Progress in e-Health – Blocked by Government Secrecy?

The Australian College Health Informatics (ACHI) is to have the CEO of NEHTA (Dr Ian Reinecke) as the Guest Speaker at its AGM in August 2006. As part of preparing for this speech ACHI members have been asked to consider what would be useful questions to put to our guest.

In reflecting on this, and wishing not to be too repetitive in addressing issues that have already been raised in an ACHI e-Health Strategy paper from late last year (which is available here from the ACHI web site www.achi.org.au), I wondered what else could be usefully explored.

The comments of another ACHI member provoked me to think about what else was needed to have the e-Health Agenda move forward. It struck me that there have been all sorts of e-Health initiatives over the last few years – both under the HealthConnect or NEHTA banners of initiated by the different States but that we know very little about the outcomes and contributions of much of this work.

HealthConnect is an interesting case study in point. While this project produced a range of strategy and research documents – some of which are still very worthwhile and useful – it also conducted a number of trials. These included Mediconnect and the following:

“HealthConnect trials have been operating in Tasmania and the Northern Territory since 2002. In 2003 another trial commenced in North Queensland, and in 2005 more trials will begin in New South Wales and South Brisbane.

The Tasmanian HealthConnect Trial took place in southern Tasmania and focussed on adults with diabetes. The Trial ended on 30 November 2004.

The Northern Territory HealthConnect Trial is taking place in the Katherine region and focuses on Indigenous health issues associated with a mobile population in a rural and remote area.

The North Queensland HealthConnect Trial is based in the Townsville region and focuses on people undergoing elective surgery at The Townsville Hospital, many of whom travel long distances to attend the hospital for surgery.

The Brisbane Southside HealthConnect Trial will test particular design architecture for HealthConnect and will focus on adults with diabetes.

The New South Wales HealthConnect Trial involves two separate pilot projects. One pilot will involve children in Greater Western Sydney, the other focuses on adults with chronic disease in the Hunter Valley region on the NSW Central Coast.”

Given all these were publicly funded, and indeed there were many publicly funded evaluations undertaken, one wonders what has been delivered in terms of learning and feedback to the Health Informatics Community.

The answer is not much we have been told about! And, as a colleague has pointed out, we all learn more from our failures than our successes (Thanks Terry).

MediConnect is the only initiative which appears to have had a substantial evaluation report published. This report, indeed, found so many problems and issues with the so called Field Trial that the initiative was cancelled and rather than moving to national implementation was folded into HealthConnect.

As for HealthConnect itself a single evaluation report has been produced. This covers the following”

“The two years of field testing MediConnect and trialling HealthConnect have provided many lessons to inform and guide the national implementation of HealthConnect. These lessons are derived from the extensive evaluation activity, the experience of trial management committees and teams in each of the trials and the Field Test and related research activity. As part of the formative approach to informing trial management, around 30 independent evaluation reports (many unpublished interim or specific issue reports) have been produced. The lessons learned documented in these reports are brought together in this overarching ‘Lessons Learned Report.”

None of these 30 individual reports on HealthConnect have been made public despite the very substantial investment of public money that has gone into them. One really wonders why? One can only assume that there is so much that was done badly, wrongly or technically poorly or that so little was achieved that these are too embarrassing to release. If not, what’s the secret? The downside is, of course that as no one know what went badly – the same mistakes are liable to be repeated.

One thing is for sure, no clinical outcome benefits were identified from any of the reported trials – such a heading did not even get a mention in the Report - and the most significant outcome of virtually all the trials is that they have either been cancelled or dramatically scaled back in utility and complexity.

Move forward to the present and we seem to have the same secrecy and media management instincts operating. NEHTA has commissioned a large range of valuable – and expensive – consulting reports on a wide range of topics including Standards Priorities, Identifiers, Clinical Terminology and Shared Electronic Health Record. Sadly virtually none of these have seen the light of day either.

Even the current Eastern Goldfields Trial looking at the Broadband for Health initiatives has been the subject of detailed evaluation but, yet again, none of the evaluation reports has been made public. For what possible reason could a project providing internet connectivity and services to some scattered health sites be controversial or need to be evaluated in secret. Such projects have happened all over the world.

It is really getting to be a joke. This is work paid for by the public to assist public decision making and the public can’t see, review or critique any of it. Frankly I think it is a scandal.

David.

HealthConnect's New Website – And a New HealthConnect!

Last week (May 10, 2006 to be exact) I had occasion to visit the old HealthConnect web site at www.healthconnect.com.au. I needed to find a copy of a study into the benefits of Health IT that I knew was there. All was as expected, I found the report and was able to send it to the colleague who wanted to read it.

On Monday (May 15, 2006) I was alerted to the fact that a major change had occurred and that the old and familiar site had disappeared. As a regular commentator on the Government’s HealthConnect saga I felt it my duty to investigate the new site. What is there to report?

First it has a uniquely unmemorable URL so it will now be necessary to bookmark the site in the hope of ever being able to find it again – did someone not pay to maintain the URL one wonders.

Second, oddly, the new site seems to have been largely developed well over three months ago but it only appeared a week ago. Enquiring minds wonder about the delay.

To more serious matters – what can one learn about the status of the HealthConnect change management strategy? The following are some random observations:

1. An all new sense of time seems to have developed for the site. We are told:

“ The expectation is that by 2008, Australia will be well advanced in achieving the goal of electronic connectivity between all major health institutions and health care providers.”

It would be difficult to imagine something more vague and non-specific. My guess is that it means someone will assemble a directory of e-mail addresses and make sure “all major health institutions and providers” can swap an e-mail. I thought they could largely do that now! Maybe I was misled?

2. We are offered on the same “What’s Happening page” the following as well:

“Looking to the future
There are a number of developments currently underway in various stages that could be nationally implemented within the next 12 to 18 months:

• e-prescriptions is about a prescription for medication in the form of an electronic message being sent from a health care provider to a community pharmacy
• e-referral could replace the current paper based referral or request sent from one health care provider to another (for example, from a doctor to a radiologist)
• hospital discharge summaries, which is a summary of the treatment provided and the proposed future care plan could be sent electronically from a hospital to a doctor, a specialist or an aged care facility.”

The operative words here clearly are “could be nationally implemented”. Not will just "could". Given the lack of HealthConnect funding in the present, just announced, budget the subtext is clearly if we can work out who will pay for it.

3. It is great to see we now know who is responsible for implementing HealthConnect. On the Governance page we find the following useful information:

“Governance arrangements
HealthConnect is managed under the national e-health governance arrangements established by the Australian Health Ministers’ Advisory Council as a joint Australian, State and Territory Governments’ project.

The Australian Health Ministers Advisory Council (AHMAC) whose members are the chief executives of Australian, State and Territory Government departments of health, has responsibility for HealthConnect.

The national implementation of HealthConnect is the responsibility of the National Health Information Group (NHIG) which is an AHMAC sub-committee. NHIG obtains stakeholder advice in consultation with the Australian Health Information Council (AHIC).”

So the NHIG is to be accountable!. Now who are they?

“The National Health Information Group (NHIG) has been established by Australian Health Ministers to provide advice on national health information requirements and related technology planning and management requirements. NHIG manages and allocates resources to health information projects and working groups where joint Commonwealth/State and Territory resources are involved.”

They are clearly a policy committee with no obvious implementation capability and no significant budget other than that they can agree on between all the jurisdictions. The committee does not even have its own secretariat to manage its internal affairs as best it can be identified.

4. The actual implementation of the HealthConnect vision it to be driven as follows:

“National coordination
The e-Health Branch within the Department of Health and Ageing has a national coordinating role in managing the implementation of the HealthConnect change management strategy. It carries out its role by leveraging existing Australian, State and Territory Government and private sector initiatives to achieve the goal of a shared electronic health record network.

The Branch, in partnership with the State and Territory Governments, is fostering strong relationships between key peak stakeholder groups representing healthcare providers, consumers and industry to engage them in the implementation of the strategy.”

Here we have a lot of fostering, leveraging, consultation and partnering but sadly not much actual spending and implementation!

5. The last really interesting point – and there are all sort of goodies to be found comes from the FAQ page.

“Where will the information be held?
Event summary information that is exchanged between providers will be held at the point of care. At the point of care, the health provider will be able to draw together, with the consumer’s permission, relevant information from other providers involved in a person’s care.”

Translation – No actual Shared Electronic Health Record is planned and no repositories are to be built or paid for – we will hold information at each point of care and exchange on demand. Much cheaper that way, assuming you can make it work.

All I can say is “Welcome to the world of New HealthConnect!” The old one has gone!

David.

Service Improvements

This tiny corner of Cyberspace has now been operational for going on for three months. In that time we have added about thirty articles commenting on the various issues as they emerge in the e-health space in Australia.

While a .atom feed and I believe and RSS feed are available - I have now managed mastery of enough html to provide e-mail updates as well. You can subscribe on the site and it does its best to make sure your e-mail is secure and that you can opt-out again as required. Feel free to tell friends and enemies that they can now know quickly about the views I am putting.

While I have your attention let me make a few points about the experience of writing the blog. First it has been useful in clarifying my thoughts and positions and has acted an interesting exercise in exploration of a range of issues - prompting extra research etc which is all to the good.

I have to say that there are ominous portents for e-health in Australia brewing. First is the awareness that Medical Observer magazine has taken the e-health section it used to have off its website. Seems no one is interested.

Second we note that HealthConnect has been removed in all its guises from the recently announced Australian Budget.

Thirdly there seems to be a pervasive feeling of despondency regarding what is possible in Australia given the politics and Governments (of all shades) views. I see this most in the nihilism and frustration expressed in private e-mail and in correspondence in the GP_Talk forum, HL7-Info and OpenHealth.

The really annoying thing is that it is now clear Health IT, done right, works! It improves care, saves lives and in the hands of competent organisations saves money!

See below for the best facts currently available.

=============================================

Chaudhry B, Wang J, Wu S, et al.

Impact of health information technology on quality of medical care
Annals of Internal Medicine 16 May 2006; Volume 144 Issue 10 (early on-line publication)

http://www.annals.org/cgi/content/full/0000605-200605160-00125v1

Background: Experts consider health information technology key to improving efficiency and quality of health care.

Purpose: To systematically review evidence on the effect of health information technology on quality, efficiency, and costs of health care.

Data Sources: The authors systematically searched the English-language literature indexed in MEDLINE (1995 to January 2004), the Cochrane Central Register of Controlled Trials, the Cochrane Database of Abstracts of Reviews of Effects, and the Periodical Abstracts Database. We also added studies identified by experts up to April 2005.

Study Selection: Descriptive and comparative studies and systematic reviews of health information technology.

Data Extraction: Two reviewers independently extracted information on system capabilities, design, effects on quality, system acquisition, implementation context, and costs.

Data Synthesis: 257 studies met the inclusion criteria. Most studies addressed decision support systems or electronic health records. Approximately 25% of the studies were from 4 academic institutions that implemented internally developed systems; only 9 studies evaluated multifunctional, commercially developed systems. Three major benefits on quality were demonstrated: increased adherence to guideline-based care, enhanced surveillance and monitoring, and decreased medication errors. The primary domain of improvement was preventive health. The major efficiency benefit shown was decreased utilization of care. Data on another efficiency measure, time utilization, were mixed. Empirical cost data were limited.

Limitations: Available quantitative research was limited and was done by a small number of institutions. Systems were heterogeneous and sometimes incompletely described. Available financial and contextual data were limited.

Conclusions: Four benchmark institutions have demonstrated the efficacy of health information technologies in improving quality and efficiency. Whether and how other institutions can achieve similar benefits, and at what costs, are unclear.
============================================

Just what has to be done to get NEHTA to develop and articulate a comprehensive e-health plan and to persuade Government to adopt it, is feeling as though it is beyond your simple scribe.

I will, however, press on!

David.

Unscripted Errors – What a Beat-Up!

Over the last few years the Australian Newspaper has developed a reputation for quality reporting in the e-Health space, led largely by Karen Dearne and James Riley (who has been doing good work on the “Access Card” front). It is therefore quite disappointing to note the article, entitled Unscripted Errors, which appeared today providing such alarmist and ill-structured comments from a different Australian journalist.

In essence the article argues that electronic prescribing by GPs, in the absence of them using the software as it was designed and the software lacking the key features (electronic decision support) that make it safe will not help reduce prescribing errors. To suggest this is stating the ‘bleeding obvious’ is a monumental understatement – and indeed is confirmed by the hospital study cited in the article.

It is little more than common sense to say that safety requires all parts of a system to work properly. (Thus having perfectly sound wings on an aeroplane does not help avoid a crash when the engines fail!). It is no news that poor computer systems in the hands of the untrained or careless may do more harm than good. It is also true to say that the current generation of Australian GP prescribing systems, used carefully and intelligently by clinicians trained in their use, are very safe and can make a real difference

In the case of prescribing the ideal system to do the job will have the following attributes:

1. It will be part of a comprehensive Electronic Patient Record which captures relevant information (ideally in properly coded form) regarding the patients illnesses, allergies and other medications (including non-prescribed ones).

2. It will have access to a rich electronic decision support framework which provides guidance as to prescribing based on age, height, weight, disease, other medications and allergies at the least.

3. All the alerts and recommendations made by the system will be evidence based and properly researched.

4. The decision support will interact with the clinician at the point of decision making to ensure all relevant information is considered.

5. The system will be easy to use and have its data bases of knowledge regularly updated and refined.

However even all this is not enough, only when the clinician is both properly trained and prepared both t0 enter all relevant information and respond intelligently to the decision support warnings and alerts will the substantial beneficial reduction in errors and patient harm be achieved.

It is what is needed, rather than what can go wrong in the hands of clinicians given poor software with out proper training, that should have been the emphasis of the article. As it stands the article did nothing but alarm, rather than fostering an effort at improvement which is genuinely needed.

The evidence that such systems work is now overwhelming if they are properly implemented.

Getting this sort of software onto clinician’s desks is yet another area where national leadership could save both money and lives. We should be working to have proper systems, properly implemented, put in the hands of our clinicians, not worrying ourselves into paralysed inactivity because a few might misuse older ones.

David.

HealthConnect Renamed - What To Unclear

In an article in the Australian Financial Review Ben Woodhead writes (subscription required) today:

“The Department of Health and Ageing has stripped references to its $128million HealthConnect project from 2007 budget statements amid speculation over the fate of the controversial national electronic health record program.

The move is likely to increase fears the government will abandon HealthConnect and shift responsibility for the development of a national electronic health record (EHR) framework to the National E-Health Transition Authority .

But it has not completely disconnected itself from the development of a national EHR, and the department has signalled it will work this year on initiatives that will eventually support a nationwide electronic patient record.”

He also notes that in the forward estimates for the next few years there are a total of $70.2 Million for COAG Health Services - Establishing the Foundations for a National Electronic Health Records System as it is described in the budget papers.

Importantly what must be noted here is that these funds – announced a couple of months ago are for “Foundations” not for the National EHR System itself. The foundations are for patient identity, provider identity and SNOMED CT implementation over the next few years.

What does this mean the Government’s strategy for EHRs for consumers is? The simple answer is “who knows?”. While NEHTA is obviously working on the nature of the approach that is to be adopted we see some odd and apparently un-coordinated things happening, such as a separate identity system being developed to support the Medicare Smartcard.

It is also worth noting that the Commonwealth Funding for this NEHTA work is very similar to the amount of money that would have been left over from the previously announced HealthConnect funding.

Currently there is a very large strategic hole in Australia’s e-Health vision. One can only hope it is soon clarified.

David.

Smartcard Stupidity

Another day another foul up for e-health (and a lot else) in Australia. Yesterday The Age’s Michelle Grattan reported in the following terms:

“The man overseeing the introduction of the Government's smartcard has resigned, citing concerns about its implementation, including privacy.

James Kelaher, former head of the smartcard taskforce, yesterday warned that privacy and the confidence of those with a stake in the card - including the public, doctors, pharmacies, states and federal departments - were likely to be compromised by Human Services Minister Joe Hockey's proposed arrangements.”

It seems the fuss is about two issues. Firstly whether there should be a separate agency constituted to establish and operate the Smartcard infrastructure and secondly whether there should be an expert and accountable board to oversee the total project and to ensure that all the necessary community expectations for security, privacy and integrity are met.

On the first point any project of the planned scale (involving over $A1.0Billion in expenditure) clearly needs focussed and dedicated management. To do otherwise breaks every rule in the Project Managers 101 textbook of implementation.

On the second it is clear, given the Australia Card debacle, that public confidence and trust is vital. To keep this all secret and in-house guarantees success for those few souls who oppose what is essentially a sensible initiative, if, and only if, implemented in a consultative, responsive and inclusive manner.

Mr Hockey needs to wake up and listen to the experts on this or a lot of money, time and effort will most likely be wasted.

James Kelaher is clearly a very sensible bureaucrat who has strong principles regarding doing things in the national interest and exposing arrant stupidity.

Well done James!

It should be noted that the writer still has major concerns about the robustness of the proposed smartcard as an e-health patient identifier and hopes the need for e-health levels of ID integrity will not be glossed over in the rush to implementation.

David

Health IT and the Australian Budget

Tomorrow is the one financial day for the year in Australia when the Commonwealth announces its budget for the next year.

What chance any joy for the proponents of e-Health in Australia?

I must say I am pessimistic. After what looked very much like a re-branding of old HealthConnect money into new NEHTA funding a few months back – and with precious little (not surprisingly) to show for that investment as yet, I think the Government will think they have done enough for now.

The usual run of leaks, typical of the pre-budget period, do not appear to have an obvious mention – but that is not to say there won’t be any new funds – given that such funding is unlikely to be “leak worthy” I would suggest.

At the risk of seeming to be repetitive, it seems to me that without a compelling business case for e-health investment, as well as some political will just nothing will happen. In this regard we can hope the NEHTA initiative on Benefits Realisation, announced a month or two ago, might just have some impact.

The obvious worry is that NEHTA recommending dramatically increased spending might be seen as having a ‘conflict of interest’ in seeking to feather its own nest. I am firmly of the belief, to be credible, such a business case needs to have been undertaken by expert, independent outsiders and not done in-house where it can so easily be ignored and left un-actioned.

If there was to be funding – where should it go?

I would like to see a real proper e-Health Business case developed along with a real implementation plan - $3-5M for one year and then sell the benefits and plan to the Commonwealth to become much more pro-active. This is vital and overdue by at least half a decade.

I also want a Certification Commission for Health IT type entity to get GP systems up to snuff - and then to get a real Health IT network going in - that can grow organically like is intended in the US. Start small and provable and get some runs on the board. ($10-20M p.a. for 4 years or so). I would also like to, as the CCHIT is doing, see the scope widen to cover Hospital Computing and so on.

Those two specific initiatives and continuation of other NEHTA initiatives might just move us forward a little.

We shall see tomorrow what the budget brings.

David.

Lessons for Australia from the CCHIT

On the first of May the Certification Commission for Healthcare Information Technology released its initial 2006 criteria for certification of Ambulatory Health IT. The scope of the documents is impressive and reflects what could be reasonably desired in an Ambulatory EHR client system for use in the US context.

The documents sensibly cover the required functionality, important interoperation capabilities and necessary information protection and security needs. After review of these documents and the associated evaluation scripts I would be surprised if 90% of the certification requirements do not fully match Australian needs - with the exceptions being in the areas of terminology, coding and billing.

This is an absolutely invaluable starting point from which NEHTA should be developing similar requirements for Australian Certification after consultation with the relevant users and industry stakeholders.

I particularly like the approach of building in a road map for system developers to permit them to evolve their systems over 2-3 years and to be, via this approach, ensuring a very high standard of system will be in the hands of clinicians only a few years from now.

This is all wonderful stuff and I commend it to readers and the Medical Software Industry Association for detailed review. This work can give us a real head start in the development of Australian certification processes and may mean a few years from now GPs will have access to clinical systems which can really make a difference and which they said they needed back as far as 1997.

David