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"

or

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

Friday, April 12, 2019

The Community Are Not The Only Ones Amazed At The Slowness Of The Roll Out Of Real Time Prescription Monitoring.

This appeared last week:

What are they waiting for?

Why are some jurisdictions dragging their feet on real-time monitoring? asks Angelo Pricolo

As Victoria powers ahead with the Australia’s first automated Real-Time Prescription Monitoring (RTPM) system, the elephant in the room is “What are the other states and territories waiting for?”
The Guild president in the ACT, Simon Blacker, said last week that ACT doctors and pharmacists could now track patient use of some prescription medicines in real time. It comes after the ACT Government introduced real-time prescription monitoring legislation last year, which was one of the recommendations from a 2016 coronial inquiry into the drug overdose death of a 21-year-old Canberra man.
But why is it taking so long in NSW and other states, when the SafeScript launch in Melbourne on Sunday saw the Health Minister announce that SafeScript is available to health practitioners across Victoria from the 1st April?
RTPM systems alone cannot fix the problem. It is widely accepted, however, that providing data about a patient’s monitored drug history in real time at the points of care enhance the clinical decision making by health practitioners. Whilst the technical solution is only one part of this complex puzzle, most health practitioners feel that having access to this information at the point of care is vital.
“RTPM systems are often proposed as part of the package needed to reduce overdose deaths due to prescribed drugs. But several evaluations of RTPM have been disappointing,” says Dr Alex Wodak president of the Australian Drug Law Reform Foundation based in Sydney.
“It is not clear that RTPMs reduce consumption of prescribed drugs, or reduce deaths from overdose of prescribed drugs or that unintended negative consequences of RTPMs are acceptable. However, a number of other effective ways of reducing drug overdose deaths are known.
“Drug supply reduction (like RTPM) often seems attractive but in practice is often disappointing whereas demand reduction and harm reduction are often far more effective, safer and more cost effective.”
According to the NSW Ministry of Health, “a timetable for implementation has not been developed and the costs to NSW to implement real-time prescription monitoring have not been determined.” In evidence tendered in these proceedings Judith Mackson, Chief Pharmacist and Director of the Chief Pharmacist Unit within NSW Ministry of Health, stated the NSW system was still in the design stage.
Ms Mackson stated that the NSW Ministry of Health was committed to waiting on the Commonwealth system rather than implementing a NSW “stand alone” system. When questioned about the Victorian Government’s implementation of the SafeScript system, she stated that in relation to NSW, she “[did not] believe that the timeframe would be any earlier if it was done on a state level as opposed to nationally”.
Pharmacy Guild Victorian president Anthony Tassone says that other jurisdictions need to act on their own systems.
“With the successful pilot of SafeScript in Western Victoria and now the state-wide rollout, there is really no excuse of any other state or territory who hasn’t implemented real time prescription monitoring,” Mr Tassone said.
“How many more people need to lose their lives to prescription medicine overdose? We have a tool that can help save lives, and the time is now for there to be a system in every state and territory across Australia.”
It was hoped “90% plus” of GPs would be on board by the time it became mandatory, according to AMA Victoria president Associate Professor Julian Rait.
Doctors can also check a patient’s prescription history for monitored medications through the SafeScript website, with one GP reporting it was “quick and revealing”, Professor Rait said. It would remain up to the GP to decide whether is was appropriate to go ahead with the prescription, he said.
“The only enforcement aspect of this ultimately might be just making sure people know about it … and don’t prescribe willy nilly without regard to what else people have prescribed, that’s the initial intention of the system.
“In the longer term, one would hope there would be more service for people who have been identified by this system to get alternative forms of pain relief and possible better pain management.”
RTPM will not stop overdose deaths, it will not stop illegal importation and cannot eliminate illicit drugs.
But as we are already seeing in Victoria, it is an opportunity to intervene when a patient history indicates that someone’s safety is at risk due to the hazardous use of high-risk prescription medicines. It can often lead to those measures Dr Wodak talks about: demand reduction and harm reduction.
More Victorians die from prescription medicine overdoses than from illicit drugs or the road toll. SafeScript, Victoria’s RTPM system, gives doctors and pharmacists real-time information about high-risk medicines taken by their patients. This will save lives.
More here:
Does anyone know what the specific blockers are that can be addressed?
David.

6 comments:

Anonymous said...

I do not see any unusual blockers here David. the arguments seem sound. If you priorities everything then through that action nothing is prioritised. Some of the Jurisdiction are involved in significant implementations at present and have a backlog of commitments. The Feds said they would implement one years ago, so why should states further increase risk to their existing commitments by diverting scant resources to this?

Bernard Robertson-Dunn said...

Many years ago, I worked on a project in the UK for the Royal Air Force. Someone had come up with an idea to take a passenger aircraft and use it to hunt down submarines. It was called the Nimrod and was initially a maritime patrol aircraft. It had sensor devices that could be dropped into the ocean to listen for the sound of an enemy submarine, and send the data back to the aircraft. See Wikipedia for details.

Sometime later, the Nimrod was equipped with torpedoes for an antisubmarine warfare role. In the late 1970s the RAF decided to upgrade the systems (the MR2 version)

My job was to model the behaviour of all the major components of the scenario (aircraft, sensors, torpedoes, submarines, ocean) and assess the behaviour of the system. How well would it work and what could be improved? Lots of advanced mathematical modelling, control theory, automation, mainframe computers and all that good engineering and technology stuff.

Essentially it was a proof of concept. The standard engineering plan was then adopted; once the proof of concept was accepted, there would be a pilot phase, a prototype phase, and a test phase all involving combinations of R&D laboratory and in flight environments.

Eventually, after lots of lessons had been learned and when everything was working as intended, the system was put into service. It works, has worked for well over thirty years and has been upgraded several times.

Compare this with RTPM and myhr. AFAIK, in both instances the governments have gone from idea straight to production. I may be wrong re RTPM but not re myhr - ADHA is running test-bed projects six years after the system was released and nobody understands exactly how it is going to deliver benefits that justify its costs. The original concept of reducing data fragmentation was never justified and has been abandoned anyway.

The article, above, finishes with “Victoria’s RTPM system, gives doctors and pharmacists real-time information about high-risk medicines taken by their patients. This will save lives.”

Oh yes? Can someone please explain exactly how this will happen? When and how the government has tested the idea? Were there pilot, prototype, test implementations? How many lives will be saved? Are there other ways of achieving this? Have they been tested? What are their relative costs/risks?

The military, for all its faults, rarely puts stupid ideas into service. They have huge research organisations (think DSTO) testing ideas and concepts, running pilot projects, working with industry to gain knowledge and learn from making mistakes. They don’t always get it right but the failures usually happen well before production, when things really matter.

What do governments do in the healthcare sector? Come up with half baked ideas about connectivity, interoperability, health records, Health IT and Digital Health. Then put them into production. In the case of myhr, fail to fully deliver the idea, hope nobody notices it and paper over the cracks with marketing.

As Andrew has pointed out, it’s a way of thinking.

One might almost think that the government is more interested in killing people than improving their health. But that would be unfair. I shouldn’t even have suggested it.

But what I will suggest is that someone should get round to looking at the real problems facing healthcare and clinical medicine and do some research into how to fix them, not blindly throw technology solutions at hard working doctors and hope something works.

Here's a suggestion. Doctors don't want more data, they don't want to spend significant consulting time putting data into their computers, they want access to better data, better managed and help interpreting it.

Bernard Robertson-Dunn said...

Based on this, it looks as though, whatever approach they try, they can't get it right.

Nadia: the curious case of the digital missing person
https://www.themandarin.com.au/106473-nadia-the-curious-case-of-the-digital-missing-person/

Does this sound familiar:

"Shergold suggested it probably demonstrated a failure on many levels, including risk and project management, design, and understanding the needs of users."

Marie Johnson’s didn't agree. Her view was that 'this was an “an ignorant and uninformed perspective” and the project was actually a huge success that social services bureaucrats just didn’t understand.'

I have no idea if she is correct in her view, but she was the CTO on the Access Card project so she might have learned something from that debacle.

Whatever the reality, the project didn't complete and no benefits were delivered.

IMHO, the government is quite capable of running and incrementally maintaining/improving large scale IT systems (e,g, ATO, Welfare, Customs).

They run into trouble when they try to innovative - Australia Card, Human Service Access Card, Health Connect, Robo-Debt, myhr, Nadia.

Seems to be something to do with mindset.

Anonymous said...

hm, the Nimrod upgrades are considered a disaster in safety circles and how not to do it and maybe not the best example to use
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/229037/1025.pdf

https://www.engineersaustralia.org.au/event/2018/06/nimrod-review-systems-safety-case-study-review

Bernard Robertson-Dunn said...

I'd suggest that it is a very good example to use in the current context.

The title of the report "A Failure of Leadership, Culture And Priorities" rather says it all.

Chapter 18 summary point six:

"The importance of investigating and understanding the organisational causes of accidents cannot be overstated."

and paragraph 18.11

“[N]o matter how well equipment is designed, no matter how sensible regulations are, no matter how much humans excel in their individual or small team’s performance, they can never be better than the system that bounds them."

"The system that bounds them" means the organisation's management.

In the present context, it means that myhr cannot be better than the team that Tim and his chums have put together.

That is a lesson worth learning. Who do you suppose in ADHA or Health is capable of learning it?

Bernard Robertson-Dunn said...

Talking about aviation disasters...

Read up on the Boeing 737 Max 8 crashes.

Engineers made changes to the aircraft to put in bigger engines.

Boeing management wanted to charge extra for the use of redundant senors (which were on the plane anyway - all it takes is a software switch)

They also wanted to pretend the changes were minimal and so there was no need for proper training. This would have involved delays and extra cost.

When there were problems with the single sensor (which would have been detected if both were operational) and the plane behaved badly, pilots were not able to handle it (which they would have if they had been better trained)

Two planes crashed and hundreds of people were killed because of bad management decisions, mostly cost driven.

When you've finished reading about the 737 have a look at the Space Shuttles Challenger and Columbia disasters.

As the Nimrod review says "The lessons to be learned from the loss of Nimrod XV230 are profound and wide-ranging. Many of the lessons to be learned are not new"

A useful quote from Laurence J. Peter to bear in mind re myhr:

“Some problems are so complex that you have to be highly intelligent and well informed just to be undecided about them.”

The biggest worry about myhr and Australia's Digital Health initiatives is the certainty that some people have that they are doing "the right thing".