative is going national”, Mr Davis said.
“CCCA offers the Victorian-developed e-health platform, cdmNet, in a proven format that links a patient with their own care plan and helps their entire healthcare team to share information and collaborate more effectively.
“Now for the first time in Australia, patients with chronic illness can access their care plan with their pharmacist in the pharmacy using a simple barcode”, Mr Davis said.
“I urge all Victorian pharmacists, patients with chronic conditions and their carers to come on board, and join with GPs, specialists and healthcare professionals to embrace innovative technologies like cdmNet, which can transform the outcomes of chronic health management, reduce costs and improve quality of life.
“With no costs to patients, the system pays for itself through efficiencies it creates in the doctor’s surgery, so everyone wins,” Mr Davis said.
“Victoria is leading the nation in e-health and chronic disease management,” he said. “In future, patients and their carers will be able to join a care conference with their GP and specialists, accessed at the press of a button from cdmNet, by video, voice or online. CdmNet is enabling telehealth.”
----- End Release:
This link allows you to explore what is presently happening:
What I find interesting are three things.
First that among a legion of Partners (IBM, Cisco, GP Organisations etc. etc.) the two that are missing are DoHA and NEHTA while the AIHW and the Broadband Ministry are involved!
Second the GP Incentive payments for chronic health care make a good commercial case for adoption.
Third what is being done looks very much like one of the major planned roles for the NEHRS.
Have I got this wrong or does the NEHRS have an already operational and successful private competitor. With this why would a patient need the Government offering?


Anonymous said...

This is great news. The local medical software industry pushes through despite everything. They always will.

I think this is probably the first of many to come. Congratulations to them!

Anonymous said...

What I notice is that:
It is not personally controlled - although I am sure you don't have to have one if you don't want to.
It is based on care plans, and has reminders and referrals etc.
It hasn't got out of date medicare claim details.

All of these are advantages over the NEHRS, and I see that they are offering it beyond Victoria. So, as a clinician which one should you look at, and what do you do if they are different?

Anonymous said...

There's nothing like working together is there!!!!!!

Whilst this does sound like it has advantages over NEHRS, it is yet more taxpayers money being wasted on the same thing over and over and over..........But what of providing something that is in the best interest of the patient (Heck, who said we had to think about them in all of this!)

When will 1) someone learn and 2) the waste stop?

Cris Kerr said...

I am all for local industry, but am not for 'silos' of anything.

I also grow concerned when I read things like; ' ... This supports the GP’s decision making. ... ' when it occurs in the absence of transparent explanations about how that's going to happen and is targeting diseases that are commercially lucrative and represent the top of the totem pole in high commercial growth markets.

How will clinical decision making be supported, to what degree, and how flexible will it be?

How much emphasis will be placed on different types of interventions, eg; lifestyle changes or supported prescribing?

Exactly how will 'the system' support clinical decision-making, and how transparent will it be?

What evidence will be made available to support clinical decision making, and who will influence or control what gets presented as evidence and what doesn't?

Who'll be monitoring/safeguarding all 'direct to patient' communications?

How will both short and long-term patient outcomes be measured, and will patients be able to contribute by self-reporting all their actual health outcomes in structured ways (eg not just glucose readings)?

How will we compare actual health outcomes under this 'system' with actual health outcomes achieved outside this system... to compare effectivness... as evidence that this system's 'supported clinical decision making' is contributing to a higher degree of improved health outcomes... or not?

Protective legislation was designed specifically for the PCEHR. Is that legislation sufficient to protect and secure patient interests in this new, separate and 'silo-ed' system, and if not, how would be know?

What is the framework and governance structure, who's responsible for it, and how will that oversight occur?

And finally, why, why, why, in this enlightened day and age, would anyone suggest more 'silos' of health information... when we all know without doubt that if you want to improve health outcomes, information has far greater value when it's pooled.

Anonymous said...

Minister David Davis said “Now for the first time in Australia, patients with chronic illness can access their care plan with their pharmacist in the pharmacy using a simple barcode”.

What has NEHTA got to say, and DOHA too? Their silence is deafening. Does this mean the Guild's eRx Script Exchange will become the defacto standard nationally?

NK said...

There's absolutely no information about exchange of data with other systems on the cdmNet site - at least, not that I could see.

So it looks like very much another silo - hardly something that can fit into an e-health transition map for the future. And nor would anyone - particularly David - be happy if NEHTA embarked on a course like that.

But kudos to them for getting approval for doing the easy things... your local medical software industry at work? (and when will it be hacked?)

Bernard Robertson-Dunn said...

Why are silos a bad thing?

Why is exchange of information between systems a good thing?

(I don't know the answer to these questions, which is why I'm asking)

For patients operating in a silo (which might mean in a local community) with a local doctor (who can integrate information from multiple sources in his/her head), silos and isolated systems may be perfectly acceptable.

One of the difficulties faced by NEHTA (but not implicitly recognised and addressed) is that they are trying to come up with a solution that solves all the problems for all the people. This big-bang, top-down approach to a wicked problem has a very low probability of success.

A lesson could have been drawn from the different approaches of OIS and TCP/IP. OSI was a better technical solution to network interoperability. It lost out to TCP/IP, which has many many faults, some of which have resulted in fraud and other bad things. But it worked and is still working.

As I've observed before, it is a leadership problem. The decision makers decided that the big-bang, top-down approach was the way to go. Unfortunately, the people who made that decision did not understand the consequences of making it.

It is a common (but not universal) characteristic of people who get into leadership positions that they are "push-through", "make it happen" people. They are prone to the big-bang method and not listening to contrary advice.

Many local, small solutions, over time and if of value, will likely morph into fewer, larger solutions. Those that are not of value will die out. It's called natural selection.

Unfortunately, it is difficult for any single person to claim credit. That's why politicians and ambitious people don't like that approach. No credit.

Grahame Grieve said...

Hi Bernard

You discuss 2 issues - top down solutions and whether silos are a good thing.

Obviously there's problems with top-down solutions, though I think it's pretty hard for government departments to not do them.

But regarding silos: presently, a person's health information is in multiple places. Each place is a partial record, and people often suffer adverse health outcomes because good information that is available elsewhere isn't in the right spot. Most people have personal experience of this within their family, and there was a powerful presentation regarding this as the keynote presentation at HIC this year (http://reginaholliday.blogspot.com.au/)

Worse, there problems *cost extra money*, and much extra money is spent trying to prevent it too.

Reports, both Government and other, in many countries, have consistently identified the existence of silos as a significant impediment to improved outcomes at lower cost - and that's not just in helathcare either.

Obviously increasing integration between silos and reducing the cost of information low is not the only game in town, but it is important, and is the current focus of e-Health.

Trevor3130 said...

On Partners, Partnerships Victoria publishes Disclosure and management of conflict of interest for advisers.
In examining close personal affiliations, the adviser must (for each project team member and supporting managers) examine direct relationships with parents, children, and siblings, other financial dependents, spouses, de-facto partners, and any other known close relatives, in-laws or people with whom a current or recent close relationship could potentially compromise the interests of the project. Normal acquaintances with work colleagues can be excluded. Where other affiliations, outside the project team and supporting managers, are known within the firm, these should also be disclosed.
It's interesting to consider that (high) standard of management of CoI against the lists of perks & lurks for pollies being published by Fairfax. Ministerial decisions on e-health may be guided by the influence of "trusted" associates with proven records of networking capabilities.

Bernard Robertson-Dunn said...


Is the problem exchange of information or identification of, and access to, patient information?

They would appear to be two very different problems.

It all comes down to point of integration (POI).

The PCEHR is trying to be the POI, but it might be better if it is the provider's desktop or somewhere else in the provider's environment.

Grahame Grieve said...

"Is the problem exchange of information or identification of, and access to, patient information?"


It's all 3. Operating on a wider scale makes these harder to solve, but the benefits of solving them are greater.

"They would appear to be two very different problems."

3 very different problems. I happened to post some background material about identificationon my blog this week: http://www.healthintersections.com.au/?p=1084

"it might be better if it is the provider's desktop or somewhere else in the provider's environment."

Can we have both please? of course we need integration on the providers desktop and everywhere else. But we need more than that.

I suppose you'll say that we can't have both - but since it's been decided that we're going to have a pcEHR, lets' try and get the most out of it.

Dr David G More MB PhD said...

Grahame said:

"I suppose you'll say that we can't have both - but since it's been decided that we're going to have a pcEHR, lets' try and get the most out of it."

If ever there was an example of throwing good money after bad this is it. As far as I know not a single e-Health expert was involved in the initial conceptual design of the PCEHR. It is a political creature born of ignorance of reality and practicality.

Getting the most out of it is a 'blood out of a stone' task. Painful and ultimately futile.


Cris Kerr said...

PART 1 of 3

Hi Bernard, yes ' ... For patients operating in a silo (which might mean in a local community) with a local doctor (who can integrate information from multiple sources in his/her head), silos and isolated systems may be perfectly acceptable. ... '

Beyond that, how effective is that silo in terms of;

(A) earliest identification of risks associated with adverse health outcomes, and;

(B) earliest identification of opportunities to improve health outcomes?


(A) Earliest identification of risks associated with adverse health outcomes

Let's say a local doctor begins prescribing Thalidomide for morning sickness.

Let's also say that at any point in time, his patient population of expectant mothers averages 5, at varying stages of pregnancy.

7 months after he begins prescribing, a child is delivered with an adverse health outcome, then 6 months later another.

Let's say he has 20 years clinical experience.

He is credentialed and well-equipped professionally to question this local anomaly.

He writes a letter to the manufacturer that produces the product, to alert them.

Here was a single concerned doctor who wrote a single letter directly to the company that stood most to lose from its content.

That letter did not create a single blip on any nation's public health radar.

At the time he wrote the letter, he was not the only prescribing doctor.

Doctors throughout the world were prescribing thalidomide for expectant mothers, with similar adverse outcomes.

A clear tragedy for the families.

A clear tragedy for their communities.

A clear tragedy for the nation.


(B) Earliest identification of opportunities to improve health outcomes

In the 1980s in NY, Dr Bernard Bihari headed a clinic treating drug addiction. His was concerned his HIV/AIDS drug addicted patients were having poorer outcomes on the standard treatment regimen, and so did some research.

He came across Dr Ian Zagon's (Pennsylvania State University) research, using low doses of naltrexone in mice with cancer.

Further research led him to prescribe low doses of naltrexone (LDN) for his HIV/AIDS patient population.

He also theorised that if LDN was taken just before bed, the short-term (approx 4 hr) blockade of opioid receptors would lift at the most opportune time, i.e.; would take advantage of the circadian rhythm, at the point in the cycle when beta endorphins (key immune system hormones/regulators) were normally produced, in the early hours of the morning.

He measured endorphin increases in his patient population between 200% and 300%, and his HIV/AIDS patients' health began to improve.

Following the success of this new treatment protocol, he also prescribed it for cancer and multiple sclerosis, and today; people across the world are taking it successfully for these and many other diseases linked by immune system dysfunction.

It is not a gold bullet. It is a subtle treatment where nothing happens overnight, but tens of thousands of patients are choosing this treatment because it's working better for them long-term than anything else they've tried... this obscure treatment option you've probably never heard of... until now.

Dr Bihari presented his findings at conferences, but not surprisingly, there was little interest in this promising new treatment regimen.

It was out of patent, cheap as chips, and would have competed with hundreds of other highly lucrative medications.

(If your curiosity is piqued, you can read more about LDN in my submission to the current Strategic Review of National Health & Medical Research here: http://mckeonreview.org.au/sub/296_Cris_Kerr_Case_Health.pdf NB There's even research on topically applied naltrexone restoring corneal reepithelialization in diabetic rats.)

Cris Kerr said...

PART 2 of 3

How I learned of Dr Bihari's LDN treatment regimen…

Through a community health service website I launched in 2001 to collect and share patient health success stories, with a view to proving the value of patient testimony to improving health outcomes.

The first LDN story was lodged in 2003. It was followed soon after by another, and another, and soon became the central focus of my research as it provided the single best opportunity for me to try to prove the value of patient testimony.

Yes, of course I wrote to 'authorities'... but inextricably found... there is no single authority responsible for investigating the potential of this or any other promising treatment, regardless of its public health potential, and specialist non-profit disease societies were more interested in discrediting than investigating.

Australia has a market-based health system, and the govt relies heavily on the market to respond to 'opportunities' such as this.

But the market only responds to 'opportunities to profit' not 'opportunities to improve public health'.

I'm quite certain there are many out there right now looking into how LDN works, so that they can improve upon it or 'discover' a 'patentable' path forward. (In fact, there was a recent news item about a 'discovery' based on another old drug, naloxone, and its potential for pain relief. Naloxone and naltrexone are very similar drugs.

A 'patentable, potentially profitable' path forward is always needed to justify the heavy dollar investment in years of double-blinded clinical trials in a market-based public health system.

Profit, or the prestige of discovery (maybe even a Nobel Prize) is the prime incentive.

Dr Bihari's patients began to benefit from this treatment over 20 years ago.

He alerted others to this treatment, yet here we are in 2012 and exactly the same environment exists, where nothing happens until there's a dollar attached to it.

In the interim, those who might also benefit from what's been working for others won't hear about it... even though it's old, cheap, has a 20+ year safety profile and is readily available.

Cris Kerr said...

PART 3 of 3

Do we have an equitable and fair system, based on equal human rights for all?

In the USA, patients and their health insurers are responsible for all their healthcare costs, where patients sometimes having to mortgage their homes to pay their healthcare bills.

But as any good economist would know, there are direct costs and indirect costs, the tangible and intangible:

In Australia, the health of the nation (public health) can be associated with a minefield of collectively substantial indirect costs; medicare rebates, subsidized drugs, disability pensions, carer pensions, aged care, public hospitals, subsidized private health insurance, drops in national productivity, misdirected health and medical research priorities and funding, overseas aid, etc, etc.

Line up the dominos one by one and the cost would bowl you over.

The long-term govt trend is to divest responsibility to lower costs... tolled highways instead of state highways... privatisation of electricity supply... everything is in the line of fire when govts want to save.
But should responsibility for public health be divested in the market.

Our own govt, and others around the world need to pause and reflect on their values, and hopefully, recognize their nations are best equipped to econonomically prosper when their population's health is optimized, not privatised.

At best, it is naive to consider divesting increasing degrees of public health responsibility to the private sector.

At worst, they are responding to lobbyists’ interests where clear conflicts exist.

Governments around the world could be/should be creating trusted, stable public health frameworks, not dismantling them.

We need to take full advantage of all the opportunities this age of technology is offering... in the public's best long-term interest and in the nation's best long-term interest.

If patients experiencing improved health after beginning LDN at doses of 1-4.5mg could self-report their health outcomes in their own PCEHR, and that was combined with information uploaded by their treating doctors, would we need to wait another 20+ years for a commercial enterprise to do double-blinded clinical trials to prove the efficacy and safety of this treatment?

Or could we collect sufficient data to justify doctors prescribing this old drug with a good safety profile, in doses 10 times less than the approved 50mg dose used in the treatment drug addiction?

Australia does need to 'pool' de-identified health information for 'secondary research use' within a robust, well-governed and transparent public health research framework that ensures the highest degree of data integrity, security and privacy within a tightly controlled environment free of all conflicts of interest.

One of the best ways to ensure data integrity and transparency is to match data from various evidence sources, which means welcoming evidence from the person at the centre of all healthcare activity, the patient.

We should encourage patients to contribute to the evidence pool, empower them with more control over their own health, and inspire them to help improve the health outcomes of all their fellow Australians.

And when all of Australia's talented scientists, researchers, and doctors are able to access the highest quality raw health data available anywhere in the world (data they can take to the bank)... to do what they do best... their research outcomes will be the most readily testable, credible, and reliable of all nations, and through the same data collection, the resulting public health outcomes/achievements will be measurable in both social and dollar value returns to our nation.

Then we, as a nation, could better appreciate and celebrate all their valuable contributions to improving the nation's public health and economic health outcomes, as well as helping us shore up the economic sustainability of that which was once hard won and now, is at increasing risk... our subsidized public health services.

Bernard Robertson-Dunn said...

To Grahame and Cris.

I don't disagree with anything about where you would like eHealth systems to get to. Apart from not being qualified to speak on these subjects, I'm not so much interested in what the end point is, but how the end point is to be reached.

The difficulty, as I see it. is in "the capacity to change".

Or as many a manager has said, don't try and boil the ocean.

Complex environments like the Australian community and the health systems that support it have a huge inertia.

IMHO implementing eHealth should be done incrementally and evolutionary, not by plonking some ill thought through IT system in the middle of the health environment and expecting enormous amounts of change to occur around it.

The PCEHR, because it is trying to invoke rapid change without its implementers having addressed many of the secondary problems it will create, is most likely going to have the opposite result. It will turn off many in the health industry and the wider community, away from the use of modern information systems.

It's not as though this sort of thing has never happened before. Read Edward Tenner's "Why Things Bite Back. Technology and the Revenge of Unintended Consequences" (1996)

Of course, one might always ask the question: Why did the developers of the National eHealth strategy not take this into account? Two words: Ignorance and Incompetence spring to mind.

Dr David G More MB PhD said...

Hi Bernard,

Go and have a close look at the National E-Health Strategy again. The authors saw the IEHR (a better approach than the PCEHR we now have) as a low priority and argued for gentle, progressive and incremental change, real private public partnership, better goverance, dismantling and reshaping of NEHTA and so on - recognising the huge inertia and change fatigue in the sector. All that was just plain ignored.


Bernard Robertson-Dunn said...


I wasn't referring to the Deloitte's document, I was referring to what is actually happening. Sorry for the lack of clarity.

The Deloitte's strategy raises many of the issues that are being discussed on this blog, including those in my post this morning.

However, there is no mention at all in the Deloitte's document about a personally controlled eHealth record.

There is a statement that eHealth will:

Provide consumers with electronic access to the information needed to better manage and control their personal health outcomes.

Better controlling one's personal health outcomes (I assume only if one chooses to and is able to) is a good thing, however, it is not the same as controlling an eHealth record.

The only place Deloitte mentions controlling access is in the consumer vision section:

Consumers will be able to control access to personal health information

As you said, the Deloitte's document has been largely ignored. Someone seems to have cherry picked one sentence out of the strategy and built a whole policy position out of it.

One might wonder, why have a document called "National E-Health Strategy" if it is then ignored? Oh, yes, I remember, it is so that they can get a tick the box labelled Strategy.

Dr David G More MB PhD said...

"As you said, the Deloitte's document has been largely ignored. Someone seems to have cherry picked one sentence out of the strategy and built a whole policy position out of it.

One might wonder, why have a document called "National E-Health Strategy" if it is then ignored? Oh, yes, I remember, it is so that they can get a tick the box labelled Strategy."

Exactly, ignored and not funded. A good part of the reason for the present mess IMVHO.


Sam Heard said...

In the NT there are 50,000 people registered and many have major illness and comorbidities. The problem is careplanning that takes comorbidity into account and merging of practice, prescribing recommendations etc. Non-medical health professionals take a bigger role.

The chosen solution has been a sophisticated decision support approach (Arrezzo from InferMed) as is used in New Zealand. The outcomes are yet to be seen but it does need a fully functional health record.

Streamlining guidelines, care plans, and workflow is difficult to get right all at once. The infrastructure should clearly support as much as possible going into the future.

The two approaches may merge in the future.