Today it has been announced that David Brailer has resigned his position as Head of the Office of the National Co-ordinator for Health Information Technology.
It seems to me this is a very significant loss, given the steady hand he has provided in the developments in this very important area in the United States.
There is no doubt the strategy he has developed to foster the use of Health IT has been largely sound and consistent with the constraints the operate in the US Healthcare sector. Inevitably some strands of the approach may need refinement going forward - especially in the area of the quality of the client EHRs that are to be implemented in physician offices and how best this transition can be managed and funded - but overall the approach of starting small and growing and linking as competencies build seems fundamentally sound.
Additionally his emphasis on the use of pragmatic proven standards -based on the CHI work undertaken in the period before his appointment - was also rational and appropriate.
However, I suspect his biggest contribution was the work he undertook in the year prior to his appointment where he as able to convince the West Wing and President Bush of the importance of the overall initiative and the potentially huge opportunity cost of inaction.
It is a pity Australia has not yet thrown up a similar individual who can weave the same magic on our Prime Minister. We need this prophet badly just at the moment!
David
Friday, April 21, 2006
Monday, April 17, 2006
Useful Standards Framework for Interoperation
In a very useful recent release the Californian Regional Health Information Organisation, or CalRHIO has released an interoperation standards framework along with a roadmap covering how they see these standards evolving over the next few years.
In their release they say they have worked to take account of all the prevailing standards initiatives in the US (from HL7, ONCHIT, Markle and so on) and have tried to form a clear direction forward.
This work is of interest in Australia because NEHTA is currently working to develop a standards catalogue, the work done here is a useful view, from other experts, on the way forward.
Notable to me was the use of the Californian HealthCare Foundation standard (ELINCS) for laboratory results communication and support of LOINC as the terminology used. This approach seems to support evolving the HL72.x standard in the same way is being developed in Australia. I hope this work can be jointly advanced until HL7 V3.0 is ready for prime time.
Also of interest were:
- The recognition that HL7 V3.0 is a little way off.
- The plan to use the HL7 (OMG) approach to Services.
- The non use of SNOMED CT in the Allergy Space where the is a developed subset already available for use.
- The planned phasing out of ASTM CCR by about 2010.
Australia could do worse than have discussions with the authors of this short (5 pages) framework to understand the rationale and motivations behind the recommended choices.
David
In their release they say they have worked to take account of all the prevailing standards initiatives in the US (from HL7, ONCHIT, Markle and so on) and have tried to form a clear direction forward.
This work is of interest in Australia because NEHTA is currently working to develop a standards catalogue, the work done here is a useful view, from other experts, on the way forward.
Notable to me was the use of the Californian HealthCare Foundation standard (ELINCS) for laboratory results communication and support of LOINC as the terminology used. This approach seems to support evolving the HL72.x standard in the same way is being developed in Australia. I hope this work can be jointly advanced until HL7 V3.0 is ready for prime time.
Also of interest were:
- The recognition that HL7 V3.0 is a little way off.
- The plan to use the HL7 (OMG) approach to Services.
- The non use of SNOMED CT in the Allergy Space where the is a developed subset already available for use.
- The planned phasing out of ASTM CCR by about 2010.
Australia could do worse than have discussions with the authors of this short (5 pages) framework to understand the rationale and motivations behind the recommended choices.
David
Wednesday, April 12, 2006
Back to the Future for E-Health
Last week CHIK Services conducted their annual Health IT conference (Health-e-Nation 2006). The slides and materials from this very useful gathering are now available on the web.
Of particular interest was one line in the presentation from Dr Ian Reineke (CEO, NEHTA). In this he says that the momentum for e-health is rising and that "The stage is set for Governments to consider a national system of electronic health records".
Reading this I must say I almost choked on my Wheaties. To my certain knowledge the stage for this was set in 1997 with a House of Representatives enquiry followed in 1999 by a large report recommending what eventually became HealthConnect in 2001/2.
Nine years into "consideration of national EHRs" we are now told the stage is set for what must be re-consideration, given the passage of almost a decade!
More than that we have the NEHTA Chairwoman (Ms Patricia Faulkner) tell us that we will all have a Shared EHR at some point in the future but that it will be six-eight years into the future.
What has happened to all the work done thus far and all the money spent. One can only assume very little since we are now to "re-consider".
The truths obvious from all this is are:
1. No national plan for Shared EHRs currently exists.
2. Those considering e-Health and Shared EHRs know they won't be around six to eight years from now to have to account for their level of success in delivery this time when what is happening now is reviewed.
3. Unless there are real funds to support develop the Shared EHR in next months Budget we can be sure "six to eight" years is an optimistic estimate of the likely time frames.
I look forward to being found to be wrong, but I doubt it.
David
Of particular interest was one line in the presentation from Dr Ian Reineke (CEO, NEHTA). In this he says that the momentum for e-health is rising and that "The stage is set for Governments to consider a national system of electronic health records".
Reading this I must say I almost choked on my Wheaties. To my certain knowledge the stage for this was set in 1997 with a House of Representatives enquiry followed in 1999 by a large report recommending what eventually became HealthConnect in 2001/2.
Nine years into "consideration of national EHRs" we are now told the stage is set for what must be re-consideration, given the passage of almost a decade!
More than that we have the NEHTA Chairwoman (Ms Patricia Faulkner) tell us that we will all have a Shared EHR at some point in the future but that it will be six-eight years into the future.
What has happened to all the work done thus far and all the money spent. One can only assume very little since we are now to "re-consider".
The truths obvious from all this is are:
1. No national plan for Shared EHRs currently exists.
2. Those considering e-Health and Shared EHRs know they won't be around six to eight years from now to have to account for their level of success in delivery this time when what is happening now is reviewed.
3. Unless there are real funds to support develop the Shared EHR in next months Budget we can be sure "six to eight" years is an optimistic estimate of the likely time frames.
I look forward to being found to be wrong, but I doubt it.
David
RAND Corporation and the Value of Health IT
As a sign of its importance the Annals of Internal Medicine has published, a month in advance of its print date, an important systematic review of the Impact of Health Information Technology on Quality, Efficiency, and Costs of Medical Care. This is a crucial review and establishes that, at least in some circumstances, there are positive impacts on quality, efficiency and costs from the implementation of Health IT.
The evidence for such value in organisations with a high level of IT sophistication was very compelling indeed and given the expertise deployed in undertaking the review can be considered definitive. In the hands of experts Health IT makes a significant positive difference.
The less good news was that, while the value appeared to obviously be available to smaller and less advanced organisations, evidence this was actually the case was lacking.
The authors then go on to, very sensibly in my view, recommend more work to adduce the required evidence and ensure the business case for Health IT deployment is as robust as possible in all sensible settings - especially in the community ambulatory setting.
What this review and the body of evidence it collects shows is that Health IT works. It is now up to those with the relevant responsibilities to learn the lessons available from this work and move forward for the good of all of us.
David
Monday, April 10, 2006
An Important Release of Information from the U.S.
Late last week the Markle Foundation released its so called "Common Framework" for Secure Health Information Sharing. This framework offers Policy approaches to the protection of private health information and Technical approaches the effective and timely sharing of relevant information.
Importantly the "Common Framework" is not a pie in the sky specification but is a demonstrated set of policies and technology which has been shown to work between 3 major sites in Boston, Indiana and California.
The importance of these demonstrations ought not be underestimated - especially as it has been achieved in a standardised conventional way and the two special pieces of software developed to enable the information sharing have been made available in open source form.
With NEHTA saying they have a three year window in which to develop the required standards for Australia it seems clear the work Markle has done needs to be carefully reviewed here. It is interesting that the approach adopted is web services based - as is being recommended by NEHTA for Australia.
It is also important to note this US initiative has avoided any need for a universal patient identifier of the sort now under development - in some form - by NEHTA.
However, it is important to recognise that care is required with the wholesale adoption of Web Services approaches - as is made clear in a recent Computerworld article entitled "Researcher: Web services security risks largely ignored".
Secure and
David
Importantly the "Common Framework" is not a pie in the sky specification but is a demonstrated set of policies and technology which has been shown to work between 3 major sites in Boston, Indiana and California.
The importance of these demonstrations ought not be underestimated - especially as it has been achieved in a standardised conventional way and the two special pieces of software developed to enable the information sharing have been made available in open source form.
With NEHTA saying they have a three year window in which to develop the required standards for Australia it seems clear the work Markle has done needs to be carefully reviewed here. It is interesting that the approach adopted is web services based - as is being recommended by NEHTA for Australia.
It is also important to note this US initiative has avoided any need for a universal patient identifier of the sort now under development - in some form - by NEHTA.
However, it is important to recognise that care is required with the wholesale adoption of Web Services approaches - as is made clear in a recent Computerworld article entitled "Researcher: Web services security risks largely ignored".
Secure and
David
Friday, April 07, 2006
They Just Don't Get It - Personal Privacy does Matter
All in all it has been a very bad week for NSW Health IT. Both the major daily papers, The Sydney Morning Herald and The Australian have been running stories pointing out how a number of years of careful policy work related to the privacy of Shared Electronic Health Records has been swept aside - basically to meet a political time line for implementation of a trial EHR system - termed Health-E-Link.
It seems the NSW Minister for Health was persuaded that every one in the target population (citizens over 65 years living in the Hunter Region who visited local outpatient facilities) would love to to have their details available for sharing with any authorised practitioner on a compulsory basis. Later it was decided that once the details were collected the citizen would have 30 days to "opt-out" of record sharing. However the records are not deleted - merely made unavailable.
Even worse the clients of the system have no say in what will be captured - so the only way to avoid having a record established is not to attend the public services in the area.
Not surprisingly, many advocacy groups and other interested parties (dismissed as "privacy zealots" by the Minister, are less than impressed with this outcome, saying to a group we don't mind records but we want a strong say in who accesses these records and under what circumstances. They are also annoyed that the regulations to allow this information capture were slipped through quietly with no public consultation or announcement.
Just the other day a powerful coalition of privacy advocates enumerated what is required in the way of privacy for records to be made available for sharing between health practitioners.
The key points they itemised were put in the following terms:-
Frankly NSW is a rogue state that will put the cause of health information sharing in Australia back decades unless a major policy about-face occurs. Those responsible for this should recognise they have made a grievous mistake and suspend the trial until proper reasonable controls can be put in place.
David
It seems the NSW Minister for Health was persuaded that every one in the target population (citizens over 65 years living in the Hunter Region who visited local outpatient facilities) would love to to have their details available for sharing with any authorised practitioner on a compulsory basis. Later it was decided that once the details were collected the citizen would have 30 days to "opt-out" of record sharing. However the records are not deleted - merely made unavailable.
Even worse the clients of the system have no say in what will be captured - so the only way to avoid having a record established is not to attend the public services in the area.
Not surprisingly, many advocacy groups and other interested parties (dismissed as "privacy zealots" by the Minister, are less than impressed with this outcome, saying to a group we don't mind records but we want a strong say in who accesses these records and under what circumstances. They are also annoyed that the regulations to allow this information capture were slipped through quietly with no public consultation or announcement.
Just the other day a powerful coalition of privacy advocates enumerated what is required in the way of privacy for records to be made available for sharing between health practitioners.
The key points they itemised were put in the following terms:-
"We urge you to build a foundation for medical information technology that is based on the following longstanding ethical and privacy principles and protections:
- Restore the patient's right of consent
- Give patients the right to opt-out of having their records in any national or regional electronic health system
- Give patients the right to segregate their most sensitive medical records
- Require audit trails of all disclosures
- Deny employers access to medical records
- Require that patients be notified of all suspected or actual privacy breaches
- Preserve stronger privacy protections in state laws
- Enact meaningful enforcement and penalties for privacy violators"
Frankly NSW is a rogue state that will put the cause of health information sharing in Australia back decades unless a major policy about-face occurs. Those responsible for this should recognise they have made a grievous mistake and suspend the trial until proper reasonable controls can be put in place.
David
Tuesday, April 04, 2006
NEHTA Interoperability Framework - Version 1.0
Yesterday NEHTA released their Version 1.0 Interoperability Framework. At the highest level this document attempts to define how the actors in the Australian e-Health domain are intended to move towards interoperability.
The document is not for the faint-hearted as it is a complex piece of work written in a style that makes no concessions to the technical or health understanding of the audience (which is said to be senior people in the e-health community in Australia essentially).
It seems to me that the value of a document such as this needs to be assessed on the value it provides to its intended audience and the change it will justify and sponsor in e-Health activities in Australia.
I think it would be fair to say the reaction thus far has been along the lines of suggesting the paper is part of an R&D program and that only once more detail and guidance is provided will much value be delivered in the real world. When e-health software developers and vendors are asked "what will you do different tomorrow?" the answer seems to be universally "Nothing".
I have reviewed the document quite carefully and my comments are as follows:
1. This is clearly a "work in progress" and should not be considered in any way final or to be offering firm guidance - consultations on its impact are still to happen with NEHTA's owners.
2. The document as it presently exists does not review available options to many of its recommendations or explain the basis for its selections.
3. The document admits much of its basis is unproven and may not be available for 3-5 years - adoption of the "bleeding edge" approaches is not wise in a sector as conservative as Health I believe. It is possible the keenness for SOA may pass as implementation experience is gained in large complex environments.
4. The proposed standards catalogue does not have scope to hold the full range of available standards that may address a topic and explain the reasons for selection of the preferred ones and at what point such preferences may be reviewed.
5. The theoretical approach adopted and the time frames suggested do not really confront the urgent need for technology to enable Health System Reform as soon as possible.
6. It is, again, not clear, just what is the strategic and requirements context in which this document was developed. There is discussion of development of undefined NEHTA solutions and this must be a cause for concern given the track record of NEHTA like organisations in the software development area.
7. It is by no means clear just what is planned to fall under the influence of this framework - given that at present it is far to vague for any practical implementation.
8. Given legacy systems can last 10+ years in this sector - it is vital to know how these are to be dealt with and have this provided in a route-map provided for all to review and discuss.
9. Yet again archetypes are cited as a good thing - but yet again there is no explanation of how the required information infrastructure is to be developed and managed.
All in all I don't believe this document adds much that is useful to progress in e-Health in Australia. It would have been better to have a much broader consultative process before Version 1.0 was reached so at least some of the issues I and others have raised could have been addressed.
David
The document is not for the faint-hearted as it is a complex piece of work written in a style that makes no concessions to the technical or health understanding of the audience (which is said to be senior people in the e-health community in Australia essentially).
It seems to me that the value of a document such as this needs to be assessed on the value it provides to its intended audience and the change it will justify and sponsor in e-Health activities in Australia.
I think it would be fair to say the reaction thus far has been along the lines of suggesting the paper is part of an R&D program and that only once more detail and guidance is provided will much value be delivered in the real world. When e-health software developers and vendors are asked "what will you do different tomorrow?" the answer seems to be universally "Nothing".
I have reviewed the document quite carefully and my comments are as follows:
1. This is clearly a "work in progress" and should not be considered in any way final or to be offering firm guidance - consultations on its impact are still to happen with NEHTA's owners.
2. The document as it presently exists does not review available options to many of its recommendations or explain the basis for its selections.
3. The document admits much of its basis is unproven and may not be available for 3-5 years - adoption of the "bleeding edge" approaches is not wise in a sector as conservative as Health I believe. It is possible the keenness for SOA may pass as implementation experience is gained in large complex environments.
4. The proposed standards catalogue does not have scope to hold the full range of available standards that may address a topic and explain the reasons for selection of the preferred ones and at what point such preferences may be reviewed.
5. The theoretical approach adopted and the time frames suggested do not really confront the urgent need for technology to enable Health System Reform as soon as possible.
6. It is, again, not clear, just what is the strategic and requirements context in which this document was developed. There is discussion of development of undefined NEHTA solutions and this must be a cause for concern given the track record of NEHTA like organisations in the software development area.
7. It is by no means clear just what is planned to fall under the influence of this framework - given that at present it is far to vague for any practical implementation.
8. Given legacy systems can last 10+ years in this sector - it is vital to know how these are to be dealt with and have this provided in a route-map provided for all to review and discuss.
9. Yet again archetypes are cited as a good thing - but yet again there is no explanation of how the required information infrastructure is to be developed and managed.
All in all I don't believe this document adds much that is useful to progress in e-Health in Australia. It would have been better to have a much broader consultative process before Version 1.0 was reached so at least some of the issues I and others have raised could have been addressed.
David
Sunday, April 02, 2006
Is E-Health Getting Harder?
Today's post has been provoked by my having been sent a report into an e-health conference which was conducted in mid September 2004 in Sydney and which brought together many luminaries in the field. The tone of the meeting was quite optimistic but, while all the important issues were raised (privacy, change management etc), it seemed there was considerable confidence that success was just around the corner - and that by the end of 2005 concrete outcomes would be clearly demonstrable. Further optimism flowed from the fact that NEHTA had recently been established and that this would quickly make an impact in the standards area.
Eighteen months later we seem to have stalled in some important ways.
Firstly the time frame to get basic delivery of the management of the identify of providers and consumers has slipped to the end of 2007 and we have seen that it is now clear development of the required extensions for SNOMED-CT (covering medications, devices and some other areas) is also going to take until 2007.
To date the details of how each of these will be achieved has not been made public so it is hard to know just how high the likelihood of success is.
Internationally it has also become obvious that progress is slower than may have been hoped for. Examples include the delays now being experienced in the well resourced Connecting for Health Initiative in the UK, the slowness with which progress is being made to finalise both HL7 V3.0 and the ISO/CEN EN13606.
It seems intrinsically many major initiatives are more challenging than they initially appear. For this reason the start small and develop at a pace that all can accept is increasingly appearing to be better and better advice.
It is interesting that an article expressing a similar sentiment appeared very recently on the US Modern Medicine website entitled "Dr. McCoy to sickbay: Not 'stat' but with all deliberate speed".
It seems to me we need to select some important do-able goals, get them done, and then take the next step - remembering that in 2006 it is the human and cultural issues that will give the most trouble - not the technical ones.
David
Eighteen months later we seem to have stalled in some important ways.
Firstly the time frame to get basic delivery of the management of the identify of providers and consumers has slipped to the end of 2007 and we have seen that it is now clear development of the required extensions for SNOMED-CT (covering medications, devices and some other areas) is also going to take until 2007.
To date the details of how each of these will be achieved has not been made public so it is hard to know just how high the likelihood of success is.
Internationally it has also become obvious that progress is slower than may have been hoped for. Examples include the delays now being experienced in the well resourced Connecting for Health Initiative in the UK, the slowness with which progress is being made to finalise both HL7 V3.0 and the ISO/CEN EN13606.
It seems intrinsically many major initiatives are more challenging than they initially appear. For this reason the start small and develop at a pace that all can accept is increasingly appearing to be better and better advice.
It is interesting that an article expressing a similar sentiment appeared very recently on the US Modern Medicine website entitled "Dr. McCoy to sickbay: Not 'stat' but with all deliberate speed".
It seems to me we need to select some important do-able goals, get them done, and then take the next step - remembering that in 2006 it is the human and cultural issues that will give the most trouble - not the technical ones.
David
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