Useful and Interesting Health IT Links from the Last Week – 11/11/2007

Again, in the last week, I have come across a few reports and news items which are worth passing on.

These include first:

Five ways to roll out SOA

Big name companies from Comcast to United Airlines are jumping into Services Orientated Architecture (SOA) , changing the way organizations plan, develop, and deploy enterprise applications

Galen Gruman (InfoWorld) 06/11/2007 10:15:14

Back when SOA first started getting traction, the goal was simply to make application functionality available as a shared service. Companies made up their architectures as they went along -- and of course, they're still doing that. The difference today is that, in the last couple of years, the business side has a better sense of the strategic value of IT, while IT has learned more about the competitive pressures business must endure. As a result, SOA now offers the possibility of greater alignment between IT and business than ever before.

What business needs is an array of services that can be recombined, resulting in new business processes that support new products or services. Publishing those services and providing a coherent framework within which they can be governed and orchestrated into applications is what SOA is all about. Although many SOA initiatives remain an early phase, the promise of increased business responsiveness is real. And we're seeing an increasing number of enterprises that are pushing toward advanced deployments. The case studies here are prime examples.

Comcast builds its SOA on domain expertise

It's tempting to start buying ESB, registries, and other tools when you decide to adopt the SOA approach. But that misses the key value of SOA, which is to have a way to align the applications you create and deploy to the business processes they execute, says Tom Adler, senior manager of application architecture and IT governance at Comcast. And starting with the architecture can help ensure you have the right framework to do that -- both now and as needs change over time, he says.

"When we started this effort 18 months ago, we resisted the temptation of bringing in vendors. We brought in subject matter experts instead and figured out what we needed first," Adler says. "All the vendors just wanted to sell us an ESB." The architecture effort does more than set the framework, he notes: It also begins identifying where you already have redundancies, both in business processes and in applications. That's key to getting business buy-in, Adler says, because it shows in very real terms where there are opportunities for savings that will help justify the eventual SOA infrastructure and tool investment, as well as show where the use of common services should help reduce maintenance and integration complexities, allowing more responsive development efforts in the future. "It's the target that lets us eliminate redundant services," he says.

After developing the architecture -- what Adler calls the common domain model -- Comcast's next step was to develop the governance framework for the service development and deployment. "Services need to go through the governance gate," he says, "otherwise no one will know that the services exist or follow the right policies and procedures." Only services that pass the governance gate are added to the service registry and thus made available for others to reuse.

One governance challenge that came up quickly was deciding who owned the services. Comcast is fairly decentralized, so the culture naturally supported having the service originators own the services in their domains, Adler says. Common services, such as single sign on, reside with IT -- their natural domain, he adds.

One step that Adler now realizes Comcast missed was developing a common data service model after defining the architecture. By not having standard data services to access corporate information and manage interactions across systems, developers have ended up designing their services to get the job done in different ways, leading to inconsistencies that break the SOA promise of allowing an easy mix and match of service components. "We underestimated the value up front," Adler says, and the price has been reworking some services to impose that model after that fact.

The architectural focus of Comcast's SOA effort has helped the concept be applied more widely than if viewed merely as a technology issue, Adler believes. For example, because Comcast didn't start with the view that SOA means the use of Web services, the company has applied the SOA concept to all its efforts, not just those that are obviously Web-enabled. "A Web service is just one way to expose a service -- it's just an implementation detail," he says. One result is that much of the initial internal SOA efforts were in fact directed at the legacy applications, reducing the integration points both within and outside the company (such as with billing vendors), a major pain point for the business.

Developers use a variety of tools and programming languages, for example, as best fit their knowledge and the application they are creating. By standardizing processes and policies instead of specific tools and technical methods, Adler says developers can better adhere to the architecture's intent rather than trying to shoehorn each effort into the limitations or assumptions of a specific tool or technology. There's also a practical reason to allow technological heterogeneity under the common architecture, he notes: In a 9,000-person company, it would be unrealistic to get everyone on the same methodology."

A company of that scale must also adjust to changing business needs and technology opportunities, Adler says. It's important to revisit the reference architecture periodically so it doesn't become a straitjacket or a document that everyone ignores; either way, you would lose the benefits of SOA. Adler revisits the architecture each month, though it is changed less often than that.

Continue reading here to hear about the other four examples:

http://www.computerworld.com.au/index.php/id;904732282;fp;4194304;fpid;1

NEHTA is very keen on the use of SOA and these examples are worthwhile to see the range of approaches commerce is using to try and obtain the various advantages.

Second we have:

Abbott health project disappears

Karen Dearne | November 06, 2007

SPENDING on e-health crashed during 2006-07, with $41.5 million allocated to national projects left unspent out of a budgeted $79 million.

Local industry observers said Tony Abbott had abandoned HealthConnect

As a result, $40 million of the unspent $41.5 million was rolled over into the 2007-08 budget, forming the total allocation for e-health programs in the current year, the Health Department's annual report reveals.

The move halved the federal Government's funding commitment to health technology reform.

E-health specialist and blogger David More said the situation was farcical, and only half of the available federal funding had been spent.

"With lack of investment being a key blocker to improved e-health, it does not look like Health Minister Tony Abbott is serious about making progress in this area, in spite of his recent rhetoric and mea culpa," Dr More said.

"Even worse, there is no apparent increase being planned."

In comparison, Canada recorded a huge rise in e-health expenditure in 2006-07, with its national co-ordinator, Health Infoway, approving investments of more than $C520 million in joint state-federal projects, Dr More said.

Read the complete article here:

http://www.australianit.news.com.au/story/0,24897,22709617-15306,00.html

It is always nice to get a reference in the mainstream press!. The points made in this article are all valid. The Government persisting with the fiction of HealthConnect being a viable strategy which is being implemented is just laughable.

Third we have:

Draft PHR Standard Ready for a Vote

HDM Breaking News, November 5, 2007

Standards development organization Health Level Seven has sent to ballot its Personal Health Record System Functional Model. Members and nonmembers of Ann Arbor, Mich.-based HL7 can vote through Dec. 1 on whether the model should become a draft standard for trial use.

The model defines a set of functions and security features that may be present in PHR systems and offers guidance to facilitate data exchange among PHRs or with electronic health records systems. The model is designed to help consumers compare PHRs and select one appropriate for their needs.

Continue reading the details here:

http://www.healthdatamanagement.com/news/standards_PHRs_consumers25130-1.html

The PHR functional model specification is available at hl7.org/ehr.

This is an important step forward in terms of developing standards for Personal Health Records. Given NEHTA is supporting HL7 Standards this standard may have directed relevance in Australia.

Fourth we have:

RHIOs aren't working, new report says

By Diana Manos, Senior Editor 11/05/07

WASHINGTON--The development of regional health information organizations may not be effective in advancing healthcare information technology, a new report by the Information Technology and Innovation Foundation contends.

"The strategy of building the network from the bottom up by establishing many RHIOs throughout the country is not working," ITIF's report said. "More than 100 RHIOs have been established across the country, but the majority are financially unsustainable. In the absence of clear national standards for sharing medical data, achieving system interoperability for RHIOs has been difficult."

The 23-page report, titled "Improving Health Care: Why a Dose of IT May Be Just What the Doctor Ordered" calls for a renewed national strategy for advancing healthcare IT.

…..

The report recommends that Congress take immediate actions to help advance healthcare IT, including:

*Pass legislation to promote the use of electronic health records and national health data standards;

*Create a legal framework for health record data banks;

*Leverage federal resources to ensure access to health record data banks;

*Require medical practices to disclose patient health information electronically upon request.

Continue reading here:

http://www.healthcareitnews.com/story.cms?id=8075

The report can be downloaded from the following URL:

http://www.itif.org/files/HealthIT.pdf

This is an interesting review of where one author thinks the US is presently situated and what strategies may be applicable to have things move forward. Well worth a download.

Lastly we have:

CCHIT certifies six EHRs for hospitals

By Eric Wicklund, Managing Editor 11/05/07

CHICAGO – Six vendors, or roughly one out of every four, offering electronic health record products for acute care hospitals have now been certified by the Certification Commission for Healthcare Information Technology.

CCHIT officials announced today that products offered by the six vendors certified have demonstrated compliance with the certification commission’s published criteria. Four of the products have been deemed fully certified:

• Computer Programs and Systems, Inc. ’s CPSI System 15,

• Eclipsys Corp. ’s Sunrise Acute Care 4.5 SP4,

• Epic Systems’ EpicCare Inpatient Spring 2007

• Healthcare Management Systems, Inc. ’s Healthcare Management Systems 7.0.

Two others – Prognosis Health Information Systems’ ChartAccess 1.0 and Siemens Medical Solutions’ Soarian Clinicals 2.0C5 with Siemens Pharmacy and Medication Administration Check 24.0 – have been ruled pre-market, conditionally CCHIT certified, meaning the products will be fully certified once their operational use in a hospital has been verified.

Continue reading here:

http://www.healthcareitnews.com/story.cms?id=8108

This is further evidence that the CCHIT is progressing a sensible agenda of identifying and certifying capable Health IT System which can reasonably be expected to work well when implemented. This certification could be of some use to Australian States that are planning major Hospital system purchases over the next few years. Would be good to see both incumbent Australian Vendors - Cerner and IBA/ iSoft submit their products to certification via this system.

All in all some interesting material for the week!

More next week.

David.

On Line and No Longer Alone with Mental Illness.

It seemed to me this was a valuable and interesting application of internet connectivity and health support.

Virtual life delivers tools for a real life

A new online computer game aims to teach young people about mental health issues, writes Lynnette Hoffman | October 20, 2007

MISSY Higgins is singing her heart out. The playlist moves from R&B to rap to alternative -- it's all decidedly hip and there's good company about, but this is no big night out.

It's a virtual world called Reach Out Central, a free online computer game created to teach teenagers some of the same sorts of resilience and coping skills a psychologist might -- and get them to seek help if needed.

Devoid of guns, guts and gore, and no high-speed chasing, ROC is a role playing game set in suburbia with a web of characters to rival Neighbours. The premise is that you've just moved into a new town, and as you navigate the neighbourhood building friendships and helping characters through typical life struggles such as dealing with divorce or low self-esteem, you will actually learn tried and true cognitive behaviour therapy principles you can apply to your own life.

Reach Out Central was launched in September by the not-for-profit Inspire Foundation in an effort to reach young people -- especially those in the 16 to 25 age bracket, young men in particular, who are notoriously reluctant to seek help from a health professional for mental health issues.

A team of 80 youth ambassadors gave a young person's perspective as the game was being developed, and have been involved with the marketing content for the program as well.

According to the latest figures, one in five adolescents experiences a mental health issue in any given year, and fewer than 40 per cent get help from a health professional. When they do seek help it's often for physical symptoms, so any underlying mental health problem can get missed or take a long time to be diagnosed.

That was exactly the case for Queensland student "Mike Jones" (not his real name). Jones had always been a social person, and had taken on the role of school captain when anxiety struck a few years ago. He "freaked out" whenever he was around people -- speeches that once made him "a little nervous" were now "completely overwhelming". Nausea, sweaty palms, a racing heart and shallow breathing were becoming everyday experiences -- and when he decided to see his GP, those were the symptoms he complained of.

And so Jones was sent for a string of blood tests and even a gastroscopy, all of which proved negative, before Jones himself suggested to the GP that perhaps he needed to be referred to a psychologist. He says it took only a few sessions of learning cognitive behaviour therapy to get himself back on his feet.

"I stopped being reactive and started to make changes," he says. "I was able to redefine who I was -- sometimes I was faking it, being really positive even when I didn't feel that way, but now it's what people expect me to be."

It's those sorts of coping skills -- and awareness about when a mental health issue is too much to handle on one's own -- that the game is designed to communicate.

A 2006 national survey of 14,700 young people between the ages of 11 and 24 by Mission Australia found suicide was among their top five concerns -- in particular, nearly 30 per cent of 11 to 14-year-olds and almost 28 per cent of 15 to 19-year-olds said it was "a major concern." Coping with stress was the top issue 15 to 19-year-olds were concerned about, and overall two in five young people were "significantly concerned" about depression. A 2005 survey by the Australian Democrats found 57 per cent of the young people knew a young person who had attempted or committed suicide.

Young people are waiting an average of anywhere from five to 15 years to do something about mental health issues, leaving themselves open to problems such as deteriorating relationships and problems with school and work, says doctor Jane Burns, director of research and policy at the Inspire Foundation.

…..

That's just now beginning to change, with researchers at ANU in the final stages of a study that trialled the internet-based MoodGym, a self-help program that teaches CBT in a non-game format.

The study compared anxiety and depression levels in 14 to 16-year-old students at 30 schools across Australia, where half were given the standard curriculum the schools would normally provide, and the other half were given MoodGym. "There was an increase in overall mental health well-being and reduced levels of anxiety and depression after six months in the students who accessed MoodGym," Christensen says.

To read the complete article please visit:

http://www.theaustralian.news.com.au/story/0,25197,22611086-23289,00.html

The web sites referred to in the story can be found at the URLs below

www.reachoutcentral.com.au
www.moodgym.anu.edu.au

What is really pleasing is that there is a concerted effort being undertaken to ensure that what is being done is evidence based and that there is hard-nosed evaluation underway to ensure what is being done is actually working as expected.

It seems to me that cognitive behavioural therapy is at one proven to be useful in a range of clinical situations and also to be a form of therapy that is quite well suited to ‘distance delivery’.

Given the amount of distress and misery mental illness brings to our society anything that can assist to lift that burden is a ‘very good thing!’

David.

The Aust. Department of Health and Ageing – Is It Australian E-Health’s Worst Enemy?

The Australian Commonwealth Department of Health and Ageing (DoHA) released its Annual Report for 2006-07 on October 30, 2007.

The report can be downloaded from here.

I was of course keen to see what was being reported for e-Health. I think it is fair to say the news is not at all good.

In the 2006-07 Budget, about $78.9 million was allocated to e-health implementation; but in fact, only about $37.4 million was spent during the period.

The precise figures are as follows – (See Page 150 of the Annual Report.)

Program 10.2: E-Health Implementation

Allocated: $78,972,000

Actually Spent: $37,408,000 – Underspend: $(41,564,000)

Budget for 2007 – 08: $40,041,000

It is worth noting that the Budget for 2007-08 allocation for e-health is now also only about $40 million) so effectively they've simply reallocated the money they didn't spend, after shaving $1.5 off the top.

This we now wind up with a situation where DoHA have effectively halved their investment for this coming year.

A review of the DoHA performance indicators in the e-Health domain makes really depressing reading and to be frank seems to me to be hardly accurate. (See pages 144 and 145)

Having a goal expressed as:

“Key stakeholders use electronic clinical communications to improve quality and safety in health

care.”

And to claim it was met on the basis of what follows is pretty cute in my view!

“The Department continued to work collaboratively with states and territories and non-government organisations, through its Broadband for Health, Managed Health Network and HealthConnect programs to provide and expand infrastructure that allows clinicians greater access to electronic clinical communications.

Broadband for Health Program take up by eligible general practices (including Aboriginal Community Controlled Health Services and Royal Flying Doctor Service sites) increased 3.6%, from 58.0% to 62.0%, and community pharmacy take up increased 8.2%, from 80.0% to 88.0%.”

As for Electronic Health Records we are told (Page 6):

e-Health

“The Department continued to provide national leadership in the electronic management of health information through a range of e-Health initiatives to improve the accuracy of patient records and other information available to doctors. For example, with our support, a Shared Electronic Health Record is being rolled out across the Northern Territory. Currently, over 12,000 people have a shared record, with their essential health information available, with their permission, to around 320 health care providers in hospitals, general practice and community care. Registered health care providers can create health profiles for their patients which can be viewed online, as well as medical event summaries and pathology results. They will also be able to access participating patients’ hospital inpatient discharge and emergency event summaries (Outcome 10).”

Last year there were 7000 people enrolled. At 5000 extra per year it will be a long while before the Northern Territory is covered let alone the other 20,000,000 of us!

With all this I thought it may be fun to go back a year or so and see what one could find.

DoHA Annual Report 2005-06

The ongoing chaos in e-Health is beautifully illustrated by the following from the Annual Report of 2005-06

“On 10 February 2005, the Council of Australian Governments decided to accelerate the electronic health records agenda. This became the impetus for the Department to realign its e-health activities. The Department disbanded the E-Health Policy Group and transferred its ongoing work to the E-Health Branch within the Health Services Improvement Division. The E-Health Branch has responsibility for all electronic health activities in which the Department is involved.”

That is two and two thirds years ago – Has anyone noticed an acceleration? I think I have noticed the opposite with a business case to COAG not even being due till 2008!

Even more amusing are the claims for the progress being made in 2005-06 with HealthConnect.

Support for Health Sector Electronic Clinical Communications

“HealthConnect is an overarching national change management strategy aimed at improving safety and quality in health care, through a range of standardised electronic health information for health care providers and consumers.

The Department put in place a number of initiatives during 2005-06. These include:

• the establishment of the National E-Health Transition Authority by the Australian, State and Territory governments, which is charged with developing the standards and infrastructure for health and medical information management systems;

• the extension of the Broadband for Health program. This initiative supports investment in secure business grade and advanced broadband connectivity for general practices, Aboriginal Community Controlled Health Services, and community pharmacies, and has seen a steady increase in uptake for the duration of the program; and

• the implementation of the Managed Health Network Grants, as part of the Broadband for Health program, which provide funding for collaborative local e-Health projects. Due to the pioneering nature of the project, uptake was initially slow, however, the Managed Health Network Grants have since had an overwhelming response and a large quantity of applications have been received.

As a result of the Department’s work, over 7,000 consumers in the top end of the Northern Territory now have a fully functioning electronic health record; in Tasmania over 3,440 consumers who have been admitted or discharged from hospitals now have their general practitioners notified electronically; and in South Australia, some 52 per cent of health providers are now connected via Broadband for Health.”

All one can say about all this is “whoopee do”. How many of these grants have yet to bear operational fruit – let alone be actually publicly evaluated over two years later! Of course we also have NEHTA beavering away in secret and yet to actually produce much except a lot of questionably useful documentation.

For the record we again had an underspend in 2005-06.

Program 9.2: E-Health Implementation

Planned Spend: $53,670,000

Actual Spend: $46,467,000

Variance: $ (7,203,000)

DoHA Annual Report 2004-05

On Page 5 we read:

A Health System Evolving Through Technology

“New information technology has the potential to greatly improve the provision of health services and reduce the number of clinical mistakes which unfortunately occur through human error. The HealthConnect system developed by the Department has the potential to set the world standard for electronic patient records.

During 2004-05, the Department reviewed the HealthConnect program in consultation with a broad range of stakeholders including State and Territory governments, industry, and health care providers and consumers. This review led to the development of a new implementation strategy for HealthConnect, emphasising connectivity of new and existing health databases.

The Broadband for Health program achieved a big uptake in high speed, secure internet technology – as a precursor to HealthConnect – in community pharmacies, general practices, and Aboriginal Community Controlled Health Services. The National E-Health Transition Authority (NEHTA) was created in August 2004 with funding provided by the Australian Government and States and Territories, to develop national standards and infrastructure to assist the adoption of e-health throughout the Australian health sector.”

Further on we read – continuing the sense of chaos

Changes to the Department

The Department engaged a consultant in December 2004 to review the support provided by the Information and Communications Division to the HealthConnect project and other e-Health initiatives.

Following the review and consultation with key Departmental and external stakeholders, the Information and Communications Division was disbanded, with its ongoing work transferred to other areas in the Department, including the newly-established E-Health Implementation Group, Business Group, Health Services Improvement Division and Portfolio Strategies Division.

Further on we also read about the following

Major Achievements

• “ In January 2005 all Australian Health Ministers agreed to an implementation plan to progress four priority areas in safety and quality improvement in public hospitals including:

- open disclosure;

- performance management;

- development of a minimum data set; and

- external review.

• The National Health and Medical Research Council awarded 930 new research grants during 2004-05.

• Revision of the implementation strategy for HealthConnect to align the program with national governance arrangements for e-health, including the establishment of the National e-Health Transition Authority (NEHTA).

Challenges

• The revision of the implementation strategy for HealthConnect has meant that the Department has had to negotiate new milestones for HealthConnect with all States and Territories, taking into account the changes to the implementation strategy including the role of the Department in the development of HealthConnect.”

The report also has some great performance claims.

Look at this one:

Goal

Research and development work to test and evaluate the feasibility of the National Health Information Network:

- including health information management

Target: Undertake research and evaluation activities to determine the feasibility of implementing e-health record initiatives nationally and develop infrastructure necessary for proposed e-health initiatives to proceed.

Result: Target met.

Revision of the HealthConnect implementation strategy was based on research and evaluation of the feasibility of implementing e-health records undertaken during 2004-05. The National E-Health Transition Authority (NEHTA) was established by Health Ministers during 2004-05 to specify the standards and architectures of the national infrastructure to support this implementation.

Target: Develop infrastructure to support electronic health information exchange, including finalisation of the first full iteration of the HealthConnect design as part of the National Health Information Network.

Result: Target met.

Revision of the HealthConnect implementation strategy and the establishment of NEHTA made this target redundant.

Target: Development of standards and other building blocks, and the commencement of implementation of a Records System (storage) in one or more States.

Result: Target met.

The development of standards and other building blocks is being undertaken by the NEHTA, and the implementation of a records system has commenced in the Northern Territory.

Target: A high level of stakeholder satisfaction with the timely development and implementation of national strategies for electronic health records.

Result: Target met.

Revision of the HealthConnect implementation strategy during 2004-05, involved extensive stakeholder consultation, and a high level of satisfaction and engagement in the new strategy.”

Actually three targets were essentially flicked to NEHTA and the other one was essentially a non target!

For the record this also cost a bit and was underspent (again)

Administered Item 4: Information Management/Information Technology

Allocated: $27,709,000

Actually Spent: $26,075,000

Underspend: $(1,634,000)

Comment:

Frankly this is a catalogue of management neglect, incapacity and strategic emptiness. On any measure DoHA’s leadership of e-Health in Australia has been an appalling travesty and is to be condemned. (Petronius Arbiter would have been proud of the number of re-organisations we have seen! ). I really find this level of apparent ongoing incompetence in a major Federal Department scary and truly a threat to our ongoing prosperity – to say nothing of our health system

David.

Useful and Interesting Health IT Links from the Last Week – 04/11/2007

Again, in the last week, I have come across a few reports and news items which are worth passing on.

These include first:

Microsoft to buy Thai health software vendor

Microsoft has agreed to buy hospital administration software maker GCS of Thailand.

Dan Nystedt (IDG News Service) 30/10/2007 06:20:02

Microsoft on Monday said it has agreed to buy a Thai software vendor that specializes in hospital administration applications, and plans to sell the software in emerging markets.

Global Care Solutions (GCS) of Bangkok, Thailand, is Microsoft's third purchase of a health-care software vendor in the past 13 months, according to Peter Neupert, vice president for the Health Solutions Group at Microsoft. The group was formed two years ago and the purchase of GCS is one more step to building the Microsoft health-care business, he said.

GCS specializes in hospital software that takes care of patient scheduling, billing, clinical workflow, regulatory compliance and medical record-keeping. The privately held company has worked for years with Bumrungrad International Hospital, a facility made famous by its focus on catering to visiting tourists.

What makes GCS software special is the amount of specialized record keeping required by Bumrungrad. Doctors at the hospital see over 1.2 million patients each year, including 400,000 foreign patients from 190 countries, meaning varying language, insurance and billing data. Half of the 3,200 patients seen at Bumrungrad each day walk in without an appointment, yet GCS's scheduling software ensures patients wait an average of 17 minutes to see a doctor.

Continue reading here:

http://www.computerworld.com.au/index.php?id=214419639&eid=-255

This is an interesting move as it does mark something of a move by Microsoft away from provision of ‘infrastructure’ software (operating systems, database etc) to application software. As others have discovered Health Information System delivery, implementation and support is not all that easy – witness the number of vendors from 10 years ago that have been merged, taken over and so on.

Second we have:

Online prescriptions - no GP squiggles

Lindsay Murdoch in Darwin

October 31, 2007

THE days of doctors writing prescriptions in a chicken scratch decipherable only by experienced pharmacists are numbered.

Royal Darwin Hospital has developed Australia's first online medication management system where bedside laptops replace handwritten patient records.

Charles Kilburn, the hospital's head of pediatrics, said the system using wireless technology linked the doctor, nurse and pharmacist to the same electronic records.

"The system allows us to be in tune with prescribing practice, assists in compliance with best practice guidelines and minimises errors," Dr Kilburn said yesterday.

…..

The system, called Medchart, was developed specifically for drug prescriptions, clinical support and drug administration.

Northern Territory health officials said they were also leading the way in introducing a shared health record system, which has been undergoing trials in the Katherine region south of Darwin since 2004.

Under that system, information about patients is sent to a secure computer network, improving the co-ordination of health care across the Territory.

Read the complete article here:

http://www.smh.com.au/news/technology/online-prescriptions--no-gp-squiggles/2007/10/30/1193618885415.html

It is good to see the NT moving along so well. I wonder why it is that the success with Shared Electronic Health Records has not been better publicised and NEHTA has not beaten a path there to spread the model nationally given development of a Shared EHR is their core mandate. It just might be that the level of success claimed is just a trifle exaggerated.

Further information is available from www.hatrix.com

Home-grown system for hospital

Royal Darwin Hospital is rolling out an online medication system developed by Canberra-based company Hatrix. Use of the MedChart system will be extended to replace all paper-based patient medication records in all Northern Territory hospitals over the next three years, claimed Stephen Moo, CIO for the hospital.

The system is used by patients' three primary carers — doctors, pharmacists, and nurses. "The tool was developed specifically for the complex clinical process of prescribing, pharmacy review, clinical decision support, and drug administration," Moo added.

Third we have:

Online Rx program helping cut errors

Big 3's e-drug plan boosts the use of generics while reducing glitches, analysis shows.

Sofia Kosmetatos / The Detroit News

A Big Three-driven effort to replace prescription pads with computers is significantly reducing patient risk from medication errors and helping increase generic drug use, according to an analysis released today by the Southeast Michigan ePrescribing Initiative.

Launched nearly two years ago, the first review of the initiative shows that it is not only protecting patients from the harmful consequences of medication errors, but is also helping them have better discussions with their doctors about medications at the time a prescription is written.

"The benefits of ePrescribing are overwhelming in terms of reducing medication errors, lowering prescription drug costs for patients and plans, and decreasing physician practices' administrative costs," said Marsha Manning, General Motors Corp.'s manager of Southeast Michigan Community Health Care Initiatives, in a statement.

Through the initiative, doctors access online software on computers in patient rooms to write the prescriptions, prompting discussions about generic alternatives, drug interactions and allergies at the time a prescription is written.

The results are savings on drug costs and fewer medical complications, doctors and coalition members say.

EPrescribing also eliminates doctors' handwriting as a source for error, and saves patients and doctors' offices time because the scripts are sent to pharmacies electronically.

The analysis of a sample of 3.3 million prescriptions showed:

• The ePrescribing technology sent alerts of severe or moderate drug interactions to doctors for about one-third of those prescriptions. Doctors changed or canceled 423,000 (or 41 percent) of those prescriptions.

• The technology informed doctors of more than 100,000 medication allergies, and doctors acted on 41,000 of these alerts.

• When an alert showed a drug was not on a formulary, the doctor changed the prescription to comply 39 percent of the time.

The initiative, involving the automakers, Henry Ford Health System, Blue Cross Blue Shield of Michigan and others, aimed to help doctors set up electronic prescribing in their offices.

The three automakers -- GM, Ford Motor Co. and Chrysler LLC -- are involved because they think the initiative can cut down on their health care costs, which add up to billions of dollars.

So far, some 6.2 million prescriptions have been written by 2,500 doctors using ePrescribing technology, with more than 282,000 written each month.

The coalition plans to extend the initiative through March 2008.

Continue reading the details here:

http://www.detnews.com/apps/pbcs.dll/article?AID=/20071029/LIFESTYLE03/710290363

For more information, there is also more detail available at medco.com.

This provides compelling evidence of just how helpful electronic prescribing with decision support can be in improving clinical practice. There should have been much more publicity of this important result.

Fourth we have:

Patient Safety Institute folds due to lack of funding

By: Jean DerGurahian/ HITS staff writer

Story posted: October 29, 2007 - 5:59 am EDT

The outlook for the creation of a self-sustaining national health information network dimmed after a decision by the Patient Safety Institute to close its doors.

The Patient Safety Institute ceased operations last week after six years, citing a lack of investment opportunities to test its locally grown information network on a national scale.

But the institute isn't the only health information network to fold this year. Several regional information exchanges could not sustain funding despite claiming to have strong participant support, and recent closures in Portland, Ore., and Pennsylvania suggest organizations haven't yet proved to the healthcare industry the need for everyone to be able to exchange data.

A sustainable business model is necessary if the healthcare industry wants to move forward with improvement—something that has been difficult to prove for physicians, said Bill Hersh, professor and chairman of the department of medical informatics and clinical epidemiology at the Oregon Health & Science University, Portland. "We have a poor business case for small practices to adopt electronic health records, since they pay the cost and others get the benefits. Same for the Patient Safety Institute and same for RHIOs. Those who get the benefit must be the ones who pay the cost,” he said in an e-mail.

The institute's technology was similar to that used by many other groups attempting to leverage networks, said Beth Just, president and chief executive officer of Just Associates, a consulting firm based in Centennial, Colo. Her company works with healthcare systems to implement patient-identity management across differing medical records. Through her firm, she works closely with the Colorado regional health information organization, a statewide information network initiative.

Continue reading here:

http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20071029/FREE/310290002/1029/FREE

This is an important article that reviews why one Health Information Network failed to achieve financial viability. It shows there is not yet developed a fool proof formula to have such initiatives be successful.

Lastly we have:

US Makes New Push on E-Health Records

By KEVIN FREKING

Associated Press Writer

5:54 PM PDT, October 29, 2007

WASHINGTON — The Bush administration is recruiting about 1,200 doctors nationally to remove the paperwork from their medical practice in return for higher Medicare payments.

Health and Human Services Secretary Mike Leavitt billed the project Monday as one of the administration's most important steps yet toward meeting President Bush's goal of nationwide adoption of electronic health records by 2014.

Medicare will pay the physicians extra for completing tasks online, such as when ordering prescriptions or recording the results of lab tests. The highest payments will go to those physicians who most aggressively use the technology and who score the highest in an annual evaluation.

Many health analysts believe widespread use of electronic health records will reduce medical errors and could potentially slow soaring health care expenses. Yet, only about 10 percent of doctors in solo or small-group practices use such records. Upfront costs for putting in place such computer systems can range from $20,000 to $40,000.

Continue reading here:

http://www.latimes.com/news/nationworld/politics/wire/sns-ap-health-technology,1,4650084.story?coll=sns-ap-politics-headlines&ctrack=1&cset=true

It is good to see that the US has recognised the need to financial incentives to encourage increased effective computer use in ambulatory care (general and office practice). In Australian a similar program is in place, but in my view the effort required to receive the financial incentives has been set so low that it is not clear just how much value for money Australia is receiving for the expenditure. The US approach seems designed to avoid that problem.

All in all some interesting material to the week!

More next week.

David.

Health IT Research in Australia – Good to See Some Activity.

On Wednesday last week (31^st October, 2007) there was a demonstration of some interesting software systems developed through a collaboration between the University of Sydney’s IT Department and the Intensive Care Department at Royal Prince Alfred Hospital. A joint press release was prepared and I think it is worth bringing to blog readers.

Begin Release -----

The first Natural Language Processing Systems to be used in Patient Care in an Australian Hospital

Sydney University’s Eureka Prize winner of 2005, Professor Jon Patrick, is once again leading the field by developing a suite of natural language processing systems to support patient care in the Intensive Care Unit at the Royal Prince Alfred Hospital Sydney. In a successful collaboration with Dr Robert Herkes, the Director of the ICU two new systems have been introduced into operations.

The first system converts doctors’ progress notes of patients into the formal medical encoding ontology SNOMED CT thus enabling more consistent descriptions of patient conditions and allowing large scale retrieval and analysis from the narrative part of the patient record.

The RPAH announced that it has commenced the use of a new Ward Rounds Information System (WRIS) developed by the School of Information Technologies at the University of Sydney. The purpose of the WRIS is

• to improve the efficiency of collecting data about patients during ward rounds, and
• demonstrate the automatic computation of SNOMED CT codes as clinicians write their progress notes.

The second system, a Clinical Data Analytics Language (CDAL) is being launched at the same time. Its purpose is to answer any question that can be answered from the data stored in the clinical information system. It will assist clinicians in the management of the vast amounts of complex information generated during an ICU admission and ultimately improve the quality and efficiency of care. CDAL allows staff to frame any question about their data in their database and get the answer almost immediately. CDAL, as well as giving access to the normal data in the clinical information system, also searches the doctor’s notes to help answer questions, operating somewhat like a Google engine would operate over the text data in the clinical information system. However it is much better than Google in that it understands a great deal about the natural language used in the notes and so it does a much better job of retrieving semantic content based on its context, for example you can ask for records where the “diagnosis is diabetes”, rather than searching for all instances of the word “diabetes”. The CDAL is supported by the SNOMED encodings created by the WRIS system so as to make its retrievals more accurate.

CDAL also has an hypothesis testing capability along with a restricted natural language interface so that you can ask a question of it directly in ordinary medical language, such as “ is there a significant difference in blood sugar levels for patients with diabetes mellitus between those over 50 years old compared to those under 50.” The CDAL engine will check the clinical notes for patients who have diabetes (excluding those records as “no diabetes”) extract their blood sugar levels from the correct records in the database and compute the significance test.

As one doctor said “I can do my research while I am on my ward rounds”. Other staff report that they expect significant time saving by being able to get accurate searching of pages of clinical notes for specific items of information when they need to resolve uncertainties for administering patient care or review a patient case.

One of the first tasks being targeted for CDAL is a collaboration with the Mayo Clinic to build an efficient and effective mechanism to identify Acute Respiratory Distress Syndrome ARDS. The Mayo and the RPAH will use an algorithm designed at the Mayo for identifying ARDS at-risk patients that can be installed in the CDAL in a minute and evaluated routinely every few minutes for all patient in the ward. The task is to assess the extent to which the constant monitoring by a CDAL routine can aid earlier detection of ARDS, and support rapid modification and subsequent evaluation of each version of the algorithm.

CDAL like WRIS, has been researched and developed to by independent of the system it is attached to so it can be moved to any other clinical information system and used in all other departments across the hospital.

WRIS achieves its purposes by two processing steps. It computes a tailored extract of the patient’s clinical record from the ICU’s information system CareVue, relevant to the needs of completing the ward round. This extract includes pertinent haemodynamic and laboratory data which is presented to the clinician on a screen, who then adds the relevant progress notes. After analysing the progress notes, WRIS computes the SNOMED CT codes in real-time, which the clinician then verifies. The correct codes are then able to be stored back into CareVue. The results can also be used to index the records so that when staff are searching for particular cases, or notes within a case, they can be retrieved directly in the same fashion that Google gives us access to relevant content across the Internet.

The WRIS system is the first example in Australia of the use of Natural Language Processing (NLP) with real-time processing at the point of care to support the care of patients.

The system will be of significant advantage to the clinician in their ward rounds. The automatic extraction of relevant content will give considerable time savings, both in terms of duplication and transcription considered to be up to 10 minutes per patient.

SNOMED CT has been introduced by the National E-Health Transition Authority (NEHTA) as Australia’s standard coding scheme for electronic clinical records. The introduction of WRIS is the RPA’s first initiative to systematically record its clinical notes in SNOMED CT codes. Automatically computing the SNOMED CT codes saves the work of the clinician needing to complete the coding.

The advantages of automatic coding will be extended and enhanced in the future with projects to:

• Automatically compute ICD 10AM and DRG codes from SNOMED CT codes.
• Improve data analytics for medical research with a stable representation of the contents of the medical records;
• Improve logistical planning for hospital management with more reliable and more detailed descriptions of the hospitals case mix;
• Engage clinicians in stabilizing their case descriptions around an agreed terminology and so enhance communications between different specialities and with the wider health community outside the hospital setting.

Research between the University of Sydney and the ICU at RPAH is on-going with projects to:

• enhance the accuracy of the text to SNOMED CT converter;
• develop a rich language for performing data analytics on the patient databases;
• automatically compute ICD 10AM codes from the SNOMED CT codes;
• automatically compute Diagnostic Related Group code (DRGs) from the combination of the electronic medical record and the ICD 10 AM codes:
• perform real-time auditing of patient care automatically by computationally comparing the patient’s record of care with the appropriate clinical guidelines.

Dr Robert Herkes

Director

Intensive Care Unit

Royal Prince Alfred Hospital

Camperdown, NSW

Professor Jon Patrick

Health Information Technologies Research

School of Information Technologies

Faculty of Engineering and IT

University of Sydney

Camperdown, NSW

End Release -----

It is really to see this sort of collaboration happening – especially for one who in another life was an ICU specialist – and to have beginning to emerge practical and useful outcomes of the use of clinical terminologies.

Keep up the good work!

I am sure there are other groups doing interesting and useful things around the ‘wide brown land’! I would love to let people know about them. My e-mail address is easy to find on the blog!

David.

What Would Get My Tick for an E-Health Policy?

We are now just three weeks from the Commonwealth Election – so it is time for my E-Health Manifesto!

A week or so ago I published a small set of points that are apparently being recommended by AHIC to the Australian Health Ministers Advisory Council (AHMAC) as the basis for a National E-Health Strategy.

These points were (my comments follow each point in italics):

1. To develop a comprehensive national E-Health strategy in consultation with the Jurisdictions, industry, community and health services.

This one is hard to argue with except that it does not go far enough in the sense that we not only need the Strategy but we also need the compelling Business Case and the Implementation Plan that should be developed at the same time.

I also think we need to explicitly recognise the imperative for a holistic approach that covers both ambulatory, hospital and community care in both private and public sectors as well as public health and the ancillary services (labs, radiology etc) and allied health.

Of course the other stakeholders need to be involved properly in the sense of the IT Industry, the funders of the overall system and last but not least the community. It is, after all, the quality and safety of the care they receive that is the key reason for doing all this.

Also, it is also important we identify the ‘real’ stakeholders. There is the risk that some elements among apparent stakeholders may not have a solid mandate from their constituency.

2. That AHMAC recognises that E-Health is the cost of doing business in the 21st century, hence requiring continued investment

All I can say is well put. It is most important to also recognise also that those who receive benefit from the investment should be those who pay.

3. That AHMAC recognise that the Jurisdictions already have many of the necessary E-Health components already, and that what is needed is a system of knowledge exchange

This seems to me to be a bit of a sop to the Ministers who all (with the possible exception of South Australia – or so they seem to think!) have not exactly made huge steps in the last few years.

This is hardly a secret when we have the likes of Crikey suggesting that the Victorian HealthSMART project is so unpopular with financially struggling health services they are being offered long term loans to fund the needed Health IT investment – in the hope that all those who both provided and accepted the loans will be long gone before they need to be repaid. I wonder is it true?

Really what is needed is an honest audit of who is up to where, and how it is actually going. This should be part of any Strategy development process.

4. That a ‘time limited’ implementation function / body be established and funded by AHMAC to integrate eHealth nationally

In this context I am not sure just what is meant by integrate - is this meant to be NEHTA or is AHIC suggesting a role change for NEHTA.

My take is that we need to continue down the standards driven path but that those responsible to deliver that initiative need to be open, consultative, pragmatic, transparent and possess a deep understanding of the health system. To achieve this will take a good deal more than a throwaway line of two in the NEHTA Annual Report saying they plan to usher in a "more transparent and consultative approach”.

My policy would also ensure NEHTA is fully exposed to Freedom of Information accountability and I would insist on public disclosure of all reports paid for by NEHTA – including the review undertaken by the Boston Consulting Group (BCG).

If not fully addressed by the BCG Report I would also review the likely value that will flow from continuing with NEHTA’s work plan and adjust it in line with the Strategy mentioned above.

5. That the core set of components for a Shared Electronic Health Record be operating across Australia by 2012

6. That an implementation plan and resources schedule be developed to deliver the AHMAC eHealth strategy

The goals identified in point five and point six are really an extension of what should happen in point one. In addition there also needs to be an explicit benefits management and evaluation plan developed to ensure all parties are getting what they need and what they are paying for.

What is missing from this is the harder part. I would suggest the policy also needs to have the following drivers:

1. Local responsiveness in the context of a national strategic direction. There needs to be clear recognition that the top-down one size fits all approach is a prescription for disaster.

2. Prevention of wasteful, half baked, poorly considered non-strategic local initiatives.

3. Substantial clinician input and leadership where appropriate.

4. Recognition of the inherent complexity of the task (especially the Shared EHR development and implementation task) and the preparedness to walk before running.

5. More intelligent balance in the investments made across the hospital, GP, specialist, public and ancillary sectors.

6. Clear recognition of the importance of getting privacy and security right (and publicly acceptable).

7. Understanding of the importance of education in the use and deployment of Health IT.

8. More than lip-service acknowledgement of the difficulties of change management of any E-Health transition.

9. Recognition we need to fully and urgently address the state / federal / local divide. We need one coherent health system supported by a coherent E-Health system. All relevant legislation and regulation needs to be harmonised.

10. Appropriate support for research in the e-health domain.

11. Support for appropriate strategic consolidation and evolution of the clinical software industry where that makes practical and commercial sense leading to improved service provision in the health system.

12. A much enhanced (and dominant) role for Standards Australia in standards setting and an emphasis on international compliance and compatibility where appropriate.

13. Development of appropriate accreditation regimes for the quality, safety, standards compliance and functionality of all software used in patient care delivery.

Well, I think that just about covers it. Anyone who promises this can have my – sadly not very marginal – vote!

David.

Note: Useful Sites for the Week will appear later in the week. Too much on to let the election slip by!

Emergency Prescription Provision for Displaced Persons – Where is Australia Up To?

The following report in Health Data Management prompted me to think how would Australia cope if 500,000 people were evacuated from part of one of our major cities.

Site Offers Rx Info for Wildfire Evacuees

(October 25, 2007) A new emergency prescription history program has been activated and updated to enable physicians to access information for residents displaced by the California wildfires.

The In Case of Emergency Prescription history service and secure Web portal were created earlier this year by several national pharmacy chains and electronic prescription network vendor SureScripts, Alexandria, Va. The program was designed to offer clinicians access to patient pharmacy records during an emergency, building on the KatrinaHealth.org Web site that was created to access electronic medical information for patients affected by Hurricanes Katrina and Rita.

Clinicians using electronic prescribing software certified to work on the SureScripts network can access the drug data via the Rx History icon in the application. Physicians without certified prescribing software can register to access the information at icerx.org. Physicians must have several identifying pieces of information about a patient to access their medication history from the site.

Continue reading here

http://www.healthdatamanagement.com/html/news/NewsStory.cfm?articleId=15951

It would seem that, given there is a record held at Medicare Australia(MA), of all the medications provided under the PBS scheme – which would cover the vast majority of important medications each Australian in taking a similar portal could be developed for Australian GPs who find themselves having to support displaced patients.

Given NEHTA is working with MA to deliver identifiers for both clinical providers and patients there seems to be little barrier to this becoming a reality with a little planning and work.

I wonder will anyone have the wit to ‘just get it done’. A lot of people might be very grateful if we have an event like Cyclone Tracy or Cyclone Larry again!

David.