Useful and Interesting Health IT Links from the Last Week – 13/05/2007

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

http://www.latimes.com/news/nationworld/nation/la-na-fda10may10,0,7729043,full.story?coll=la-home-nation

Senate passes sweeping drug-safety bill

The FDA's powers and staff would be enlarged to more quickly scan the marketplace for risky medications.

By Ricardo Alonso-Zaldivar
Times Staff Writer

May 10, 2007

WASHINGTON — The Senate overwhelmingly approved a landmark drug safety bill Wednesday, doubling the number of government scientists assigned to ferret out risky side effects in medicines already on the market.

The measure also would create a computerized network to scan medical insurance and pharmacy records for signs of trouble with new drugs, and significantly expand the Food and Drug Administration's power to require drug makers to reduce risks.

"This is unquestionably the biggest change in the FDA's regulatory authority in a very long time," former agency Commissioner Mark B. McClellan said. "It is really a new era for the FDA that will start after this law is implemented."

The Senate bill was drafted in response to highly publicized safety lapses — including the belated withdrawals of the painkiller Vioxx and the diabetes drug Rezulin, as well as the FDA's tardy warning about the suicide risks of antidepressants.

Rezulin, which was found to cause liver failure, was pulled from the U.S. market after being cited in more than 500 deaths. Vioxx was found to increase the risk of heart attacks.

David Willman, a veteran reporter in The Times' Washington Bureau, won a Pulitzer Prize in 2001 for his investigation into FDA approval of seven drugs, including Rezulin. The Times investigation found that the FDA had given the drug fast-track approval despite concerns within the agency over its safety.
…..

Key Points of Legislation

Drug safety

Some highlights of the prescription drug safety bill passed by the Senate:

• Creates a computerized system to monitor potential problems with new drugs.

• Gives the Food and Drug Administration stronger legal powers to require follow-up safety studies and stronger warnings for medications already on the market.

• Provides significant increases in funding and staff for the FDA drug safety office.

• Expands public disclosure of clinical trials and their results.

• Requires the FDA to release dissenting opinions of agency scientists.

• Imposes stricter conflict-of-interest rules for the FDA's outside advisors.

This is really a major set of changes for the US Food and Drug Administration to try and improve drug safety and drug side effect monitoring. Of course it is only through more effective use of Health IT that such improved outcomes and safety can be achieved.

In Australia we will soon have a new regulator. The new regulator will be the Australia New Zealand Therapeutic Products Authority (ANZTPA), and will replace Australia's TGA and NZ's Medsafe in evaluating the risks and benefits of prescription and non-prescription medicines, blood products and medical devices. This planned new regulatory agency should look very hard at what is happening in the US in this area.

Second we have:

http://www.e-health-insider.com/comment_and_analysis/index.cfm?ID=212

Deal or no deal?

10 May 2007

With a full blown bid for iSoft by Australia's IBA Healthcare now appearing imminent, a number of pressing questions are raised by the potential deal.

Not least, is whether the acquisition of the principal clinical software supplier to the NHS IT programme by a smaller Australian rival would best serve the interests of the NHS?

First, it's worth remembering that iSoft is not spoilt for choice of suitors. IBA Health is the only potential bidder to yet identify itself publicly. Press reports suggest that the likes of health IT giant McKesson withdrew after taking an initial look.

After a suffering a litany of body blows in the past 18 months – most notably mounting delays in delivering the key Lorenzo product, ongoing regulatory and financial investigations and being forced to restate its accounts – iSoft has seen its stock market valuation plummet, together with City confidence.

Since taking over at the helm last summer executive chairman, John Weston, has managed to bring stability and cut costs sufficiently to ensure the company remains a going concern until November. But it must deliver the next generation Lorenzo product to its key LSP customer, Computer Sciences Corporation, and has a pressing requirement to secure long-term funding or find a buyer.

The key question for NHS customers remains whether IBA will be able to deliver Lorenzo any quicker or more effectively than iSoft or whether it would instead offer alternative products – potentially iSoft legacy products. The current stated delivery deadline for Lorenzo is early 2008; would an IBA acquisition make this more or less likely to happen?

…..

It will be fascinating to see how this plays out. It is well worth while to read the whole article for background. My views on this proposed takeover are to be found here:

http://aushealthit.blogspot.com/2007/02/some-gratuitous-advice-for-iba-health.html

To date I have had no reason to change my views.

Third we have:

http://www.healthleadersmedia.com/view_feature.cfm?content_id=89387

Avoiding the Iceberg: Technology's Affect on Operations

Cynthia Centerbar, for HealthLeaders News, May. 10, 2007

Over the past 20 years, healthcare information technology has improved dramatically (remember when a 14K speed modem was considered fast?). Likewise, healthcare managers have become more sophisticated technologically-speaking. There is no shortage of meticulous IT implementation plans replete with specific objectives, critical success factors and detailed timelines. However, more often than not these plans neglect a crucial element that can determine whether the entire project fails or succeeds: The effect of the technology on operations.

…..

This article is well worth a read and makes the vital point that the impact of technology on those at the workplace is a very important aspect of health IT technology implementation.

Fourth we have:

http://www.fcg.com/Research/FCGNewsletters-HealthcareIndustryNewsSummary.aspx

Healthcare Industry News Summary

April 2007

This News Summary contains synopses of, and commentary on, health-related articles that have been published in the industry and popular press. The Summary is posted by FCG to this website monthly to help you stay abreast of industry issues and trends. The Summary is not intended to be a comprehensive review of these publications, but it will highlight innovations, advances in the state of the art or practice, interesting facts, and "scuttlebutt" about the industry that will help you keep up with what is happening. The information has been sorted into categories to assist you in identifying information that is relevant to your interests.

…..

This monthly newsletter from the First Consulting Group in the USA – which is a major Health Consulting firm with a very significant interest in Health IT – typically extends to 30+ pages of very useful summaries on topic of interest to readers of this blog. I strongly recommend those interested sign up for the monthly alert.

Last we have:

http://www.smh.com.au/news/technology/privacy-concerns-over-government-net-plans/2007/05/07/1178390224540.html

Privacy concerns over Government net plans

• Saved
  

Adam Turner
May 8, 2007
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Privacy advocates fear the introduction of a single-user name and password for accessing all online government services has the potential to become a digital national ID card.

Today's Federal Budget allocates $42 million to create a single sign-on service as part of the Australian Government Online Service Point. To be built at australia.gov.au, the service will enable Australians to carry out transactions with multiple government agencies, and move between government websites, without the need to reconfirm their identity.

In addition, australia.gov.au will use "smart forms" to automatically draw a user's details from various government departments - such as inserting Medicare details into electronic tax forms. The site will also offer a National Government Service Directory and a change of address service to eliminate the need for users to notify multiple government departments when they move house.

Around 500,000 people currently visit the site every month and 20 government agencies use australia.gov.au to provide search services for their own websites. From next year, users will have the option to create a single sign-on account.

…..

This particular announcement may have not attracted your attention but, at first look, this seems to be yet another identity management system which has the potential to create yet another data-base of the Australian citizenry. The list of these demographic databases existing or planned in the federal public sector now seems to include the Access Card Database, the various Medicare Australia demographic databases, the Document Verification System database, the NEHTA IHI and now this current proposal.

One really wonders why we can’t develop a co-ordinated national approach to electronic individual identity management.

More next week.

David.

NEHTA Really Gets One Right!

On May 8, 2007 NEHTA released a report entitled “Standards for E-Health Interoperability, An E-Health Transition Strategy Version 1.0 – 08/05/2007”. As someone who has been involved in assisting NEHTA in developing reports in this area in the past, and so has considerable familiarity with the issues and difficulties that surround the area, I must say I am genuinely impressed.

It seems to me the key messages contained in this document are all very robust and sound and should be strongly supported by the e-health community. It would be of much benefit to everyone concerned with the future of e-health in Australia if the vendor community at large and anyone else took a little time to lodge their comments in that regard on this blog site - anonymous or otherwise. I repeat, I am genuinely impressed.

The key messages I draw from the report – in my words - are as follows:

1. Clarity and clear differentiation is required when thinking about and deciding how to approach health messaging and the internal structure of electronic patient records.

2. There is a recognition that e-Health in Australia is going to be largely delivered by commercial off-the-shelf software and that any approach to standardisation of interoperation needs to recognise this fact.

3. NEHTA’s customers (the Australian jurisdictions) are interested in deploying web services approaches and SNOMED CT in future systems, but right now they are wanting to implement and utilise what they already have and to consider such steps in parallel with future upgrades.

4. That Australia does not have sufficient critical mass (too small) to try to be a global standards trend setter given the investments in e-health standardisation that are now occurring in the rest of the developed world. We need to be a contributor and ‘quick learner’.

5. Just as the CEN / ISO EN13606 standard was unfinished and incomplete 18 months ago it remains so today, and with the progress being made by HL7, it is increasingly becoming practically irrelevant.

6. For the present the incumbency of HL7 V2.x messaging should be recognised and supported – and extended where appropriate – while planning commences for ultimate migration to HL7 V3.x when that is assessed as appropriate. There are still some concerns about the technical viability and implementation complexity of V3.x, but with the evolved NHS approach to its use it is highly probable useful results will be obtained in the medium term.

7. The Healthcare Services Specification Project (HSSP) seems to be an initiative with a lot of intellectual and practical fire-power behind it and looks likely to deliver highly useful outcomes over time.

8. Efforts to persuade Health Information System Vendors to change key underpinnings, internal structures and design approaches in their software are likely to be resisted unless a very compelling business case is provided.

9. The report sees no substantive place for openEHR type approaches in Australia’s e-Health future.

10. To have actual full scale implementations before standards are agreed is essentially a sensible approach wherever possible

On the basis of these insights and findings – the following conclusion and recommendation seems both rational and sound:

“On the basis of this assessment, migrating to a Document/Services-Centric HL7 v3 approach was selected as the preferred longer-term direction, complemented by support for continued use of HL7 v2.x and development some limited extensions in the short-to-medium term.”

This clearly defines the long term future as being based on migrating to a document/services-centric approach using HL7v3 CDA R2 and HSSP. (and I presume successors). This is certainly a choice I endorse.

Implicit in all this is a new sense or practicality, pragmatism and a recognition of the reality that actual achievement of goals such as ‘semantic interoperability’ are very much more difficult and complex than may appear even at a third close look – let alone at first glance. This change is to be welcomed heartily.

If I have one problem with the report it is that in deciding not to utilise openEHR it failed to make clear the complexity of openEHR deployment at any substantial scale which I remain convinced is a major problem.

Overall it seems to me this is an excellent review and heads in the right direction.

It seems on this basis we can now adopt some of my other pragmatic suggestions from previous blogs given the place we now, at long last, find ourselves.

Steps might include:

1. A major pragmatic review of the current further standardisation priorities (in conjunction with industry and Standards Australia).

2. A review of how best to get short term improvements into the field ASAP – again in conjunction with industry.

3. Re-shaping of the NEHTA work plan to be more aware of outcomes and clinical needs.

4. A new work program to ensure appropriate information flows between the major actors (GPs, Specialists, Hospitals and Service Providers).

5. Suppression of initiatives which do not conform to the directions defined above (e.g. the money wasting activities in South Australia and Tasmania under the dead HealthConnect banner).

6. A careful review of just what Information Infrastructure is required with this direction now so determined. (Where does the Commonwealth Government single-sign-on initiative fit, and also where do the Access Card project and the Medicare e-Prescribing work now fit, etc.)

7. A re-assessment of just what may be a practical and useful SEHR that offers utility and value for money and is politically and financially acceptable. A study of the quality of the present document on that topic would be invaluable for all concerned.

8. Utilise the same, or even wider QA processes, to ensure deliverable quality is at the level seen in this document.

I see this report as a watershed – I wonder whether it can be successfully built on?

David.

One small nit:

“Each of the approaches and the strengths and weaknesses of each are discussed in Section 0.” Page 12. This needs to be Section 4.1 I think.

The Not-so-Special e-Health Budget Special

It is fair to say it has been a bad budget for e-Health in Australia at the Federal Level.

The National e-Health Implementation Expenditure has essentially been halved from the 2006/7 financial year to the 2007/8 year.

According to the Departmental Papers the plan is as follows:

Progressing the e-Health Agenda

In 2007-08, the Government, through the Department, will continue to work with all states and territories, health professional groups and consumers, to address those aspects of e-Health which require national leadership and coordination. The Government will continue to invest in key elements of e-Health infrastructure where a common, national approach is required. The Department will specifically oversee the development of national standards to ensure compatibility of e-Health systems across the health network.

Program 10.2: e-Health Implementation

The e-Health Implementation program funds a range of activities aimed at delivering e-Health infrastructure where a common, national approach is required. This is achieved through encouraging the development of national standards to ensure compatibility of e-Health systems across the health sector. The contribution to this outcome is measured by the uptake of e-Health initiatives.

Program 10.2: e-Health Implementation

Appropriation Bill 1

$,000

2006/7 2007/8

Budgeted 78,972 40,041

Actual 78,972 40,041

It is useful to compare this with what was said last year( 2006/7).

Leadership in eHealth

In 2006-07, the Department will focus on supporting the development of the electronic clinical communication’s architecture, individual health identifier and provider index, to enable a national electronic health record, which will contain a summary of important health information for use by both health care providers and consumers. The Department continues work in collaboration with all States and Territories on the e-Health strategy, and with the National E-Health Transition Authority on standards and infrastructure.

Program 10.2: e-Health Implementation

The Broadband for Health Program provides funding to health care providers for connection to high speed broadband. The program’s success is measured by the number of community pharmacies, general practices and Aboriginal Community Controlled Health Services who have connected to a broadband service that qualifies under the Broadband for Health Program.

Program 10.2: e-Health Implementation

Appropriation Bill 1

$,000

2005/6 2006/7

Budgeted 53,670 56,768

Actual 53,670 56,768

The most interesting changes from last year are:

1. We now have no mention of national e-health strategy

2. The concept of an national electronic health record has gone from the papers

3. The proposed funding has been essentially halved.

4. Broadband for Health seems also to have vanished.

For context the total Commonwealth Health spend is 42,964M, so the e-health spend is less than 0.001% of the total!

Note that neither HealthConnect or NEHTA are not mentioned as being funded in either sets of papers – so I have no idea where the NEHTA money as well as money being spent in Tasmania, SA and the NT actually comes from. Certainly it seems HealthConnect is dead!

The other implication of all this is that should the Australian Health Information Council come up with a useful e-health strategy it would be be the 2008/9 budget before it would get funded - barring a real miracle and Health Ministerial change of mind.

I think it is pretty clear the Commonwealth Government simply does not get it! If anyone can spot any other e-health investments in the papers please let me know

A sad day.

David.

Here We Go Again!

The following statement was issued by the National E-Health Transition Authority (NEHTA) last week.

“Conversation: STATEMENT on the NEHTA Review

Subject: STATEMENT on the NEHTA Review

For more information:

Gabrielle Lloyde

NEHTA

gabrielle.lloyde –at- nehta.gov.au

0408 170001

STATEMENT on the NEHTA Review

Friday, May 04, 2007

The Directors of the National E-Health Transition Authority (NEHTA) wish to advise that they are seeking to complete an independent review of NEHTA as required under NEHTA¹s constitution.

NEHTA Ltd was established in July 2005 and funded jointly by all federal, state and territory governments for a three-year period to accelerate e-health in Australia. NEHTA¹s constitution requires Directors to commission an independent review of NEHTA¹s future direction two years after the company¹s formation.

The review will address the effectiveness of NEHTA in meeting its objects, as set down in the constitution, including whether these objects remain valid and appropriate.

To this end NEHTA will be engaging, via open tender, a suitably qualified professional services firm to undertake the review. The selected firm will gather information on all aspects of NEHTA¹s operations, including information obtained from:

• NEHTA and its Directors;
• Jurisdictions;
• Key stakeholders; and
• Independent research.

In addition, the review will consider the future direction for e-health reform and appropriate vehicle(s) to deliver the future directions. The review is required to be finalised by October 2007.

The findings of the review will be provided to the Directors in the first instance. A General Meeting of Members of NEHTA LTD will be called within two months of the review being completed to consider the findings.

ENDS

About NEHTA

The National E-Health Transition Authority Limited is a not-for-profit company established by the Australian Commonwealth, State and Territory governments on July 5th, 2005. It aims to develop better ways of electronically collecting and securely exchanging health information, to:

* Improve the quality of healthcare services, allowing clinicians to more easily access accurate and complete information about their patients

* Streamline the care of people with long term illness, who need to be looked after by many different health professionals, by enabling seamless handovers of care through for example electronic referrals and discharge summaries.

* Improve clinical and administrative efficiency, by standardising certain types of healthcare information to be recorded in electronic systems; uniquely identifying patients, healthcare providers and medical products; and reforming the purchasing process for medical products.

while maintaining high standards of patient privacy and information security.

NEHTA¹s Board of Directors is composed of the heads of all nine government health departments. In effect, this means that the national health care system owns NEHTA and its decisions.

Gabrielle Lloyde

Communications Manager

nehta National E-Health Transition Authority

Tel 61 2 8298 2620

Mobile 040 817 0001

E-mail gabrielle.lloyde – at-nehta.gov.au

Web www.nehta.gov.au”

There are a few comments that need to be made about this release.

First let us consider what the NEHTA review is meant to ascertain.

Excerpt from Constitution:

“41. REVIEW

41.1 The Meeting of Directors will facilitate an independent review of the Company in the first Month of the third year from the time of this Constitution being adopted to assess whether it has met its objectives and should continue in operation.

41.2 The Members will assess the review procured under clause 41.1. The Directors must call a General Meeting within 2 months of the completion of the review and (whether in person, by representative or by proxy) the Members present and eligible to vote may pass a resolution to wind up the Company by a 75% majority or determine the basis on which the Company will proceed.”

So the press release somewhat diminishes the importance of this review. This is an existential review to decide of NEHTA has met its objectives – and if so, how the work is to be continued and if not what new approach and plan will be adopted.

So just what are the objectives of NEHTA constitutionally?

Excerpt from Constitution:

“3. OBJECTS

The objects of the Company are any or all of the following:

3.1 To provide the critical standards and provide and manage the development of infrastructure, software and systems required to support connectivity and interoperability of electronic health information systems across Australia;

3.2 To research, develop and implement national health information projects including (but not limited to):

3.2.1. clinical data standards and terminologies including the development of standards and common terminologies for health information for clinical service delivery, planning, policy making and research purposes and communication between health systems in Australia;

3.2.2 patient, provider and product / service standards and directories / indexes that contain information necessary to uniquely identify patients, providers, products and services and other relevant information across the whole of the health sector in Australia;

3.2.3 identification standards to define the data structure and specification for capture and storage of information required or (sic) the identification of patient, provider and products / services in Australia;

3.2.4 a product services directory which contains information for identification of products and services;

3.2.5 consent models governing collection and handling of electronic health information;

3.2.6 EHR standards;

3.2.7 technical integration standards to define the structure and rules by which information is exchanged between systems and users;

3.2.8 supply chain efficiencies, including exploring options such as common forms of procurement, standard contracts and common purchasing processes;

3.2.9 user authentication and access controls to ensure compliance with privacy laws and the consent models which have been developed;

3.2.10 EHR secure messaging and information transfer including identifying and managing the development of a national security model for messaging and information transfer between healthcare providers’ systems;

3.2.11 a knowledge centre, providing knowledge-sharing and expert advice to the public and private sectors on business case development and implementation requirements for health information systems so as to meet national standards and architectures;

3.2.12 to encourage health information industry reform and to facilitate opportunities in driving technological reform in health information technology, so enabling consistent interoperability and implementation of national health information technology priorities; and

3.3 Any additional object with 100% of Members determine should be included in this Constitution at a General Meeting.”

A careful review of this set of objectives leaves on with the sense that the drafters expected substantial progress to be evident when the review is undertaken – noting that NEHTA was actually commenced in July / August 2004 and had its CEO appointed in November / December 2004 – giving the period to be assessed a length of 30 months at least.

My assessment of where NEHTA is currently at is as follows:

1. Thus far I cannot see a single life saved or a single dollar saved as a result of NEHTA’s exertions. I can however see the expenditure of tens of millions of dollars.

2. NEHTA has done some research but essentially has failed to develop or implement anything tangible.

3. It seems clear the Federal Government recognises that the decision to hand e-Health to NEHTA to solve the problem has been, at least, a partial failure – given the recent resurrection of the Australian Health Information Council (AHIC) by the Commonwealth Health Department. The alternate explanation that AHIC has been resurrected because NEHTA’s work is almost done and the next steps need to be planned – i.e. the post finalisation of e-Health Standards phase has arrived in Australia– is so crazy as to be laughable!

4. NEHTA is essentially unknown to the Health Sector at large and is seen as essentially irrelevant by most of the Health IT industry as they have yet to provide any additional value to that already delivered via Standards Australia.

5. NEHTA Compliance is treated as a joke essentially, even by Member governments, – see the various initiatives funded out of HealthConnect for all the evidence you need.

6. NEHTA continues to deny its need for a strategic view to guide its actions and preserve coherence.

7. The imminence of the review has resulted in a flurry of releases of half done and half thought out draft work to try and demonstrate value – which is clearly lacking.

I leave it as an exercise for the reader to determine their view as to how well NEHTA has met its Constitutional objectives, and how closely what is now says it is doing matches with what it was meant to do.

Sadly, we all know what comes next.

The independent review will be undertaken as a ‘commercial-in-confidence’ engagement by a tame and friendly professional services firm in private, the NEHTA Board will receive the report they want, to avoid any possible criticism, and the report will disappear and never be made public. Some time, probably just before an October 2007 election, NEHTA will issue a one page press release to say it has been independently reviewed, needs to change one or two small elements of its plan but otherwise all is well. Note the Constitution does not seem to require regular further reviews – so that is that – and we have NEHTA forever!

See how close I get to what actually happens over the next six months.

At the very least the review needs to be commissioned by, funded by, and reported to the Commonwealth Department of Health and then made fully public. It also needs to ask for public commentary and submissions on a final draft. Having NEHTA commission the review itself, and then to have its officers manage the review, is a “putting the fox in charge of the henhouse situation” in spades! NEHTA Officers are clearly in a situation of major conflict of interest, after all, the review is meant to determine if NEHTA should continue to exist or not . To not fully separate the reviewers and the reviewed, as seems to be proposed, is just a farce!

David.

Useful and Interesting Health IT Links from the Last Week – 06/05/2007

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

The Informatics Review : May 1, 2007 : Vol.10 No.9

http://www.informatics-review.com/index.html

Ten Simple Rules for a Successful Collaboration

Given that collaboration is crucial, how do you go about picking the right collaborators, and how can you best make the collaboration work? Here are ten simple rules based on our experience that we hope will help. Above all, keep in mind that these rules are for both you and your collaborators. Always remember to treat your collaborators as you would want to be treated yourself—empathy is key.

Ten Simple Rules for Reviewers

There is no magic formula for what constitutes a good or a bad paper—the majority of papers fall in between—so what do you look for as a reviewer? We would suggest, above all else, you are looking for what the journal you are reviewing for prides itself on.

Ten Simple Rules for Getting Grants

At the present time, US funding is frequently below 10% for a given grant program. Today, more than ever, we need all the help we can get in writing successful grant proposals. We hope you find these rules useful in reaching your research career goals.

Ten Simple Rules for Making Good Oral Presentations

Clear and logical delivery of your ideas and scientific results is an important component of a successful scientific career. Presentations encourage broader dissemination of your work and highlight work that may not receive attention in written form.

Ten Simple Rules for Getting Published

When you are long gone, your scientific legacy is, in large part, the literature you left behind and the impact it represents. I hope these ten simple rules can help you leave behind something future generations of scientists will admire.

…..

This is a useful collection of tips for those in the academic community who need to develop and maintain an academic profile. Useful for all those hoping to establish them in Health IT Academia!

Second we have:

http://healthdatamanagement.com

EHR Pioneers Try to Stay Out Front

Latest projects include adding decision support, improving connectivity and developing PHRs.

By Howard J. Anderson, Executive Editor

Like the pioneers who headed West, blazing trails for millions of others to follow, a handful of hospitals and clinics in the final decades of the 20th century were electronic health records pioneers. They took the risk of automating clinical information at a time when many organizations were just taking the first steps toward automating financial records.

Many of these same trailblazers are leading the way toward a new generation of clinical automation decades after they began their original quests. And their efforts continue to yield many important lessons for others following in their paths.

…..

This is a useful set of suggestions as to where the second generation of EHR’s is heading. A long but worthwhile article. In the same May issue there is also quite a useful discussion on the unexpected security risks associated with embedded software in hospital equipment such as dispensing machines.

Third we have:

http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20070502/FREE/70502003/1029/FREE

Paper records more secure: survey

By: Joseph Conn / HITS staff writer

Story posted: May 2, 2007 - 9:02 am EDT

A plurality of people in a recent survey indicated paper-based medical-records systems are more secure than electronic records, but under emergency circumstances, a large majority also indicated the rewards of having their medical records made electric outweigh the risks, according to a survey released today by Kaiser Permanente.

The Oakland, Calif.-based integrated delivery system sponsored the random, national telephone survey of 1,000 adult U.S. residents by StrategyOne, a unit of the Edelman public relations firm. Kaiser, which is undertaking an overbudget and overdue multibillion-dollar healthcare information technology rollout, is hosting a healthcare IT conference today in Washington.

According to the survey, when asked which form of record system was more efficient, 72% of respondents chose computer-based compared with 19% for paper-based, with 8% answering they were unsure. But when asked which type of medical records system was more secure, 47% chose paper, 42% computerized, and 10% were unsure. (Some numbers do not add up to 100% due to rounding.)

Survey participants also were asked whether they agree or disagree with the following statement: "The benefits of electronic medical records, such as better treatment in an emergency and a reduction in medical errors outweigh any potential risk to patient privacy or the security of patient information." Their answers: 21% indicated they strongly agree, 52% somewhat agree, 16% somewhat disagree, 9% strongly disagree and 2% indicated they didn’t know or were unsure.

…..

The complete article provides a range of interesting findings that slightly belie the headline. Indeed the relative safety of paper vs. electronic records was close to balanced and that many people clearly understood the benefits of electronic records. It seems likely that even a limited public educational program regarding the risks and benefits of EHRs is likely to be quite successful.

Fourth we have:

http://www.dallasnews.com/sharedcontent/dws/classifieds/news/jobcenter/news/stories/DN-informatics_29emp.ART.State.Edition1.4320696.html#

Nurses bridge gap between IT, care

Brave new paperless world opens opportunities for more nurse informaticists

08:59 AM CDT on Monday, April 30, 2007

By SUSAN KREIMER / Special Contributor to The Dallas Morning News
More and more nurses have been bridging the gap between information technology and clinical practice. And Mary Beth Mitchell, a registered nurse, finds herself happily positioned at these crossroads.

"It is not enough to have programmers and engineers designing and implementing these systems," said Ms. Mitchell, director of clinical informatics at Presbyterian Hospital of Dallas.

Nurse informaticists are needed as the advent of electronic health records ushers in a preference to go paperless. At least 75 percent of nurse informaticists are developing or implementing clinical information or documentation systems, according to an industry survey. A shortage of these experts bodes well for nurses considering this niche.

…..

An interesting article revealing the truth those of us who have been in the field for a while. “Don’t forget to involve and work with the nurses from the very start of any project”!

Enjoy!

David.

A Useful Contribution from the e-Health Initiative and Foundation

The following arrived in my e-mail today – and is really worth passing on as it provides some useful information and resources. Registration is free.

This material will really be of interest to all those with an interest in health information sharing.

----------

Dear eHI Members and Friends,

I am delighted to share with you, the eHealth Initiative Foundation's (eHI's) release this afternoon, of both research findings and a fully customizable set of new communications tools designed to enhance consumer understanding of the benefits of health IT and health information exchange (HIE). This work is in support of eHI's mission, which is to improve the quality, safety and efficiency of healthcare through information and information technology.

The public education and communications toolkit being launched today, entitled the InformationSTAT Program, was developed by eHI with support from the U.S. Department of Health and Human Services, which provided funds to strengthen Gulf Coast health care services and regional electronic health information infrastructure in the wake of Hurricanes Katrina and Rita.

The eHI web-based tools and resources include downloadable public announcements for radio, "print-ready" artwork for advertisements and billboards, case examples, and brochures on the importance of electronic health information exchange. The more than 30 resources made available today also include partnership development guides and customizable brochures and powerpoint presentations which local sponsors can use to reach out to practicing clinicians and employers to engage them in health information exchange efforts across the country. Access to the InformationSTAT program materials are available free of charge through the eHI Connecting Communities Toolkit. Sign-in is required.

These communication tools were informed by consumer research on health information exchange conducted by Public Opinion Strategies LLC also being released today. A summary of research findings is below:

• Support is extremely strong among consumers for secure electronic health information exchange with 70 percent of respondents favoring its development;
• Consumers recognize the benefits of secure electronic health information exchange and that the more they learn, the greater their support;
• Addressing policies for information sharing up-front and explaining those policies is a must have, particularly in the areas of security, patient permission, consent and access;
• Consumers overwhelmingly trust doctors the most to deliver them information about secure electronic health information exchange; and
• Almost half of consumers believe that their doctors already keep their medical records in electronic form, and a majority believe that it is likely that their doctors' medical records have a back-up copy off-site in electronic form.

These important tools are designed to support both national organizations and states and communities in the early planning stages as they reach out to the public in their regions, to raise awareness of why health information exchange is important, while highlighting safeguards that are in place to protect privacy and confidentiality of health information.

I am delighted to say that eHealth Initiative Vice President Ticia Gerber is spearheading this communications effort within our organization. Please feel free to reach out to her directly (via email at ticia.gerber@ehealthinitiative.org or by phone at 202.624.3264) or to me if you have any questions, would like more information on the eHI communications toolkit and related research, or would like to help eHI "get the word out" on the importance of health IT and health information exchange to as broad an audience as possible.

Sincerely Yours,

Janet M. Marchibroda
Chief Executive Officer
eHealth Initiative and Foundation
818 Connecticut Avenue, N.W., Suite 500
Washington, D.C. 20006
(202) 624-3270

----------

The material can be accessed at the following URL:

http://www.ehealthinitiative.org/news/CommToolkit.mspx

David.

Finally, An Communiqué from the Australian Health Information Council - Almost!

The Australian Health Information Council (AHIC) has finally released the communiqué you release when you don’t want to release a communiqué! To cover two meetings, of a still unknown number of members held over the last two and a half months, we get a single page notification that the meetings have been held.



What else do we learn?

1. The AHIC has a one year work program.

2. The Chairman is Professor James Angus, Dean of the Faculty of Medicine, Dentistry and Health Sciences at the University of Melbourne.

3. There are two executive committee members 1. Professor Enrico Coiera, Director of the Centre for Health Informatics, and Ms Yvonne Allinson, Executive Director of the Society of Hospital Pharmacists of Australia. The rest of the membership is not disclosed.

4. The role of AHIC is now that “The AHIC gives independent policy advice to Australian health ministers through the Australian Health Ministers’ Advisory Council (AHMAC). It provides the end users’ perspective on long-term directions and national strategic reform in health information management and information communication technology.”

5. A generalist Health, and non Health IT, consultant has been engaged to develop a yet to be finalised and possibly disclosed work plan for the next 12 months – after which time who knows what will happen.

6. There will be, at some future point, an e-Health Future Directions Summit, with members of the National Health Information Management Principal Committee being invited to attend.

7. The summit will examine the elements that will need to be in place in the next five to ten years to increase the provision of high-quality, timely information that will help consumers, clinicians and the health system to make the best decisions.

8. The new committee likes workshops rather than business meetings.

What have we not been told?

1. Just what the terms of reference of AHIC now are, who are the members and their affiliations, what were the criteria for selection and what proven track record do the members have in national health IT strategic planning.

2. Why AHIC just vanished and stopped meeting for approximately two years and has suddenly been resurrected.

3. What has happened to the AHIC web-site at www.ahic.org.au

4. Now we have resumed the a full work program – what were the outcomes of the old work program. (Does this remind anyone of the evaluation reports for the HealthConnect Trials?).

5. How end-users doing a future plan is going to influence the evolution of the supporting technology.

6. What is the relationship between AHIC and NEHTA? How are the work plans co-ordinated etc?

7. What are AHIC’s actual powers or is it just an advisory toothless tiger. The transmittal e-mail strongly suggests the latter.

“Subject: The Australian Health Information Council Communique - April 2007 [SEC=UNCLASSIFIED]

Dear eHealth Industry Member

Please find enclosed the April 2007 Australian Health Information Council Communique for your information.

The Australian Health Information Council (AHIC) is a multidisciplinary expert group that provides advice to the Australian Health Ministers via the Australian Health Ministers Advisory Council (AHMAC) on information management and communications technology development in the health sector from the end user perspective.

AHIC is an advisory rather than a decision making body and works in conjunction with industry, the public and private health sectors and professional bodies to formulate strategic advice.

The Council is chaired by Professor James Angus, Dean of the Faculty of Medicine, Dentistry and Health Sciences at the University of Melbourne, who also represents AHIC on the NHIMPC.

The AHIC has agreed that a Communique outlining their activities will be forwarded to eHealth industry members following each meeting.

The AHIC Secretariat is provided by the Department of Health and Ageing. Should you wish to contact the Secretariat please email ahic.secretariat – at- health.gov.au”

8. Other than one page communiqués are there going to be any substantive documents and reports produced by AHIC.

9. Is AHIC going to at any time publish minutes of meetings etc so those interested can be informed as to the directions considerations are taking.

10. What is to happen after the one year resurrection is over in April 2008.

11. What accountability will the AHIC members have for the outcomes in the e-Health domain.

12. What budget has been allocated to support the AHIC Strategic Planning Process?

The important point I see is that AHIC's role seems to be fundamentally different from the past. Rather than being concerned with e-health strategy and its implementation it is now an end user committee based on the assumption that it will all magically come technically together under NEHTA's skilful strategic guidance.

This is really nonsense - we need to get the user needs and the technology aligned and managed as part of a coherent forward plan. I don’t see AHIC being tasked or enabled to really undertake this. The complexity and subtlety of the plan that is required would severely test the Booze Allen’s and McKinsey’s of this world - The clinician engagement strategy of itself will need to be a masterpiece!

Some colleagues are suggesting I wait and see what happens over the next few months. From what I have seen so far I do not hold out much hope for real improvement unless the complexity of developing such a plan is fully recognised and addressed – and time allowed to consult very widely and get to some sensible answers.

I see it as vital there is a push pushing for openness and for doing this plan properly - rather than the planned approach of develop a briefing paper and having one day a meeting with 30 people around the table try to solve some really hard problems on a limited (very limited) information base of where everyone is up to (govt private sector, vendors etc), where the big gaps are and having no clear developed view of what is possible and doable and what the strategic choices really are.

I really feel that unless a really expert in-depth piece of work is done it won't go anywhere and another opportunity will be wasted.

Australia has done the lacking real depth type of planning exercise that is proposed couple of times in the last decade, and we find ourselves where we are.

I also don't think this can be done in chunks or parts - I really believe a proper job needs to be done - looking at current state of e-Health, e-Health governance, technology futures, clinician engagement approaches, costs, benefits, risk management, sector participation and so on.

Surely the lesson of the last decade is that if you do it by half you wind up with very little!

I believe it is time to give it one really good shot and get it right!.

David.

Are You Tired of Being Treated Like a Mushroom – Kept in the Dark and Fed Manure?

This posting will be short and to the point. I was wondering, over the weekend, how many others in the e-Health community feel that all the confidentiality and secrecy surrounding e-Health planning and progress has got a little out of hand. I suspect it may be part of the present electoral cycle but recently I have been seeing two main things happening.

First we have seen all sorts of documents from NEHTA which even by their own admission were just a preview rather than something that could actually be implemented for testing etc. Among the documents I put into this category are:

1. The various technical documents incorporated in the e-Procurement Hub Tender released a month or two ago.

2. The so-called Release 1.0 of the Australian Medicines Terminology (AMT) which was much more like a Release 0.01

3. The Pathology Terminology Reference List v1.0 - Release Note and associated documents

4. The still unreleased document explaining the Selection of HL7 for Australia and what the reasons for the decision were and what the implications for the e-Health Community are. (This document also is one of the secret ones that has been reviewed by consultants – but not been made public for comment by others who might be interested.)

The big question here is why all the haste and why release work that is half finished. Another secret I suppose but I can guess. Maybe a performance review is due?

Second we have news that the Department of Health and Aging (DoHA) and the Australian Health Information Council (AHIC) are working to develop a new e-Health Agenda for the country through a process that is distinctly reminiscent of the work undertaken by the Boston Consulting Group in 2004 and which has led to the present rather unsatisfactory situation in e-Health overall.

Last week a colleague mentioned, in passing, that this directional study was being commissioned and that it was intended that the outcome would be available for consideration by July / August 2007.

Having considered the prospect of such a strategic study, I responded as follows, outlining three points I found concerning about an apparently time, depth and transparency limited approach to the planning.

“First an assumption I have always had regarding any new national strategy is that we should work hard so we don't repeat the mistakes of previous work. These mistakes have certainly included a lack of inclusiveness and a lack of proper consultation with the actual health system and health system providers rather than bureaucrats, peak body representatives and medical politicians as to needs priorities and problems to be addressed. I am not sure what is now asked for is very much the same or not but I think it needs to be raised as a possible risk.

Second, even with a very clever approach, there is a risk of having “lots of time to do it again but not enough time to do it properly”. I also see that as a risk as this is very much a 'last shot in the locker' for 5 years at least. I also fear the political cycle may put time pressures on the project that may make the outcomes less than useful.

My last comment is that, with the way this is all unfolding, the standard operations procedures of DoHA and NEHTA, with almost paranoid confidentiality etc will dominate. This is a worry as it will be a block to getting a real diversity of view and choices to consider. Being 'inside the beltway' can give a very false view of the world.”

I hope my colleague can feed back some of these concerns to the powers that be!

I have no idea how all this will work out ultimately. Given that AHIC has already met twice and there is no public outcome one cannot be all that optimistic. When checked today the AHIC URL was still inactive and I discovered we have a new peak Health Information Management Committee – called the National Health Information Management Principle Committee . There are only two references on the web to this committee and its membership seems pretty obscure. Their functions etc can be found at the following non-DoHA site. More secrecy and very odd I must say!

http://www.e-health.standards.org.au/cat.asp?catid=11

It is amusing that the page lists all the key standing committees but does not mention AHIC!

I really despair of all this – but must continue to hope I guess.

David.

Useful and Interesting Health IT Links from the Last Week – 29/04/2007

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

http://www.fiercehealthit.com/innovators/2007

Top Healthcare IT innovators

Hello, and welcome to the first edition of our Top Health IT Innovators list. We’re excited to be showcasing what are regarded as some of the most interesting—and disruptive—companies we know of in the healthcare IT industry, including some we can
more or less guarantee you’ve never heard of (yet).

Consumer Health IT?

Wondering why you see so many companies working on consumer-type problems on the list, rather than the back-end gear touched by CIOs and network admins? That’s because this may be the year when consumers have more contact with enterprise health IT than they ever have had before. Many of the intriguing technologies we’re highlighting are designed to guide consumers in their care electronically, using smart interactivity and content. Why? Because while doctors are already good at working with standard internal records, they currently don’t have a smooth way to interact with patients online, link the patients into their own decision-making process or collect patients’ self-reported impressions of how they’re doing. We’re not talking about a big boost in the use of PHRs, though that may indeed happen; we’re talking about a two-way flow of clinical and personal information that the industry has never seen before.

If some of the vendors below get their way, though, patients, clinicians and health organizations will have an online data-sharing dialogue, improving outcomes and saving time and money in the process. It’s an interesting shift in the business, and one, that we think is long overdue. We also think it’s going to hit big and take root quickly, so look for some major changes in patient-doctor interactivity this year.

…..

This is a fascinating collection of ideas for Health IT Innovation. Visiting the site provides access to 10 different start-up Health IT entities all of whom have interesting ideas that may make a difference either in how health care is delivered or managed. Well worth a browse.

Second we have:

http://www.kablenet.com/kd.nsf/Frontpage/F3416139CA164565802572C9005A59E3?OpenDocument

MPs warned about e-health records

27 April 2007

The government has been accused of ignoring concerns about the privacy of the NHS e-care record

Contributors to a hearing of Parliament's Health Select Committee on 26 April 2007 claimed the government is pressuring patients for their information to be included on the Care Record Service.

One claimed that the Department of Health has adopted an attitude of "suppressed hostility" towards patients who choose not to be included in the electronic care record system, NHS patient Andrew Hawker told MPs.

Andrew Hawker, an academic who has written about information systems and described himself as "an NHS patient", warned that the implementation of e-care records should be deferred until core IT systems are fully installed and it has been "thoroughly tested for privacy".

"I feel like a passenger on board a plane," Hawker said. "The plane has not had many test flights, and some of those have crashed. Meanwhile flight attendants are handing out brochures saying how safe it all is."

Further warnings were made by Paul Cundy, chair of the General Practitioners' Joint IT Committee. Cundy said that the summary care record, even in early adopter sites, shows signs of becoming far more than just a "summary" care record.

…..

This is another piece of evidence for three of the major contentions I have put in this blog. First that major technology initiatives have to be managed in a way they fully involves those at the coal-face. High level consultation during planning and implementation (with executives and managers) that does not reach the grass roots can pose a great risk to overall project success. Second developing an approach to managing privacy that clinicians and patient are happy with is vital. Third it seems increasingly likely that the best way to approach national e-health projects is to develop ‘bottom up’ implementation approaches and not ‘top down’ methodology.

On the same topic the following is also well worth a careful read – written by the developer of the 1998 Connecting for Health Program.

http://www.publications.parliament.uk/pa/cm200607/cmselect/cmhealth/422/422we54.htm

Evidence submitted by Mr Frank G Burns (EPR 60)

INTRODUCTION

It is, frankly, astonishing that a Committee of the House of Commons should, at the beginning of the 21st century feel compelled to undertake an inquiry into the value and mechanics of managing health care records in electronic form.
…..

The last important item regards SNOMED CT.

SNOMED sold to international organization

The College of American Pathologists has agreed to sell the intellectual property rights to its Systematized Nomenclature of Medicine Clinical Terms, or SNOMED CT, to the newly formed International Health Terminology Standards Development Organization, based in Denmark, for $7.8 million. CAP's decision to hand off SNOMED to an international organization was announced in January. To provide a smooth transition, CAP will continue to support standards-development operations with the new entity under an initial three-year contract and will continue to provide SNOMED-related products and services as a licensee of the terminology, according to an announcement today by the 16,000-member, Northfield, Ill.-based medical specialty society.

Charter members of the successor organization to the CAP and its SNOMED International division are organizations representing Australia, Canada, Denmark, Lithuania, the Netherlands, New Zealand, Sweden, the U.K. and the U.S.

"As the international adoption and use of SNOMED CT has grown, it has become apparent that an international governance structure that is open to the entire global healthcare community would be to everyone's benefit," said CAP President Thomas Sodeman, in a news release. "The college is proud to have assisted in this important milestone." -- by Joseph Conn / HITS staff writer

Details of what is happening in Australia can be found here:

http://www.nehta.gov.au/index.php?option=com_content&task=view&id=187&Itemid=144

A Canadian announcement of similar news can be found here:

http://www.infoway-inforoute.ca/en/News-Events/InTheNews_long.aspx?UID=267

The next step, for us in Australia, will be for NEHTA to announce the license conditions that will now operate and what the going forward arrangements for maintenance of the Australian version – including extensions for medicines etc.

http://www.healthdatamanagement.com/html/news/NewsStory.cfm?articleId=15057

Standard for ER Systems in Works

(April 25, 2007) A new “registered profile,” or a subset of an existing standard, could ease the creation of criteria to certify the functionality, interoperability and security/reliability of emergency department information systems.

Standards development organization Health Level Seven has adopted the Emergency Care Functional Profile as the first registered profile based on HL7’s EHR System Functional Model standard that was adopted in February. The functional model contains about 1,000 criteria covering more than 150 functions in such areas as medication history, problem lists, orders, clinical decision support, and privacy and security. The functional model is designed to provide guidance to electronic health records software developers and purchasers.

The new Emergency Care Functional Profile is a subset of the functional model, containing criteria specific to emergency department information systems.

…..

This profile is a useful step forward and will be of interest to all involved in emergency and ambulatory care system development. More information at the site.

All in all quite an interesting week.

David.

Something You Might Be Missing – The Comments.

As the blog has gradually acquired more readers there has gradually been an increase in the number of Comments posted after each article is published.

Neither the RSS Feed or the e-mail Alert lets readers know that new comments have been posted.

Since the beginning of 2007 there have been a range of really insightful and useful comments posted. (Thanks to all who have done so!) Can I suggest that readers occasionally scroll down the last few articles and check for new comments when visiting as I can find no obvious way to ensure these gems are not missed.

It is of note that many users often carefully consider their comments for two or three days before commenting so it is worth checking out at least the last week when visiting the site.

Oh! and before I go - yesterday it was a month since I have the note from DoHA regarding my letter to Mr Abbott. No response as yet.

David.

It Really is Very Hard to Make Shared EHRs Work.

Sobering news for all the proponents of Shared EHRs came in overnight.

The original article from E-Health Insider can be found at the following URL:

http://www.ehiprimarycare.com/news/item.cfm?ID=2635

iHealthBeat (http://www.ihealthbeat.org/) summarises the key findings well.

“Majority of British Physicians Oppose IT Project, Survey Finds

Sixty-six percent of British general practitioners said they will not allow their own health records to be shared through the National Health Service's Summary Care Record program, according to a survey of general practitioners by Pulse magazine, E-Health Insider reports. Only one-third of respondents said they plan to advise their patients on sharing their health information.
The survey also found that:

• About one-third of physicians said they will allow full sharing of their patient records;
• Four out of 10 physicians say they will opt out completely from the program and allow none of their records to be shared;
• 80% of physicians surveyed still think that sharing electronic health records can threaten patients' confidentiality, despite a government marketing campaign to promote the IT program; and
• 67% of general practitioners oppose the implied consent "opt out" model, which has formed the basis for the program to be rolled out, E-Health Insider reports.

Lord Warner, the former head of the NHS IT program, said that physicians have become "over-protective" of their existing health record system, according to E-Health Insider (E-Health Insider, 4/24).”

The lessons here are clear. The first lesson is that the implementation of a Shared EHR is a project which must be undertaken with continuing and ongoing consultations with clinicians and patients to ensure the directions being adopted are acceptable and will foster adoption and use.

The second lesson it seems to me is that in 2007 the Shared EHR is not a technical problem but a cultural change problem where is the trust of the users of the system is not developed and maintained the risk of failure of the overall project failure is greatly increased.

The third important lesson is that if the approach adopted minimises compulsion, maximises patient control of their information and maximises voluntary choice as to whether to use the technology or not, assuming good technical design, while slower to reach, genuine adoption and use is much more likely.

Separate from this report, the interested reader is referred to my article of March 15, 2007 which is found at the following URL:

http://aushealthit.blogspot.com/2007/03/shared-ehr-can-it-be-done-simply-and.html

Without going over old ground it seems to me a simple Shared EHR can be very useful, but only if it is developed in the context of using the information from advanced clinical systems to provide information to and retrieve information from the shared record. Clearly the shared record also needs to be properly standardised and securely transmitted, received and stored.

All this is easily done, using standard and well tried technology. Making use of the record voluntary for both doctor and patient is the way to go. With a voluntary record, I am sure what will happen is that those for who having their record available is important the service will be used, and those who are unsure or uninterested simply won’t. It should really be as simple as that.

I suspect that among those with chronic and complex disease, in the scenario I suggest above, there would soon emerge pressure on clinicians from their patient’s to upload records as “information insurance” for the chronically ill as well as assisting in the overall co-ordination and delivery of their care.

We must make sure any Australian initiative to develop and deploy a Shared EHR has these lessons from the UK firmly in mind and approaches the project in a genuinely voluntary way!

David.

It’s the Season for Silly Health IT Benefits Claims!

No sooner have we had NEHTA tell us how much we can save from e-Health but now we have a second entrant to tell us something different and even more incredible.

The Australian Centre for Health Research has just published (April 2007) a 19 page document entitled “E-Health and the Transformation of Healthcare”.

For those interested in reading the full document it can currently be found at the following URL:

http://www.achr.com.au/pdfs/ehealth%20and%20the%20transofrmation%20of%20healthcare.pdf


The headline claims from the executive summary are as follows:

“The impact on the individual can be imagined; the cost to the nation is immense. In Australia, it’s estimated that improved knowledge sharing and care plan management for patients with chronic disease would generate direct savings to the health care system of more than $1.5 billion per annum. Savings to the community from associated non-health care costs are of the same order. And increased workforce participation and productivity could add a further $4 billion per annum to the economy.

For the patients, home monitoring could reduce emergency room visits by up to 40%, hospital admissions by 30-60% and length of hospital stays by up to 60%.”

All I can say is “Here we go again!

”The argument made in the paper is:

• Disease Management (DM) and similar process improvement processes work
• Technology and ICT is an important enabler of DM
• If we approach Chronic Disease with technology there is a huge benefit possible.

This is all true as far as it goes. There is also no doubt – from a huge range of studies mentioned in other reports not cited here - that Health IT can make a difference. However the evidence as I read it does not support the proposed approach.

The paper does however get one point exactly right in the following:

“The Paper raises one final, important point - that of incentives. There is a cost to building this connectivity and information sharing but there is a mis-alignment between those who pay and those who receive the benefit.”

And rightly suggests who should pay

“Another important component is for the major beneficiaries of more efficient and effective health care (that is, governments, private insurers, and employers) to provide incentives for the use of electronic services, broadband health networks, and best practice processes.”

Of course we have yet to see any offers from Government etc to really ante up what is needed!

In summary the suggested approach is:

“ We should focus on three important areas:

1. get healthcare providers connected to one another
2. track health events across the continuum of care
3. create a broadband network of health services

In business, most high priority and high volume communications are handled electronically. But in health care, high-importance communications – e.g. referrals and hospital discharge summaries – are created using paper and pen and delivered via fax, letter and even by hand.

This is the point where we should begin – simply, aim to get referrals and discharge summaries to be delivered electronically in a convenient and secure form.”

To be polite this is a spectacular over-simplification of what is needed to achieve substantial benefit. Sure, - I have always been very keen on aiding the flow of key clinical documents electronically – but for a lot of good reasons this should be done in a secure, standardised, managed fashion and not as seems to be suggested here by provision of simple connectivity.

Likewise the second and third focus areas are dramatically more complex than identified in the paper.

The document has a ready, fire, aim feel to it. It is of note that the only Health IT benefits study that seems to be cited is this one while there are many other much deeper and much more recent studies readily available:

DMR Consulting, “HealthConnect Indicative Benefits Report”, Final Version, February, 2004 (extrapolated to latest chronic disease data). This can be found here:

http://www.health.gov.au/internet/hconnect/publishing.nsf/Content/C50C3B807441ADBACA257128007B7EC4/$File/hcibrv1.pdf

This document was so unpersuasive as to the available benefits of HealthConnect that the Commonwealth commissioned a review by the Boston Consulting Group (April 2004) and this review resulted in the change of HealthConnect from a funded strategic program to nothing more than a “change management strategy”.

Let me be clear about the problem I have with all this. Realistic estimation of the value of benefits from Health IT requires a clear exposition of what technology is to be implemented and how it will then provide benefit. To not have a Strategy for what is to be done, an Implementation Plan that describes how it will be done and a realistic Business Case that identifies both costs and benefits no one is going to care to take notice of, or action, unsupported claims of benefits.

We have seen two claims for major benefits that can be derived from Health IT (This present one and the study mentioned in NEHTA’s recent presentations). It seems passing strange that the two studies identify largely different sources of benefits and seem to come up with wildly different estimates of what is achievable.

The flaw in both studies is that they don’t proceed from a deep understanding of the business of Health Services Delivery and are not informed by what is needed at the clinical coal face. Only once the requirements and problems of the sector are clearly identified can a strategy to deploy technology to assist be developed and have a chance of success. Implicit in the strategy will be the benefit opportunities that will need to be firmed up. This is what then needs to be refined through the development of the implementation plan and business case which will reveal where investment makes sense and can make a difference. The last step (not the first) is to estimate the quantum of benefits and develop the approach to be used to capture them as implementation proceeds.

As I have said before the work required to convince the hard heads in Treasury to invest is substantial and needs to be a comprehensive package (Strategy, Implementation Plan, Business Case and Benefits Realisation Plan).

Without this work being done to a high quality I predict just nothing will happen.

These half baked studies do more harm than good I believe.

David.

Useful and Interesting Health IT Links from the Last Week

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

http://www.govhealthit.com/article98187-04-16-07-Print

Finding Foreman

George Foreman named his five sons George. Will the National Health Information Network be able to pinpoint his health records? Maybe. Maybe not.

BY Nancy Ferris

Published on April 16, 2007

George Foreman — boxer, clergyman and entrepreneur — named his five sons after himself. So when the Nationwide Health Information Network (NHIN) is up and running, how will a doctor find the records for the right George Foreman?

Accurately matching patients with their electronic records is at the heart of the proposed network. But what if doctors search NHIN and find no records for anyone named George Foreman? If few matches are found, users will soon pronounce the network a waste of time and money, and they’ll abandon it.

However, if too many George Foreman records are found, the network could seem equally useless. Just imagine the number of records created over the years for the boxer’s sons and others with the same name who are not related to the more famous Foremans.

In that case, a doctor might be unable to determine which of the many records relate to his or her patient. If the doctor guesses wrong, the patient could end up with treatment that’s ineffective or even harmful. What’s worse in the eyes of many people is that the doctor’s employees could see the records of someone else’s patients.

Alternatively, someone from the doctor’s office could call the patient and ask questions such as, Did you ever live on Maple Street? Did you seek treatment for a broken leg in Grand Rapids? What was your maiden name? But that approach is labor-intensive and hardly seems to fit with the notion of a 21st-century information network. It also isn’t likely to provide enough value in return for the billions of dollars it will cost to create the network.

…..

As always see the sites for the full article. This is a useful listing of the problems you can face without really robust unique identifier approaches and is an especially large problem for Shared EHRs which do not have such technology at their core.

http://www.e-health-insider.com/news/item.cfm?ID=2618

IT and e-health is 'every nurse's business'

17 Apr 2007

IT and e-health is every nurse’s business because it has to be integrated into practice, nursing leader, June Clark, said on the eve of a major discussion at the Royal College of Nursing’s annual congress this week.

The discussion on the theme “Computerised records – what can they offer?” will be available online at the College website. Professor Clark, a former president of the college and chair of the RCN Information in Nursing Forum, told E-Health Insider she hoped as many people as possible in the e-health community would get involved.

She hopes the session will raise awareness on several fronts: “The first is awareness among nurses that e-health and IT and the introduction of IT into the NHS is every nurses’ business because it has to be integrated into nursing practice,” she said.
“The other awareness that I want to get across to this audience and more generally that electronic patient records must have appropriate nursing content, not just medical content.”

…..

Another useful point is being made here – the reason we prefer the term “Health Informatics” rather than “Medical Informatics” - it the Health IT needs to be used by all health professionals if the full benefit is to be achieved.

http://news.zdnet.co.uk/itmanagement/0,1000000308,39286714,00.htm

Parliamentary report urges action on NPfIT

17 Apr 2007 09:26

Public Accounts Committee has published a report that calls for urgent action to reduce the risks of the NHS National Programme for IT.

The success of the NHS National Programme for IT is precarious, with key projects running late and suppliers struggling to deliver, according to a long-awaited report from Parliament's influential Public Accounts Committee.

"There is a question mark hanging over the National Programme for IT (NPfIT), the most far-reaching and expensive health information technology project in history," said committee chair Edward Leigh on 17 April.
…..

The full report can be found here:

http://www.publications.parliament.uk/pa/cm200607/cmselect/cmpubacc/390/390.pdf

There seems little doubt that the huge UK programme has a large number of both good and bad bits. Despite the differences in Health Systems there is always a lot to learn from such reports. Careful reading recommended for those involved in major Health IT projects.

Further perspective can be found in a recent editorial in the MJA entitles "Lessons from the NHS National Programme for IT" written by Professor Enrico Coiera of UNSW. See the following URL:

http://www.mja.com.au/public/issues/186_01_010107/coi11007_fm.html

http://www.smh.com.au/news/National/Report-backs-electronic-health-records/2007/04/19/1176696992965.html

Report backs electronic health records

April 19, 2007 - 5:39PM

Up to $7 billion could be saved each year if Australia's health providers shared patient data electronically, says a new report.

Commissioned by the Australian Centre for Health Research, the report argues a broadband network of health services should be created to allow patients to be tracked no matter where they go for medical services.

Monash University e-health research unit director Michael Georgeff said about one-quarter of all Australians suffered from a chronic illness and many had complex health needs.

"Chronic illness requires close monitoring and, often, intensive management by a team of health professionals," Professor Georgeff said.

"But because of the way our health system currently operates, one doctor will often not know what tests or medications have been prescribed by another doctor even when they are members of the same team."

…..

The full report can be found at the following URL:

http://www.achr.com.au

I have deep concerns about this report and it claims which will be the subject of a future article. Download it and consider the claims it makes for yourself. (It’s only 19 pages)

David.

Policy Relating to Comments on the Blog.

The purpose of this blog is to provide a forum for discussion of the issues surrounding Health IT in Australia.

In that purpose there is the desire, from me, for accuracy, honesty and openness from all contributors.

Lately there have been a number of anonymous / whistle-blower comments on specific topics.

My view is that I will publish these – as long as they are free of direct personal attack and other objectionable comment on the basis that sunlight is a very good thing in the public policy arena – which is where this blog engages.

I am also more than prepared to publish any contrary views – both anonymously and as named contributions. Such contributions are both welcome and encouraged. Objectivity and truth is what is sought here!

I am also not planning to censor discussion – but I will protect any party from gratuitous personal abuse where possible - , including deleting posts I am informed or see are defamatory, obscene or deeply personally offensive. I will, of course, be the arbiter of that.

I believe in an open and transparent society and that the organs of government that support society should be equally open and transparent.

Would it were so!

David.

ps - I know that this is obvious - but it needed to be said. D.

A Few Other Things Regarding the AFR Article on E- Health.

The Australian Financial Review Article of the 13^th April, 2007 entitled “National e-health would save $30bn” by Julian Bajkowski makes a few comments I really don’t think should go through to the keeper.

The article states:

“The study has increased pressure on the federal government to abandon a number of failing federal electronic initiatives, including the $128 million HealthConnect project, which has yet to deliver tangible results.”

I would suggest this is wishful thinking as we see the grossly overfunded non-strategic trials which are being still being conducted by HealthConnect SA and HealthConnect Tasmania. It would be good however if this was an outcome and they were canned.

The article states:

“ Doctors, clinicians and hospitals have long sought electronic health and medical records that could be used across Australia's different state health systems.”

This really misses the mark. Most care (95%+) is delivered within a patient’s local area and virtually all care is delivered in the state of a patient’s residence. Doctors would be very keen to see records for their patients able to be used between the local practice, the local hospital and the local investigatory providers. The rest would be a cherry on the icing on the cake I would contend.

The article states:

“But developing the standards has been a battle because of a series of bitter quarrels between technology suppliers and standards bodies.”

This is largely just wrong. Between NEHTA and Standards Australia’s (SA) Health IT working parties there have been tensions and a lack of quality two way communication – but the Health IT industry has, for the most part, very good relations with SA. Relations between the Health IT industry and NEHTA are dodgy, at best, despite anything NEHTA may say.

The article states:

“NeHTA recently recruited the former head of Queensland-based Cooperative Research Centre for the Distributed Systems Technology Centre, Mark Gibson, as its chief technology officer.

The hiring represents a coup as it will ease NeHTA's access to a vast repository of e-health-related intellectual property held in trust by the shareholders of DSTC after the group's funding was terminated by the federal government in 2005.”

While not commenting on this particular appointment directly, I seriously doubt there is much useful intellectual property held in trust by DSTC given the failed and never properly reported HealthConnect trials it was involved in.

I hope these comments assist in understanding where things currently sit.

David.

A Headline To Die For - National e-health would save $30bn – Pity it’s a Wild Unsupported Bit of Speculation.

Friday 13 April, 2007 will go down in history as a very black day for e-Health in Australia. On that day, based on an apparent back door leak, Julian Bajkowski of the Australian Financial Review published an article entitled “National e-health would save $30bn”. This assertion is based on work undertaken by the National E-Health Transition Authority (NEHTA) under its Benefits Realisation work program and is based on a Systems Dynamic Model developed by modelling consultants. Before discussing the details it is important to keep in mind a very important fact about all such models. That is that ‘no models are correct, but some are useful’ (Robert Box)

Regular readers of the blog will wonder why I should be concerned by this claim of such huge net benefits. The reason is very simple. While I firmly believe there are major benefits to be harvested from the deployment and use of e-health – and I believe the literature makes it reasonably clear where they are to be found – such claims are simply unsupportable without very substantial additional evidence.

NEHTA talks of the model they have developed in the following terms:

Modelling approach used for the study
• System Dynamics Model:
- Increasingly preferred (e.g. NHS)
- 900+ variables, 300+ calculation nodes, 25 sectors
• National and international expertise engaged:
- Jurisdiction, consumer and clinician input
• Focuses on major e-health benefits, costs and relationship to demand, quality and safety as e-health initiatives are rolled out over a 10 year period

Additionally they cite a range of published evidence from CITL, RAND etc and claim that from 3400 papers published since 1980 that Adverse Drug Events can be reduced by 50% (or more) by using Computerised Physician Order Entry (CPOE) with effective interactive decision support – among a range of other benefits that have been identified for e-Health.

They also suggest that there are 500,000 years of life to be saved in the Australian Population over 10 years with the implementation of e-Health.

What is conspicuously absent from all the presentations is the ‘how’? We are not told any of the basics that are required to make this credible. Obvious questions are:

What is the strategy, transition and implementation plan to move from where we are now to this 10 year future nirvana? If you don’t have that properly understood, documented and agreed with stakeholders how can you make any sensible comments about possible benefits? This is serious cart before the horse material I believe!

What are the assumptions for the capabilities of the systems to be used in hospitals and ambulatory practice to achieve these benefits? (It should be noted CPOE is notoriously difficult and complex to implement in hospitals – to the extent that – when last I looked – no more than 5% of hospitals globally have such systems in place. They are also not cheap to buy and implement.)

How much will such systems cost and who is going to pay for them?

What is a realistic time frame for replacement of present systems with the new more capable systems assuming they are readily available?

Given the vast majority of patient care is delivered in the private sector just what incentives (from Government) will be required to get the private sector on board?

Do we have the doctors, nurses and pharmacists who are sufficiently well trained and skilled in IT to make the transition to the e-health way of doing things?

Who is going to capably manage and co-ordinate such a huge change management and technology implementation program?

Are the assumptions in the model regarding a Shared EHR strategy correct? Is that ultimately the right approach for Australia? There is certainly a case for a careful review of the options being deployed around the world.

So what do we have here? Essentially what we have is a model without a strategy for architecture, implementation, funding and subsequent benefits management. There is no point putting out a generic claim about a possible scale of benefits without laser like clarity on just what is being proposed – or the economic hard heads in Treasury will shoot you down before you get started. This is where my concern lies. We have a once in a generation chance to propose a major re-investment in e-health for Australia and for it to succeed we need a model of an implementable and stakeholder approved strategy and implementation approach. Without clear and totally credible answers to all the questions I pose above, this initiative will turn out to be an expensive waste of time and effort.

It is vital in all this that those managing this proposed implementation ‘under promise’ and ‘over deliver’. I see no evidence of that approach in all this.

It is all very well for the Financial Review to publish an exciting headline and it is always important not to let the facts get in the way of a good story but I really think a little more digging regarding the reliability of NEHTA’s numbers, the assumptions and risks involved, the underlying strategic assumptions and recognition that things are usually much more complicated than they appear in a proposed, and largely yet to be defined, project of this scale would have been useful.

I look forward to NEHTA’s release of the Strategy and Implementation Plan that the model assesses along with the model and its assumptions. I will not be surprised to find I am once again disappointed and that sadly it all turns out to be largely ‘smoke and mirrors’ which will get us nowhere.

A final point that should be made is that the NEHTA Benefits Case relies on the deployment of clinical decision support (CDS). That, CDS, is sadly not actually part of NEHTA’s work plan as currently published. If it is actually worth so much, focus is needed and fast! Whoops!

We will wait and see!

David.

Useful and Interesting Health IT Links from the Last Week

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

http://www.reuters.com/article/healthNews/idUSN1236605720070412

Wal-Mart sees medical clinic boom in retail stores

Thu Apr 12, 2007 4:40PM EDT

ORLANDO, Florida (Reuters) - Wal-Mart Stores Inc. is forecasting more than 6,600 in-store medical clinics will open their doors in the next five years in retailers nationwide, a company official said on Thursday.

"I think it's an indication of how bullish individuals (chief executives of clinics and retailers) are," Alicia Ledlie, senior director for Wal-Mart's health business development, said at a health care retailers convention in Orlando.

With 75 clinics in Wal-Mart stores in 12 states, the company has ended its pilot program and plans a faster roll-out of additional clinics nationwide.

Ledlie said Wal-Mart is considering providing its in-store clinics with a common electronic medical records system so patient care can be tracked from store to store.
She said the system could ultimately be part of a universal electronic medical record system for the country

…...

See the rest of the article at the URL above. This is a really interesting development where the world’s largest retailer is developing both a huge number of medical clinics and, presumably for good commercial reasons, to utilise a sophisticated EHR system to provide seamless care to their customers no matter which store the seek care from. 6,600 clinics is an amazing number of clinics!

Second I noted this report from Europe. The value is in the second and third URLs that permit access to a wide range of information on e-health plans in all 27 member countries of the EU.

http://www.euractiv.com/en/health/report-shows-good-progress-health/article-163098

“Report shows good progress on e-Health

Published: Thursday 12 April 2007

Member states have made good progress in implementing the EU's e-Health strategy but have failed to address education and socio-economic issues falling under their responsibility, a new progress report shows.

An EU report confirmed that good progress has been made across the continent following EU member states' commitment, in the European e-Health action plan to develop a national or regional roadmap for e-Health.

http://ec.europa.eu/information_society/activities/health/docs/policy/200703ehealthera-countries.pdf

"e-Health is increasingly becoming an integral element of national health system objectives. It is seen as a key enabler in wider contexts like improving the quality and efficiency of public services, or speeding up the development towards knowledge driven societies," states the report, drafted by a project entitled Towards the Establishment of a European eHealth Research Area (eHealth ERA).”
…..

A useful listing of European Approaches to E-Health

http://www.ehealth-era.org/database/database.html

The third is a short piece of Australian news.

http://www.computerworld.com.au/index.php?id=523856106&eid=-180

“E-health authority appoints new chair

Sandra Rossi 10/04/2007 10:31:43

Director-general of the Queensland department of health, Uschi Schreiber, has been appointed chair of the National E-Health Transition Authority (NEHTA).
Schreiber will replace the outgoing secretary of the Victorian department of human services, Patricia Faulkner.”

There is but one comment to be made on this appointment. Ms Schreiber needs to be a hands on Chairperson of NEHTA and ask the hard questions about the appropriateness of the current NEHTA strategic directions. This is the core function of the NEHTA Board and especially its chairperson. If she does not do this – and listen to a broad range of voices who are not largely beholden to NEHTA for their income - she runs the risk she will be seen my many in the e-health domain as a dog who is being wagged by an organisational tail!

A good place to research for some had questions might be this very blog.

David.