A Good Vision for The Future Evolution of E-Health. I Like This Perspective!

The following came out a few days ago. It provides a solid rationale for the pursuit of sensible e-Health initiatives.

Thursday, September 1, 2011

The Rise of Electronic Medicine

Medicine today is a sea of paper and fax machines, privacy barriers, and unconnected data. The public is ready for a better system.

By John D. Halamka

Last November 9 at 2 a.m., I received a phone call from a hospital in Southern California. "Your mother needs an emergency operation," said the voice on the line. "Your father had chest pain while at her bedside and both are in ICUs. We have no idea what medications they take, what allergies they have, or what problems they have been treated for. Can you help?"

This is medicine today. A sea of paper and fax machines, information silos, privacy barriers, and unconnected data. And yet, we know the public is ready for a better system. According to a 2010 Harris Poll, four in five Americans believe any doctor treating them should have instant access to their medical record online.

Today, we are moving quickly in this direction. In 2009, President Obama signed the HITECH act, creating a $27 billion stimulus package to accelerate health-care information technology in the United States. The law pays doctors to adopt electronic records, and penalizes those who don't. Fueling the change are data standards that make it easier to share health information, maturing software, rapid innovation linked to mobile computing, and policies to protect patient privacy. As a consequence of this perfect storm of incentives and disincentives, the next five years will see an unprecedented acceleration of electronic medicine in the U.S.

Other countries are moving along a similar path. Some wealthy nations with socialized medicine are far ahead; in the Netherlands, 98 percent of primary care doctors already use electronic records. But most nations—including Japan and China—are just beginning to bring IT to bear on health care in a systematic way.

Will we solve the problem of runaway health costs? The health reimbursement system in the U.S. pays doctors and hospitals for how many treatments they provide, not how good that treatment is. In Massachusetts, for instance, I estimate that 15 percent of lab and radiology tests are redundant or unnecessary. Evidently, one man's redundancy is another man's country club membership.

An important aim of health-care reform is to change our broken incentive structure by instead paying doctors a yearly fee to keep patients healthy. For doctors to survive this reimbursement change, they will need to keep electronic health records, share data, apply telemedicine to monitor sick people at their homes, engage patients continuously, and integrate the latest treatment knowledge into their workflow. That's electronic medicine.

The transformation of the health-care industry to embrace the levels of automation typical of travel and financial services will not be easy. Health care has unique payment models, referral patterns, workforce expertise requirements, customer needs, and privacy regulations. For these reasons, the centerpiece of the HITECH Act is the concept of "Meaningful Use"—paying doctors and hospitals only after they have installed electronic records and shown that they are using them wisely as measured by specific goals. Starting this year, your doctor will need to keep a computerized list of your medications, problems, and allergies. By 2013, your doctor will need to be able to share these data among all your caregivers (with your permission). And by 2015, the hope is that the combination of electronic health records, data sharing, and novel technologies will enable your primary-care doctor to recommend best treatments based on the experience of tens of thousands of similar patients.

Here's my prediction for the major developments in the next five years:

·         Electronic Health Records in the Cloud

·         Modular Software Unleashes Innovation

·         A Network of Networks

·         Engaged, Connected, E-Patients

·         Genomes Lead to Information Prescriptions

John D. Halamka, M.D., M.S., is a professor of medicine at Harvard Medical School, chief information officer of Beth Israel Deaconess Medical Center, chairman of the New England Healthcare Exchange Network, and co-chair of the national HIT Standards Committee.

Copyright Technology Review 2011.

The full text under each of the bullets is found here:

http://www.technologyreview.com/business/38473/?nlid=nldly&nld=2011-09-01

It will be interesting to see how prescient these are - but I suspect most will become realities over the next decade. We are already seeing the first two points starting to be seriously considered.

It would be really good if we had a ‘meaningful use’ style of approach - with the associated incentives to really ramp up e-Health involvement in Australia - and of course we need to automate the providers first before working on the consumers!

David.

The Importance Of Evidence In Providing Quality Clinical Care. Getting This Right Can Possibly Make More Difference Than the Proposed PCEHR.

This appeared a few days ago and is really germane to the current PCEHR discussion.

Clinical Decision Support Closes Medical Evidence Gap

Best practice data is available for most healthcare decisions, but health IT teams are doing a lousy job of getting it to doctors, says Ascension Health informatics chief.

By Neil Versel,  InformationWeek

September 08, 2011

If Meaningful Use of electronic health records is ever going to fulfill its promise of better care at lower cost, clinical decision support (CDS) systems had better play a central role delivering relevant medical evidence to the point of care, according to one veteran informatics physician and patient safety advocate.

"The evidence of best treatment, if not the right treatment, is available probably 85% of the time," Dr. Jeffrey Rose, VP of clinical excellence and informatics at St. Louis-based Ascension Health, tells InformationWeek Healthcare. Unfortunately, information is not often readily accessible.

This opinion runs counter to a widely cited statement by Kaiser Permanente's Dr. David Eddy that just 15% of medical treatment is supported by scientific evidence. "That's old and wrong," according to Rose, a former chief medical officer of EHR vendor Cerner. "When you do further studies, information is available, it's just not in the clinical environment."

It's also been widely cited that it takes 17 years for new medical evidence to find its way into practice. By the time that happens, the evidence could be outdated. That, according to Rose, is symptomatic of practicing without computer assistance. "The overarching problem is that doctors cannot possibly update their knowledge as fast as the evidence changes," Rose said, echoing sentiments that medical informatics pioneer Dr. Larry Weed has been expressing for half a century.

That's where IT, in the form of CDS, comes in. "It's critical in being able to fill in that gap," Rose said. According to Rose, CDS really has three components, and they are not always used together.

Learn more here:

http://www.informationweek.com/news/healthcare/clinical-systems/231600988

There are two reasons for raising this right now. The first is to note that in the recently released Finalised PCEHR ConOps that Clinical Decision Support is the very last on the list of proposed enhancements to the PCEHR System (See Page 28).

The second is to point out that a real evidence based intervention of making currently available clinical literature available via a Government Sponsored Portal - as mentioned in the Deloittes Strategy of 2008 is still being ignored. It is only with solid current clinical information can be make any difference in the adoption of improved clinical practice within the medical (and other clinical) professions.

As far as I can tell it is planned that the consumer portal will provide some user education features but for some reason this does not seem to be planned for the provider portal. Why that would be just eludes me!

David.

They Are Rushing Ahead Silly Them. The E-Health Component of Health Reform Looks A Trifle Optimistic - To Say The Least!

Late last week we had this really ‘puff-piece’ press release appear.

Launch of Health Implementation Plan

The plan charting the path for national health reform implementation has been released by Minister for Health and Ageing Nicola Roxon.

7 September 2011

The plan charting the path for national health reform implementation was released today by Minister for Health and Ageing Nicola Roxon.

"The Implementation Plan shows how the benefits of health reform—increasing the sustainability of public hospitals, delivering unprecedented levels of transparency and accountability, less waste and significantly less waiting for patients—will be achieved.

“It builds on the extensive progress that has already been made in the past 18 months by consumers, clinicians and governments in achieving health reform.

"To support national health reform, the Commonwealth has committed $66.6 billion in key new health spending measures since 2007. At least $19.8 billion of this will provide more beds and better care in our hospitals over the next decade.

“The Implementation Plan outlines the plans and milestones to be met in achieving health reform in: hospitals, GP and primary care, aged care, mental health, national standards and performance, workforce, prevention and eHealth.

“For example, the plan outlines in detail the different components of the $2.2 billion package of mental health reforms announced by the Commonwealth.

“Work also continues to establish the National Health Performance Authority and the Independent Hospital Pricing Authority as the Commonwealth successfully moves its health reform Bills through the Parliament.

"National Health Reform: Progress and Delivery demonstrates the significant progress in implementing health reform that has already been made,” Ms Roxon said.

There is then a list of achievements (not mentioning e-Health) that can be found here:

http://www.health.gov.au/internet/ministers/publishing.nsf/Content/mr-yr11-nr-nr173.htm

You can download the 72 page document from this direct link.

http://www.yourhealth.gov.au/internet/yourhealth/publishing.nsf/Content/nhr-progress-delivery/$File/National%20Health%20Reform%20Progress%20and%20Delivery.pdf

E-Health coverage begins on Page 58.

Stream 8 - eHealth.

Here is the overview provided

Overview

The Commonwealth Government recognises the significant value of eHealth in underpinning the agile, patient-centred health system that national health reform aims to facilitate.

This recognition of the importance of eHealth has been marked with two landmark investments. The first, $467 million over 2010–11 to 2011–12, will deliver the key national components of an electronic health record system, so that all Australians who choose to

can have access to a personally controlled electronic health record (PCEHR). Over time this investment will deliver substantial benefits to consumers and the health system by reducing the potential for medication errors and duplication of tests.

The Government will also invest $621 million over five years to support and expand telehealth services. This initiative is intended to address some of the barriers to access to medical services, and specialist services. In particular, this will benefit Australians in remote, regional and outer metropolitan areas.

Together with the Government’s investments in the National Broadband Network, these investments will begin to enable consumers to be more active in their health care management, regardless of where they live or when they seek care.

Pages 63 and 64 provide an overview implementation plan with costing.

This is really remarkable as it:

1. Shows the money really does stop June 30, 2012 - just before you are meant to be able to sign up for a PCEHR.

2. That Standards to be used in the PCEHR system are yet to be sorted out - which makes one wonder just how all the Wave 1 and Wave 2 sites will glue together, if at all. I note the MSIA as saying in The Australian that the PCEHR is a ‘standards free zone’.

3. Governance is coming much later - so anyone who tells this system anything about themselves is really taking a risk regarding what may happen to their information!

And so it goes on. I leave it as an exercise for the reader to rate the chances of all this actually working and working out!

Already we know the Standards work is badly delayed due to the delays in having DoHA and Standards Australia agree on a new contract. This only happened a day or so ago - 2.5 months late!

David.

There Is Some Really Flawed Logic Here. We Don’t Have To Have A Second Rate PCEHR. Think About It!

The following article appeared today.

E-health blueprint needs 'fine tuning': Industry

The finalised Concept of Operations document still lacks answers to all the issues raised by the RACGP, according to the organisation

• Chloe Herrick (Computerworld)
• 14 September, 2011 10:10

The Federal Government’s finalised Concept of Operations on its $466.7 million Personally Controlled Electronic Health Record (PCEHR) project still needs “fine tuning”, according to the Royal Australian College of General Practitioners (RACGP).

The document (PDF), released earlier this week, finalised details put forward in the draft report issued in April this year.

RACGP National Standing Committee on e-health chairperson, Dr John Bennett, said despite the document failing to address all the issues previously raised by the college, it was important that stakeholders “join forces” to ensure the rollout is completed by July 2012.

 “The RACGP is pleased that the final plan for the PCEHR has been released and whilst not all our previously raised issues have been addressed, it is important that Australia gets underway with the implementation of the PCEHR,” Bennet said in a statement.

“The Government’s final PCEHR plan has taken on board most of the RACGP’s concerns that were in our response to the draft plan, including our recommendation that emergency access will be provided to the full record where required, and that this is supported by a full audit trail so patients can see who has accessed their record.”

However the college did raise concerns that the current plan still lacks any incentives for GPs and urged the government to consider how the extra effort required by GPs will be acknowledged.

“We would like to see amendments to the Medicare Benefits Schedule to recognise the additional workload GPs will undertake in consultations initiating and maintaining the patient’s shared health summary and other elements of the PCEHR.”

More here:

http://www.computerworld.com.au/article/400800/e-health_blueprint_needs_fine_tuning_industry

The problems with this comment - “it was important that stakeholders “join forces” to ensure the rollout is completed by July 2012” are at least threefold.

First we know for certain the PCEHR system will be in no way finished or complete by 2012.

Second why would a leading clinical college say well this is really much less than we wanted but we will just wear it. I am sure that is hardly the leadership their members are hoping for from the RACGP. I wonder how much of the RACGP’s acquiescence is because of the sponsorship relationship between NEHTA and the College.

Third just why should a learned college accept a deeply second best:

In their submission they said there were issues in the following areas:

2. Key issues

The RACGP would like to focus our response on the following aspects of the PCEHR Concept of Operations:

1. Data quality

2. Role of the nominated provider

3. Workload for general practices

4. Privacy and confidentiality

5. Terminology used within the PCEHR

6. Complexity of the PCEHR design

7. Change and adoption/support

8. Funding

It is clear the College is just one of many stakeholders who have not seen even the majority of their issues addressed - data quality is a real biggie they can’t be at all happy with!

Just why we all have to have a system with so many flaws just eludes me and to say ‘it’s not much good but we have to go with it” is just nonsense.

Mad stuff!

David.

It Seems NEHTA Is Having Some Employee Relationship Issues And Is Really Becoming Self Destructive and Damaging to At Least Some Employees.

In the last few weeks I have been hearing what is building to a crescendo of rumblings and concerns about the way NEHTA is being managed.

Before listing what I am hearing I have to make the point that virtually all those who have been in touch are, for one reason or another, no longer with the organisation.  In my opinion this gives veracity to their comments as they really have no reason to be untruthful - given that their relationship with the organisation has been severed. I also think that to have multiple former employees actively seeking out ways of drawing attention to perceived or actual wrongs (including by contacting me)  - certainly indicates a considerable depth of feeling, annoyance and frustration.

I have listed some of the major concerns that I have heard below, and although I cannot confirm the factual accuracy of any of the key concerns, I have heard all of the below sentiments from multiple sources. 

Some consistently raised concerns  include:

1. That there is a culture of bullying among some layers of management that has been the cause of a significant number of resignations and departures. I have also been told that there are rumours of consultant help being sought - as either a real effort to fix things or maybe just to ‘whitewash’.

2. That there have been at least some Workcover investigations of what is happening at NEHTA.

3. That there have been instances where the Human Resource function may have been less than even handed in mediating issues that have arisen between staff and management.

4. That within NEHTA there is a sense of entitlement of managers which is leading to some rather exceptionally extravagant behaviour - expensive restaurant usage, very expensive mineral water use etc .

5. That the attitude of some NEHTA staff to various volunteer contributors to the e-Health program has been less than reasonable.

6. That NEHTA’s status as neither a Government or Private entity has led to a very concerning lack of accountability for public funds which many suggest is being wasted at an alarming rate.

7. That’s, as an aside I am told that the HR department re-christened itself "People Culture and Change", an acronym which the employees mockingly call the "Praetorian Council of Control".

That I am hearing these stories from multiple sources tends to suggest, to me at least, that we have a situation where the smoke is suggesting there is a fire somewhere that needs to be dealt with.

Given what we all need NEHTA to be and to deliver this all seems a bit sad.

For anyone who feels that they need some external support here are the relevant contact numbers:

Workcover NSW Hotline 13 10 50.

Workplace Health and Safety Queensland has a Workplace Bullying Hotline 1800 177 717.

Those who have been not treated as they might wish should at least explore making contact with the services above.

Of course anonymous comments are always welcome to allow people to share their problems.

I realise some will say this is part of David’s general anti-NEHTA propaganda but nothing I cite here has less than a really trustworthy source and I really feel there are some people who are feeling pretty disempowered and voiceless in all this who would like the issues aired.

I have compared stories from the various sources and what I am reporting seems to stack up. Given this, although my opinion is set, I leave my readers to decide what to take away from this. My feeling is that major change is really needed with all this if Australian e-Health is to actually progress.

David.

Minister Roxon Decides To Sink Her Very Own PCEHR Project. Not Very Smart!

Two reports have appeared today which, in my view sink the PCEHR program.

First we had.

E-health rebates ruled out

• Karen Dearne
• From: Australian IT
• September 13, 2011 9:08AM

HEALTH Minister Nicola Roxon has flatly ruled out paying for doctors to create and maintain electronic health records on behalf of their patients.

In a doorstop interview at the launch of a model e-health display in Parliament House yesterday (MON), Ms Roxon replied "no" when asked if there would be a special Medicare rebate for doctors using a new $500 million nationwide patient electronic record system due to start next July 1.

"Look, we're not contemplating a special rebate," she said. "I'm sure that over time there'll be all sorts of different options and requests and they'll be considered as they come."

Ms Roxon said many doctors already use computerised systems to create electronic records.

"Our challenge, and what we're funding, is to make the system as simple as possible for people to use," she said.

"We are convinced that health professionals and patients understand the value of adopting this."

More here:

http://www.theaustralian.com.au/australian-it/government/e-health-rebates-ruled-out/story-fn4htb9o-1226135420748

Additionally we have:

No rebate for PCEHR adoption

• By Michael Woodhead on  13 September 2011

The government has ignored advice from medical groups on the PCEHR,  with health minister Nicola Roxon ruling out any special rebate to cover the costs of adopting the new system.

In an interview yesterday she said GPs were already using computerised systems and would see the value in switching to a new and better record system.

“The government's commitments are to fund the infrastructure that's required so that the system can talk to each other. It's not to fund each and every bit of a general practice or a health practice of any type which is going to constantly update itself and want to keep up with modern technology,” she said.

The RACGP had previously lobbied the government for a rebate to cover the extra training and support that practices will need to adopt the PCEHR and “to recognise the additional work GPs will undertake in consultations initiating and maintaining the patient’s Shared Health Summary and PCEHR.”

More here:

http://www.6minutes.com.au/news/no-rebate-for-pcehr-adoption

It seems Ms Roxon just does not have a clue. She does not seem to grasp that in the small business that is General Practice that time is really money (and income) and that if you cost GPs even a small amount of time you decrease their income.

I costed all this here:

http://aushealthit.blogspot.com/2011/05/funny-how-even-nehtas-experts-know.html

Even the NEHTA Clinical Lead agrees!

As we know every other section of the community - and especially unions - simply don’t tolerate that sort of thing. Remember the GPs have a pretty powerful union of their own - called the AMA - and unless this is quickly reversed to some sort of sensible compromise - you can essentially forget the PCEHR.

I note, in passing, the Government is also in denial about the likely costs of identifying and enrolling consumers for access to their now unsupervised and information quality poor PCEHR.

This just get sillier by the day!

David.

B Comments on the PCEHR ConOps Revision

There are two Design Notes in the final ConOp:

"Design notes: Advance care directives allow individuals to make choices about future medical treatment in the event they are cognitively impaired or otherwise unable to make their preferences known. The consequences of acting on an individual’s preferences, as set out in an advance care directive can be significant, sometimes final. At this stage, the directive itself will not be uploaded on the basis that, if uploaded, it would raise issues of currency or contain legal implications that are outside the scope of the current work. Future work will look at including the directive itself (see Section 2.8)."

From a system design perspective, this is not a major issue. It's just  a document.

Whichever way it is resolved, the system won't change much.

However, the second one is much more fundamental.

"Design Notes: Limiting access to clinical documents is challenging.

A number of the controls described above aim to accommodate the need for all individuals to set some basic controls around their PCEHR. It is recognised however that some individuals may wish add information to their PCEHR over which they wish to apply tighter access restrictions (and closer management). It is also recognised that concerns have been raised by healthcare providers about the utility and potential impacts of this feature.

However, failure to include this feature may result in some individuals changing their behaviour (e.g. withdrawing participation, refusing to grant access, withholding information, etc.) to work around the absence of this feature. Therefore in line with the central concept of a personally controlled EHR, ‘limited access’ has been included as an advanced feature.
The inclusion of this feature means that improving health literacy will become more essential and individuals need to be educated about the consequences of limiting access. As a result, the individual is required to assert they have reviewed the educational material around access controls before using the more advanced controls.

Implementation of the limited access feature has also been acknowledged as challenging. The proposed approach does not require the source system to support the feature and limits the ability to change the status of a clinical document to being accessible only via the consumer portal. The design trade off means that only individuals who are able to use the portal and have set up a PACC/PACCX will be able to access this feature.

With regard to visibility of ‘limited access’ information, users will not be aware of its presence if they do not have access to it. This decision was made so that the individual is not pressured into revealing  the limited access information."

This one is far more serious. The PCEHR is designed to facilitate access to a patient's health information. It is intended to improve the delivery of health care, however, concentrating health information and improving access to it is likely to have the unintended consequence of exposing that same health information in ways that are unacceptable to many citizens. There is a conflict of interest here. That between trusted, practicing medical professionals need full access to as much information as possible on the one hand, and citizens, who don’t want un-necessary access to their private data on the other. There is also a range of access needs in between that required by the trusted, practicing medical professionals and that of no un-necessary access. The solution that NEHTA has come up with – an advanced feature called  “limited access” - is a half-baked idea that will not address the  problem and will, IMHO, alienate many citizens. Limited access does not  deliver a range of access controls, it can only be set up by savvy net  users and it is a significant change to the data architectures in the  products contained in the NIP’s solution.

Changing a data architecture is not a simple exercise. It’s like moving  a house three metres to the left, once it has been built.

Referring to it as a Design Note, is also most inappropriate. It's a  part of the problem and needs to be addressed as such, not as a solution  option.

Managing Health Information is a very difficult, social problem. I don’t  think it has yet been solved. And it won’t be solved by technologists.


----- End Post.

David

AusHealthIT Poll Number 87 – Results – 12th September, 2011.

The question was:

Should There Be A Major Review of the Australian Medicines Terminology (AMT) To Make It Maximally Useful for Clinical Use?

For Sure

- 26 (68%)

Probably

- 9 (23%)

Probably Not

-  2 (5%)

No Its Fine As Is

- 1 (2%)

Votes 38

A stunningly clear cut vote. This project needs a careful and in depth rethink seems to be the large majority view!

Again, many thanks to those that voted!

David.