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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."

Sunday, January 31, 2021

The COVID19 Rollout Is Going To Be A Pretty Large Exercise With Lots Than Go Amiss.

A good summary of what will happen is found in this transcript.

Acting Chief Medical Officer, Professor Michael Kidd's interview on 4BC Breakfast on 26 January 2021

Read the transcript of Acting Chief Medical Officer, Professor Michael Kidd's interview on 4BC Breakfast on 26 January 2021 about coronavirus (COVID-19).

Date published: 28 January 2021

Media event date: 26 January 2021

Media type: Transcript

Audience: General public

NEIL BREEN:

I've got the Deputy Chief Medical Officer, Professor Michael Kidd, on the line to explain. Good morning to you, Professor.

MICHAEL KIDD:

Good morning, Neil.

NEIL BREEN:

It was an exciting day, wasn't it?

MICHAEL KIDD:

It was a very welcome announcement, absolutely.

NEIL BREEN:

The plan for the roll-out - okay, I look at the numbers and they're eye watering. You've got 80,000 a week to start with, okay we'll eventually get more; then the Government's talking about four million by April. How on earth are you going to get needles into the arms of four million in a short space of time?

MICHAEL KIDD:

Well, you're exactly right. This is the largest mass immunisation programme in our nation's history. But, there has been a lot of work happening over recent months to prepare the nation to get the vaccines out and administered as quickly as possible. Clearly, what we're aiming to do with those people in the initial priority group is to protect the people who are most at risk, and particularly those who are most at risk of serious disease and deaths related to COVID-19 which, of course, includes the residents of aged care facilities and disability care facilities around the country. But, there's been a lot of work happening between the Australian government and with the states and territories identifying the initial hubs around the country where the Pfizer vaccine will be sent to, and from those hubs, people will either be coming to those hubs to receive their vaccines or the vaccine in smaller amounts will be transported out in the special containers to the residential aged care and disability care facilities to provide coverage to the residents and the staff.

NEIL BREEN:

I've read that there were about six hubs in, I'm not sure if it was Queensland or Brisbane. You're talking about that sort of number?

MICHAEL KIDD:

Yes. So we're looking at between 30 and 50 hubs right across the country.

NEIL BREEN:

[Talks over] Okay.

MICHAEL KIDD:

Many of those hubs - and it will depend on the state or territory - but many of them will likely be based within major hospitals because, of course, the facilities are there and the staffing is there to allow the vaccination programmes to roll out very quickly and efficiently.

NEIL BREEN:

I'm talking to Australia's Deputy Chief Medical Officer, Professor Michael Kidd. Are you thinking GPS and nurses and trained people for the Pfizer vaccine?

MICHAEL KIDD:

Certainly GPS and nurses who are involved in either working in hospitals, in emergency departments, or those who are running the 150 general practice led respiratory clinics across the country - and many of those clinics are also running in Aboriginal Community Controlled Health Organisations across the country. So, those people who are at risk of coming in contact with people infected with COVID-19 are in that 1a category of frontline health care workers; along with the people working in our hospitals, in intensive care units, in COVID-19 wards.

NEIL BREEN:

So five million Pfizer jabs we have - is that two and a half million Australians? Or is that five million times two jabs?

MICHAEL KIDD:

Yes. So it'll actually be 10 million doses of the Pfizer [indistinct]…

NEIL BREEN:

[Talks over] Okay, so it's five million Australians?

MICHAEL KIDD:

… five million Australians. We don't know how quickly those 10 million doses will come into the country, they'll probably come into the country sequentially over the coming few months. But, we also have the AstraZeneca vaccine which has been going through the Therapeutic Goods Administration approval process at the moment. If and when that is approved, we will- we expect to receive doses of that vaccine coming into the country in early March - it's being produced offshore. But, we also will be producing that vaccine onshore in Australia through CSL. So, from the middle of March, we expect that we will be producing in Australia the AstraZeneca vaccine. And this overcomes one of the very serious problems which has faced many other countries which have been rolling out the vaccines under emergency provisions over the last few months where they haven't had surety of supply of the vaccine. It's very important that people get two doses of the vaccine to make sure that they get the sustained immunity, and that has to happen within a recommended timeframe. So, once AstraZeneca is approved and is being produced in Australia, then we will have that surety of supply.

NEIL BREEN:

Is AstraZeneca two jabs as well?

MICHAEL KIDD:

Absolutely.

NEIL BREEN:

Okay, it's two jabs as well. Now, most of us will get AstraZeneca. So, if I pose a hypothetical, I'll pose it about myself. So, I'm a 52-year-old male in good health - when do you think I'll be getting my vaccine? And where will I get it?

MICHAEL KIDD:

Okay, so it's a little too early to speculate exactly when you'll get your vaccine, Neil. You'll you be in group 2a. So there's about seven million people in phases 1a and 1b who are ahead. The vaccine will likely be administered either through a general practice in your local area. By the time we get to phase 2a, we may well also have accredited pharmacies which are involved in administering the vaccine, and we'll have continuation of state and territory vaccination centres. We're looking at a booking process - so people will be looking for when they get the vaccine - very important that people do make an appointment to get the vaccine, that they turn up on that time on that day to receive their vaccine.

NEIL BREEN:

[Talks over] So, you'll make a booking?

MICHAEL KIDD:

You'll be making bookings to get your vaccine, that's right.         

NEIL BREEN:

And then it'll be hooked to your Medicare card so they know you've got it?

MICHAEL KIDD:

We will be following everyone who gets their vaccine, every dose of the vaccine will be will be introduced onto the Australian immunisation register. It'll also be on your My Health record if you've got a My Health record, and that way people can make sure that they are then followed up to make sure they get the second dose within the right time frame.           

NEIL BREEN:

I've definitely got My Health record. That scare campaign over that was disgraceful.

MICHAEL KIDD:

[Talks over] Good on you, Neil.          

NEIL BREEN:

Hey, Professor Kidd. I've got Bob on the line from Murrumba Downs. He's got a really good question to ask you, and I think the wider public would be thinking the same thing. Bob, go ahead with your question.

CALLER BOB:

Good morning, mate. Hey listen, I was just wondering, with all the hoo-ha with the COVID vaccine…        

NEIL BREEN:

[Talks over] Yes.

CALLER BOB:

… what's happening with the standard annual flu vaccine?

NEIL BREEN:

So are you asking whether you need to get that as well as the COVID vaccine?

CALLER BOB:

Well, I'm assuming you have to. And I'm just wondering whether - because I get it every year and have done for over 40 years - but, is it okay to get them both together?

NEIL BREEN:

Well, I'll tell you who's got the answer for you is Professor Kidd. Did you hear that question, Professor Kidd?

MICHAEL KIDD:

I did. Thanks, Neil, and thank you, Bob. That's a fantastic question. So, the annual influenza vaccine programme will be rolling out as normal. We expect that to roll out in April, May and June in preparation for the risk of getting seasonal influenza during the winter months in Australia. The important thing about the flu vaccine and the COVID-19 vaccines is they cannot be administered at the same time. And the recommendation that has come through from the Australian Technical Advisory Group on Immunisation, which advises the Australian Government, is that you need at least 14 days between having the COVID-19 vaccine and getting the influenza vaccine. And the reason for that is that if people did get an adverse reaction to one or other vaccine, it's very important that we know whether that adverse reaction was related to either the COVID vaccine or the influenza vaccine. If we give the two vaccines at the same time, of course, we don't know which vaccine caused problems.

Having said that, we are not expecting a lot of adverse reactions from the COVID-19 vaccine. People may get a bit of a sore arm, as you often do after you've had an immunisation. Some people may feel a little bit tired or achy after the vaccine, which can occur with the flu vaccine as well. We have seen some very rare cases of people getting an allergic reaction to the COVID vaccine, and there are going to be recommendations that people who are susceptible to having severe allergic reactions not get the vaccine at this time. But, we're waiting for those specific details to come out from the Therapeutic Goods Administration over the next couple of days. But, thank you, Bob. That's a great question.                       

NEIL BREEN:

Okay, good stuff, Bob. Well, Deputy Chief Medical Officer, Professor Michael Kidd, you know, we're so well blessed for medicine in this country. I did my bowel cancer screening, okay?

MICHAEL KIDD:

[Talks over] Good on you.                 

NEIL BREEN:

You know, you- I get it in the mail, I've done it because I turned 52 - it was my second one. I put it in the mail last Thursday and I got my result text to me yesterday. We live in a fantastic country, we're looked after. Trust people like Professor Kidd, get the vaccine. Thanks, Professor Kidd.

MICHAEL KIDD:

Thank you so much, Neil, and thanks to all your listeners.   

Here is the link:

https://www.health.gov.au/news/acting-chief-medical-officer-professor-michael-kidds-interview-on-4bc-breakfast-on-26-january-2021

You would have to say this is a pretty optimistic view of how it will go.

A slightly more sceptical view is found here:

The inside loop on the secret squirrel govt COVID vaccination booking system (not)

January 28, 2021       Jeremy Knibbs

As they say in the navy, loose lips sink ships. But that’s the navy. This is a national health crisis. Why is the digital health industry almost completely in the dark on the government’s plans (or even actions) to provide the country with a centralised COVID vaccination booking system?

Can the Department of Health really build a centralised booking system for GP COVID vaccinations within the next three weeks – or has it already built one?

That’s what it promised us all in last week’s release of expression of interest for GPs wanting to partake in the rollout.

Not that anyone actually understands yet what the DoH actually mean by a centralised government booking system for GP COVID vaccinations, as so far the only official words we have on the subject are:

  • Participating GP clinics will receive “vaccine stock and access to a National Booking System”
  • Said “National Booking System” will integrate with the major GP patient booking systems.

Three weeks?

OK, that feels ridiculous given that we’ve asked every major tech vendor how busy they are providing specifications and working on integrations, and none so far has a clue what the government actually wants or is doing. Our market leading GP patient management system Best Practice appears not even to have been contacted yet by the DoH, or any contractor working for it. Some of the major booking engines have had a chat to the DoH but they remain in the dark as to what the DoH actually is thinking or wants.

Let’s give them six to eight weeks for a fighting chance and call things even here.

They still need to do a hell of a lot to make such an idea work.

I’ve contacted a few serious healthcare software tech heads and they all agreed that if you were doing all of this, probably six to eight months might be a better timeline.

It’s not like the DoH or the government has a stunning track record on building software that works, especially cloud based software, which such a system would surely need to be. Perhaps unfairly, all that comes to mind for me is Robodebt and the My Health Record.

One government related agency person has claimed that they “have seen” the system, which is intriguing. When asked what they’d seen this person said that they shouldn’t be talking about it. Apparently the whole thing is top secret.

But why would such an important piece of COVID infrastructure be so secretive?

Why would most of the major PMS and booking engine vendors be so out of the loop? Surely you wouldn’t rewrite an entire booking engine yourself and bypass well established and working infrastructure and marketing distribution channel to patients like this.

Conspiracy theories have started, one being that one of the major consulting firms is busy at work building it behind the scenes. Really? Without any due diligence or public scrutiny the DoH has handed a pivotal piece of COVID logistics over to an Accenture or PWC? That would be odd, even for the DoH.

The description so far of said booking system is so vague that you can’t guarantee that all of the following shopping list  would be part of the functionality. But if you were after a central booking system you’d probably want the following as a minimum:

  • Integration with all the major booking engines who already have patient access and marketing in their hands. All these systems have current and ongoing patient users, integrations to all the major PMS systems and robust working booking software.
  • Integration with the major PMS systems for direct access to the Australian Immunisation Register, for booking the second dose for continuity and logistics planning, access to the MHR and – well, it would just be good hygiene to have each patient in the normal base infrastructure for GPs, especially given it wouldn’t be that hard to do.
  • Something that takes GP COVID bookings and talks to a central government logistics group who is distributing the vaccine so they know how much each GP needs and when
  • Something that is able to send a patient who is booking a screening check and consent forms so screening is automated and a patient can pre-consent and get electronically signed up before they turn up to clog already busy GP surgeries, (Note: the government has chosen quite deliberately to pay GPs less for a COVID vaccination than the base A consult and insist all COVID vaccinations are bulk billed, so essentially, GPs can’t afford to do vaccinations anyway. Having to get consent on site would be ridiculous in terms of ROI for any GP.)
  • Clinical notes, which can talk not only to a GP patient management system when GPs are vaccinating, but of course, which hospitals can use, and which would be cloud based and be able to talk back to a local GP.

A couple of other things you’d think the DoH would consider. Obviously the booking engines are important and you could go to just one of them and use that for your central system. But surely you’d go to the top three (HotDoc, HealthEngine and Appointuit) and build an API to each one because if you did that you’d have near national booking coverage for all GPs immediately. But we aren’t aware that any of the major booking engines are working with the DoH yet.

Vastly more here:

https://wildhealth.net.au/the-inside-loop-on-the-secret-squirrel-govt-covid-vaccination-booking-system-not/

As you read through the transcript you come away with a sense of just how large this vaccination task is and when you browse the second it becomes clear just how complex the task of matching a patient, a vaccination site and clinician and a dose of such fragile vaccines is going to be!

Of course you have to lock in a second dose in a reasonable time and then create a record to follow up any adverse side effects and so on.

The more you think about it the more difficult and complex the whole thing feels.

In passing I will choose to ignore Professor Kidd enthusiastic endorsement of the #myHealthRecord. From within the DOH he can hardly do otherwise!

I note that the ADHA is meant to be helping with all this and has received so funding to do so.

This rollout will bear close watching! Anyone with some insider details of what is actually going down?

David.

 

50 comments:

Amanda Kelly said...

That all sounds very confused and open to risk of enormous consequence. Not sure I am comfortable with HealthEngine getting anywhere near all this with their track record.

Maybe the plan involves integrating with Telstra efforts on those national registries that seem to have faded from oversight?

Trevor3130 said...

From https://www.technologyreview.com/2021/01/30/1017086/cdc-44-million-vaccine-data-vams-problems/

Why was Deloitte awarded the project on a no-bid basis? The contracts claim the company was the only “responsible source” to build the tool.

Perish the thought that Aust Govt will hand out no-bid contracts.

Anonymous said...

If the "Digital Health IT" industry can't even build an administrative oriented booking/appointment system, what hope is there for real health care systems?

Anonymous said...

Reading a PulseIT posting today has me very concerned. We seem to be heading for a disaster on a number of fronts. I would like to believe someone has this under control but the responses from DoH do not provide comfort. Comments made on the PulseIT blog paint a troubling landscape.

Is this only me? And why is the general press not looking at it?

Anonymous said...

Excellent summary of the 'State-of-Play" in Pulse-IT. It's enough to give me complete confidence one thing alone will reign supreme - complete confusion!

Confusion reigns over national booking solution for vaccine roll-out
Written by Kate McDonald on 02 February 2021.

The Australian government is not going to build a new national booking system to support the COVID-19 vaccination roll-out, instead relying on a mixture of existing online booking systems, Healthdirect’s National Health Services Directory and direct appointments with regular GPs and pharmacies.

Confusion has reigned over what the government has been calling a national booking solution, which it was promising to provide to general practices and pharmacies putting up their hands to take part in Phase 1b and 2 of the roll-out, which will see the AstraZeneca vaccine provided to priority groups and then the bulk of Australia’s adult population.

Peter Padd said...

Ironically the ADHA announces its revolutionary, once in a generation human imperative strategy on ‘groundhog day’

The agency is also shortly to name the successful tenderer for the new API gateway that will provide a single point of access to its digital health systems and services, including the My Health Record, and hopes that the statewide secure messaging system that South Australia is building with HealthLink will see FHIR-based secure messaging interoperability in action this year.

ADHA CEO Amanda Cattermole said the API gateway replacement was a significant body of work that will form the first piece of the national infrastructure modernisation (NIM) program.

Anonymous said...

ADHAs API gateway replacement ??????????

Anonymous said...

Bizarre. Gateway to a mish-mash of digital health data called My Health Record. The underlying rationale has to be that the Record must be 'good' else why build a 'better' API into the Record?

Bernard Robertson-Dunn said...

Looking at the pretty architecture pictures they have released, they appear to be building an ecosystem that sidelines MyHR and creates a channel that can suck data out of other health care systems straight into Federal Government databases. It is not clear how, or even if, the supposed MyHR legal safe-guards would apply.

Anonymous said...

@9:37 AM Exactly. A 'new' API will do nothing to make the 'Record' any 'better'.

The Record needs to be redesigned again from scratch. That includes structure, architecture, navigation, user-interface, including past and current data relevance and data and file inter-dependencies.

While this is not a difficult concept for me and some of my enlightened experienced colleagues to embrace it is for the ADHA, for politicians and bureaucrats. Their minds are fixated on what is and old ways of thinking rather than on what might be when underpinned by new ways of thinking.

Andrew McIntyre said...

Never fear, they can solve the semantic problems using some new innovations! eg Trying to line up different biochemistry tests by name in MyHR was proving difficult so they managed to come up with the brilliant solution of calling all biochemistry "General Biochem" - problem solved! I was proposing using the snomed hierarchy to allow composition of tests using the Snomed-CT codes, while giving the labs the ability to name them any way they liked, but no, that was to hard as had to use the text description only. Silly me, I didn't think of just naming all the biochemistry tests the same. Perhaps we could name all clinical testing "Test" then everything would line up perfectly. These people are setting health IT back decades.

Anonymous said...

"The Record needs to be redesigned again from scratch."

How about someone does some deep thinking about the value of a health record and the costs of data management?

All the evidence of the past 10 years strongly suggest that the value is minimal and the costs enormous.

Governments only insist on the use of scientific evidence when it suites their agenda.

Anonymous said...

Adding to my 10:59AM comment I believe that "If well-designed the value will not be minima and if well-designed the cost need not be huge.

Anonymous said...

@6:14 PM. I am of the same view as you. Your 10:59 AM comment resonates strongly with me too. I have access to some seed funding (up to $5M) which should be sufficient to get the ball rolling with a small cohort of the right people. I would like to meet privately with you for a preliminary discussion to explore how closely aligned are our ideas and approach to establishing the core project foundations.

Anonymous said...

More information is coming to light on the logistical rollout of vaccines. There seems clear lines of separation for states and feds. All looks reasonable until you hit to last leg. I do hope the front line healthcare services can cope, and that normal GP and pharmacy services continue with minimal disruption.

Anonymous said...

@10:59 AM "The Record needs to be redesigned again from scratch. That includes structure, architecture, navigation, user-interface, including past and current data relevance and data and file inter-dependencies."

You should also include:
- Security and Authentication Levels,
- Grouping, Classification and Specification of Application Program Interfaces (? number & type),
- Clinician and Data Workflow Modelling (Tools).

What Modelling Tools would be most appropriate? (Flexibility and maturity are essential prerequisites).

Dr David G More MB PhD said...

Before any of the above we need to work out what use-case the #myHR is actually addressing, if it is actually needed, and just how worthwhile addressing that use-case would be!

To me unless we properly understand what the #myHR is actually for and if it is actually worthwhile we will just be spinning our wheels!

Just claiming a national, partial and incomplete, out-of-date EHR is fundamentally good and needed does not cut the mustard!

David.

Anonymous said...

@1:02 PM Exactly. So:
1. What is the MYHR for?
2. What is it intended to achieve?
3. Is it needed, and if so why is it needed?
4. Who needs it?

All good questions. I thought the RACGP, the AMA, the Health Department, the CHF, the MSIA, the PGA, NeHTA and the ADHA had all answered these fundamental and most basic of questions a long time ago.

Am I wrong?
Were the answers they provided wrong?
How can that be so? They had lots and lots of experts to help them formulate their answers!

Bernard Robertson-Dunn said...

@1:26PM
re
1. What is the MYHR for?
2. What is it intended to achieve?
3. Is it needed, and if so why is it needed?
4. Who needs it?

1 and 2 are answered in the legislation and in the recent Audit Office report.

MyHR is intended to reduce data fragmentation. It was supposed to connect existing health databases (repositories) and facilitate access to them. Because NEHTA couldn't solve the interoperability problem it has become a centralised database containing a mishmash of uploaded, low value MBS/PBS, test and summary data with little to no history. In short, it hasn't delivered.

re 3 and 4 - those questioned have never been answered. The closest are claims that reduced data fragmentation would be a "good thing", allow patient's to be in better control their healthcare and save billions of dollars.

The access controls built into MyHR show that the patient is in control, which means that there is a a degree of uncertainty in the data (has the patient not facilitated data upload and/or deleted any data)

The current push for an ecosystem is, in effect, another attempt to deliver the answers to questions 1 and 2, without answering questions 3 and 4.

The government is in a bit of a bind. If they start from scratch and ask/answer the four questions, it will become obvious just how much of a failure MyHR actually is.

This would prompt two further questions: 1: Why did it fail. 2: Why was it not fixed/abandoned years ago?

Anonymous said...

So, the conclusion to David's 'comment' is that the MHR is not needed and never has been needed! Oh! But the $2 billion which has been spent surely is needed.

Anonymous said...

Why did it fail, you ask. Because it wasn't needed? Because it wasn't fixing any problem(s)? Oh, as for fragmentation of the health system - who says fragmentation is a problem? Why is it? Does "fragmentation" justify building the MHR?

Bernard Robertson-Dunn said...

"fragmentation of the health system" is not the same as "fragmentation of data"

The first is a valid criticism. The healthcare system is not "patient friendly" with patients bouncing from speciality to speciality, hence the cry for a "patient centric" system.

However, reducing data fragmentation will not fix a non-patient centric system.

Anonymous said...

@5:31PM You make an excellent distinction Bernard. It helps to explain why the ADHA is prevailing over such a shambolic mess.

Anonymous said...

Just put your faith in digital and QADHA.

Bernard Robertson-Dunn said...

IMHO, The Dept of Health, NEHTA and ADHA have done nothing to improve the healthcare system, as experienced by patients.

The Department is concerned only with cost. NEHTA and ADHA think that more data is better.

MyHR is a data dump with no functionality related to the content of all the documents it holds.

For example, as a patient, I can't ask MyHR to search for all the data relevant to a particular disease or symptom. AFAIK, a GP or other health professional can't do a similar search on a patient's MyHR.

The MyHR knows nothing about the data it holds other than the patient to whom they refer.

As we have been saying for years, MyHR is a document management system, and not a very good one either.

Healthcare is all about decision making. Until data is understood, managed and utilised in the context of clinical decision making, an electronic record keeping system will have limited use and could impose unacceptable costs and risks.

Gary Carter said...

AnonymousFebruary 06, 2021 10:00 AM

At first I questioned your use of Q but on reflection.

If you dare question you are part of a conspiracy.
There is a belief that along with their own opinion they are allowed their own facts
Although no use of secret alien bases or lasers, they are on another planet and make cliams regard usefulness during fire season
My Pillow - My Health Record? Coincidence?? I will leave that for the internet to decide

Anonymous said...

@1:15PM You said "UNTIL data is understood, managed and utilised in the context of clinical decision making .... " .....

?UNTIL?,??

Is there nowhere that can demonstrate this has been done? Nowhere? America?, UK?, Canada?, Australia?. Nowhere?

Anonymous said...

@2:38 PM There is not much hope if there are no systems working which convincingly demonstrate how data is effectively being 'used' (Bernard @1:15 PM) in the context of clinical decision making which addresses data fragmentation issues and which reflects that the data is being "managed, understood and utilised" appropriately.

While these concepts are subtle and complex I find it impossible to believe that such integrated clinical decision-making systems do not exist. Surely the big vendors like EPIC and Cerner would claim otherwise and that Bernard is being somewhat blinkered and a tad out-of-touch.

Bernard Robertson-Dunn said...

@2:38 yes ?UNTIL?,??

I have never found anything that even claims to how to understand, manage and utilise health data.

I have found plenty on:

Health/Medical record keeping,

Clinical Decision Making Systems, which are mainly alert systems which many health professionals hate because they just beep mindlessly

Various research papers and books that discuss how doctors think and reason.

This is a good starting place:

National Academies of Sciences, Engineering, and Medicine 2015.
Improving Diagnosis in Health Care.
Washington, DC: The National Academies Press.
https://doi.org/10.17226/21794.

You can get a copy here:
https://www.beckershospitalreview.com/docs/iomdiagnosticerrors.pdf

It covers all three topics above but the terms "data management", "data architecture" and "data organization" are absent.

"Information acquisition, information integration and interpretation" are mentioned but primarily as tasks performed by clinicians.

In Table 3-3 the report specifically states, under "Contribution to Diagnostic
Errors"

Technology
"Lack of support for stages/steps of diagnostic process: information gathering, information integration, information interpretation"

IMHO, if you are going to design a system that is to be automated, you need to understand processes, data and their relationships in the conceptual, logical and physical contexts. It's called enterprise architecture.

Bernard Robertson-Dunn said...

@5:13, I'm only quoting reports like this:

Alert Fatigue
https://psnet.ahrq.gov/primer/alert-fatigue

Effect of alert fatigue on patient safety

Much of the literature on alert fatigue derives from studies of CPOE and clinical decision support systems, in which alerts are provided to warn of potentially harmful drug–drug interactions or incorrect medication doses. These studies consistently show three main findings:

* Alerts are only modestly effective at best. A systematic review of computerized reminders found only minor improvements in targeted processes of care, and, while CPOE systems have been shown to markedly decrease prescribing errors, this can largely be ascribed to their ability to standardize drug doses, provide decision support, and eliminate errors from poor handwriting or incorrect transcriptions.

* Alert fatigue is common. Clinicians generally override the vast majority of CPOE warnings, even "critical" alerts that warn of potentially severe harm. There is less literature on other types of warnings, but it is likely that rates of overriding or ignoring warnings in other settings are also high.

* Alert fatigue increases with growing exposure to alerts and heavier use of CPOE systems. This finding is intuitive, but also raises the important implication that without system redesign, the safety consequences of alert fatigue will likely become more serious over time.

Andrew McIntyre said...

Medical-Objects has had a R&D interest in decision support for over a decade, and we have corrected the international GELLO standard for its second release and done a lot of work with GLIF (Guideline Interchange Format). We have implementations of both, but you need reliable data to really do useful things and need properly coded atomic data, ideally that can be exchanged in referrals. There is a vMR (Virtual Medical Record) specification in the current Australian HL7 V2 standard.

However the complete lack of focus on compliant well coded messages for both pathology and clinical data. Its this level of compliance that the various national eHealth Authorities should have been focusing on, as if you have good quality data you can build useful things on top of it. If you don't have it doing decision support becomes unreliable.

The recent ADHA focus has been on pdf reports of a very narrow scope which is useless for decision support, it requires a human to read it. After 20 years of trying to get "value" from eHealth the ADHA have discovered and reverted what is in reality PIT with fonts and pictures. It might please some people, as its prettier, but its the equivalent of a 1963 VW beetle with a Ferrari fiberglass body fitted... It sort of looks good, but performs exactly the same as a 1963 beetle. If find it hard to support, and I am not even sure the ADHA understand what they are doing.

Anonymous said...

@5:35PM ".... enterprise architecture."

That's been around for a long time! It's not rocket science! So what has gone wrong?

Highly paid consultants, leading global consulting firms, numerous well-funded multi-million dollar projects across the globe - surely they have had plenty of access to top Enterprise Architects!

All of which leads me to again ask - So what has gone wrong Bernard?

Anonymous said...

@2:13PM and 5:35PM As you both say "There is not much hope".

I think this means it's too hard, too political and too costly to address. And with no viable sustainable business model it is reasonable to conclude "There is not much hope".

Bernard Robertson-Dunn said...

@9:52PM

My understanding is that a lot of the early architecture/design work was done either wit or by a consulting organisation.

NEHTA then took it over and made a dogs breakfast of it all.

There are tw key documents, the Concept of Operations (which no longer exists on ADHA's site, but is freely available if you look for it) and the High Level System Architecture.

There is a diagram in the architecture document that shows the order of deliverables.

The order includes:
1 Concept of Operations
2. High Level Design
3. High Level System Architecture.

When I was at IBM I was a certified architect which is recognised by the Open Group as equivalent to their Open Certified Architect (This is not TOGAF certification, which only means you know the table of contents, not how to be an architect) so I claim to know something about what I'm talking about.

What NEHTA produced was not recognisable as accepted architecture deliverables, especially their definitions of conceptual, logical and physical architectures. I've banged on about this often enough and believe I got up the noses of the consultant.

At the ime my criticisms were not aimed at the consultants, in fact I was not aware at who authored the documents. It turns out that the NEHTA people who took over the design and architecture work, along with the odd project manager or two, were responsible for the deliverables.

To answer the question "So what has gone wrong?" my response is that the Federal Government has over the years hollowed out its expertise in Information System development. A large part of which was the abortive attempt to do whole of government outsourcing.

When at IBM, I worked on the bid for the Health group, which we won. The whole project got into a real mess and there was a clear-out of staff on both sides, which is when I took over the role of project architect. At that time all Health's IT workers had been transferred to IBM, or had left. That's when I saw at first hand their information system problem solving capabilities.

IMHO, Health has never recovered from that experience. When Health took back its IT (they still outsource parts) they had no Information Systems Development resources and their corporate memory was non-existent. The whole of government outsourcing only impacted their internal IT systems, but it had a flow-on effect.

Health has partially recovered from the outsourcing debacle but are (IMHO) left with the wrong sort of people to manage any sort of national development initiative. Their natural inclination is to keep outsourcing such projects but they 1) can't define what they want to the level necessary and 2) can't manage those who can help.

To get back to "So what has gone wrong?" the simple answer is: simplistic management fads and a failure to appreciate that if you want to understand what you are doing takes a lot of expertise and knowledge that the government threw away years ago.

And the people left don't understand that and so they can't fix the problem, but think can.

Anonymous said...

Thank you for your most informative comprehensive response to the question "So what has gone wrong?"

I have been close enough to the history and 'documents' published since NeHTA was established to both understand everything you have said and to agree with you. I could never have summarised the 'answer' as well as you. Well done and thanks again.

Notwithstanding all that, I am still struggling with 10:48 AMs comment.

So many people have so many views. Nothing gains much traction.

The waves keep rolling in, crashing on the beach, the froth and bubble dissipates, turbulence subsides, the waters recede, and the waves roll in once more.

Dr David G More MB PhD said...

All,

I would argue that "what went wrong" was that no-one thought to ask clinicians what they needed and wanted from a shared EHR. Without that information being totally clear and fact based a useful system was never going to be developed. Similarly no one asked patients what they needed or wanted properly.

Put simply you can't develop a system whose purpose is unclear, its target user not defined, and the need for it unproven. What was developed was never going to deliver the utility, timeliness or usability needed!

The other key flaw was trying to develop a system that was at once useful for clinicians AND for patients. I don't believe that is possible. Fish and fowl are two different things!

David.

Anonymous said...

@1:29 PM Which confirms the view: "There is not much hope".

Bernard Robertson-Dunn said...

David
re "I would argue that "what went wrong" was that no-one thought to ask clinicians what they needed and wanted from a shared EHR."

I totally agree. I was explaining why "no-one thought to ask clinicians". The people in NEHTA were naive and arrogant. They thought they knew the answers and didn't have to involve others.

There's one very good principle they try and teach at IBM - as an enterprise architect you know next to nothing about the problem - the people who need the system know everything. As an architect you are a facilitator, not a decision maker. You help people better understand their problems and the solution options. They can then make well informed decisions.

If you listen to what people like Tim Kelsey say, they want to lead the way, not help other people solve their problems.

Have a look at
https://www.digitalhealth.gov.au/

Asking the Big Questions:
What is an electronic prescription?
What are the benefits of telehealth?
What is My Health Record?
Why keep important health information in one place
What is digital health
How can technology improve my health?

Are these really the big questions being asked about healthcare?

How about "when can I get vaccinated?" "what are the side effects?" "I'm immunocompromised. What should I do?"

That last one in the list "How can technology improve my health?" is instructive; the answer is "Technology can help you get the healthcare you need, on your terms. For example, you can chat to a doctor over the phone with a telehealth consultation. You can get a prescription sent as an SMS or email. And you can store your vital health information online for access anywhere, any time."

Pick a typical complaint: endometriosis. This is famous for being hard to diagnose and it is common for doctors to blame women for complaining about their symptoms. Whole books have been written about it.

What does ADHA's facile answer to "How can technology improve my health?" do to help women suffering from endometriosis? Or any other common complaint?

ADHA is living in a world of its own. It's a bit like celebrities who are famous for being famous. ADHA exists because it exists.

Grahame Grieve said...

> no-one thought to ask clinicians what they needed

But, in fact, they did ask, at length. Because that's obviously something you should do. But in fact, asking the clinicians which was taken seriously failed deeply in several regards. So it's not going to work to simply ask. You have to ask the right questions, in the right language, and have the right discussion. What is necessary is to be nimble and responsive, which is not exactly the strength of a government department.

Dr David G More MB PhD said...

Grahame,

I would argue that they asked but just plain ignored what they heard and did what they thought was needed - not realising they did not understand what they were being told!

NEHTA set a high watermark for ignoring / dismissing feedback from public / expert consultation. So far the ADHA is not much better!

Typical Government I guess!

Anonymous said...

Mmm @1:46 PM Not much indeed.

Andrew said...

Bernard, did you get a soap box for Christmas? Your criticism lacks context or actual knowledge of the larger picture. Like most ‘architects’ you seem to live in a world that does not exist. IBM is not something I would boast about in the eHealth domain.

Anonymous said...

... unless or until someone can come up with a different approach which cannot be interfered with or undermined by politics and bureaucrats.

Anonymous said...

Andrew. What are you trying to say?

Bernard has a solid grounding in systems architecture and complex problem analysis.

Your 'claim' to have actual knowledge of the larger picture and able to put everything into correct 'context' is curious. Clearly, if you are an 'architect' you are not like all those 'other' architects to whom you refer. No doubt you have a track record of great successes in complex system design. That being so, if it is, we clearly need to hear more from you.

Andrew McIntyre said...

I am a little concerned about the "Enterprise" word as an enterprise architect can design a system that is run in a data center, on a high end server, with a dedicated admin and lots of dependencies, but often you are running on the receptionists basic computer with little security and no real admin to back it up. You can't even be sure it will get turned on every day, let alone 24/7 uptime. We spent a lot of time on automated setup and the ability to diagnose and monitor issues that occur in an unreliable environment.

This is why messaging works well, as it copes with downtime and failures, but problems occur when the message is badly formatted, or the message is perfect but the endpoint system is full of legacy spaghetti code where they are to scared to fix anything because it might break everything..

Really getting messages/acks working smoothly and ensuring systems produce compliant messages and can handle compliant messages reliably is the job that after 20 years has not been done, and until it is trying to built enterprise level systems on top of crappy messages is fraught with danger. ADHA appear to have given up and just want to get pdf messaging working, but that is a glorified fax system and will only deliver what a good quality fax system could deliver. I have no faith government will ever make rational decisions, so the less they try and do the better! What we do need however is a requirement to sell reliable, compliant software that has proven, tested compliance with standards. Government appears to listen the howls of protest from vendors, but when patients safety is at risk they should just say "If you do not have proven compliance in March 2022 you cannot send or receive messages, full stop" If you can produce compliant software then who knows what errors/omissions/failures are happening now? I know its a significant amount, I see incorrect messages every day, even from pathology systems, which are the best of the bunch!

Long Live T.38 said...

AnonymousFebruary 07, 2021 5:15 PM - you probably answered your own question to Andrew. You are referencing a computer system. Just a drop in the ocean in a system of systems. Many decision are not architecture decisions. Their are many viewpoints and many agendas.

Anonymous said...

@6:58 PM I don't see any reference to a computer system. Rather I see reference to complex systems, which includes so many things including system workflows, data interelationships and interdependencies, organisational structures, cultures and records.

Bernard Robertson-Dunn said...

@4:55 PM

Be careful pigeonholing people. FYI, I am looking at healthcare from the perspective of someone with a PhD in computer modelling of the human small intestine and over 50 years experience modelling complex dynamic systems. Just because I have worked as an architect at IBM does not mean I have a narrow view of systems.

When it comes to the "larger picture" I start with the practice of clinical medicine. So far I have seen very little connection between health IT and the problems faced by clinicians. Andrew McIntyre is one of the few people I have come across who understands the practice of medicine and the challenges of applying technology to its problems.

I don't think Andrew and I are too far apart in our criticisms of current Health IT. We come from different perspectives (although we both seem to have more than a passing interest in neuro-gastroenterology) but I think we agree on our assessment of the larger picture.

Why don't you share with us your credentials?

Anonymous said...

Andrew sounds more like a Senior Management Consultant. Perhaps he consulted to NeHTA and the ADHA in years past.

Beryl Stuart said...

AnonymousFebruary 08, 2021 4:39 PM - what's your beef with consultants, you seem to think they are lesser humans? Or are you going to tell me some of your friends are consultants?

I am sure some of you have very red sports cars and lovely ponytails.