Sometimes We See Some Real Academic Nonsense Published!

The following appeared in Australian Doctor this week.

Performance-pay side effects cause concern

10-Oct-2008

By Paul Smith

MJA

PAYING GPs to hit performance targets undermines professional autonomy and job satisfaction, according to leading international academics.

State governments and leading Australian health reformers are pushing for a pay-for-performance approach in a bid to drive up primary care quality and improve patient outcomes.

Drawing on the results of the introduction of the policy in the UK’s National Health Service, where 25% of GP income is tied to meeting performance targets, researchers from Kings College, London, said it had led to substantial improvements in intermediate clinical outcomes. They included blood pressure, cholesterol and glycosylated haemoglobin controls as well as the proportion of heart attack and stroke patients treated with aspirin.

Health inequality gaps between the least and most deprived neighbourhoods had also narrowed.

Writing in the Medical Journal of Australia (21 July), Dr Mark Ashworth and Professor Roger Jones, of the university’s department of general practice and primary care, said that “taken together these achievements should translate into substantial national public health gains”.

But they warned that the UK Government had used pay-for-performance — dubbed P4P — as a “big bang solution” and the system was failing to capture the elements of general practice in which many GPs found the greatest professional satisfaction.

More here (needs registration)

http://www.australiandoctor.com.au/articles/e1/0c0587e1.asp

The full editorial is to be found here (free registration required):

http://www.mja.com.au/public/issues/189_02_210708/ash10534_fm.html

Most interesting I find is that while ‘pay for performance’ is clearly working to make a difference there is concern that it might destroy professional autonomy.

Let us be quite clear here. The framework seeks to encourage important evidence based clinical behaviour and imposes some measures which encourage clinicians to conduct their practices in a way that suits patient needs. Patients are thus getting better and more patient focussed care – which seems to me to be a very good thing.

The complaints centre around apparently restricting professional autonomy and not measuring things in the patient interaction. The following quote, from the article, seems to reflect the view:

“More fundamentally, P4P has divided GPs on issues of professionalism. For some GPs, the electronic QOF prompts that accompany a consultation with a patient act as useful reminders and allow the GP to give more thought to deeper issues during the consultation. For others, these prompts represent the intrusion of a reductionist, points-driven approach to patient care that undermines professional autonomy. Furthermore, it is readily apparent that measures of patient satisfaction, patient enablement, listening skills, continuity of care, and many of the aspects of general practice that give GPs their greatest professional satisfaction lie outside the scope of any of the performance indicators.”

There are two points I would make. First, it is possible to measure most of what is mentioned in the quote – so it simply needs some clinician push to make the changes – not just complaining from the side.

The second point is that if professional autonomy means the freedom to ignore evidence of correct practice because you don’t like it that is not autonomy but stupidity!

The GP systems in the UK make conformance with the guidelines easy to capture and record as I understand it and there is no real reason not to follow evidence other that in situations where patient complexity demands adjustments (not all that common).

I really wonder what these academics are trying to say other than we want to right to ignore evidence and couldn’t be bothered trying to improve an already proven to be useful system?

Very odd.

David.

Stating the Bloomin’ Obvious On Health IT.

The following appeared in e-Health Insider a few days ago.

ASSIST says idea NHS like a bank 'fundamentally flawed'

08 Oct 2008

NHS informatics professional body ASSIST has published a paper saying the original NHS National Programme for IT plan of one size fits all approach “does not work”.

The paper says attempting to treat the NHS as if it were a bank when the NPfIT strategy were misguided, and failed to understand the NHS.

ASSIST says there has been too much focus on standardisation of system rather than standards, and stresses that both national and local systems have a role to play but cannot succeed if they are imposed.

It says a revised strategy must reflect the shift to a pluralistic, federated model of care delivery, in which information follows the patient.

The paper calls for changes to NPfIT to take account of the changed policy environment, for mistakes to be acknowledged and lessons learned.

ASSIST, which is affiliated to the British Computer Society, says the standardised systems approach of the original NPfIT strategy, emerged from a “misguided attempt” to see the health service as analogous to a big business.

“We reject the notion that the NHS is analogous to a bank (especially in the current 'credit crunch'!), a global telecommunications company or an airline, and this believe that focusing on their ICT models for a healthcare environment was fundamentally flawed.”

…..

ASSIST makes the following recommendations

• Focus on the basics before trying the ambitious

• Do not lose or threaten hard won successes

• Focus on standards not standardisation

• Achieve a balance between technology, systems, people, process and culture

• Ensure much earlier and more integrated policy planning at both national and local levels

• Invest in a systematic health informatics research and development programme

• Avoid structural change

• Avoid stand-alone data demands

• Avoid insular systems development

• Invest in developing informatics skills, leadership and the profession

Jon Hoeksma

The full long article, can comments are here:

http://www.e-health-insider.com/news/4219/assist_says_idea_nhs_like_a_bank_%27fundamentally_flawed%27

The submission that prompted the article is found here:

Independent Review Commissioned by Conservative Party

ASSIST has made a formal submission to an Independent Review Group, commissioned by and reporting to Stephen O'Brien MP, the Conservative Shadow Health Minister.

The Review Group has been established to inform the future policy for the use of information technology in the NHS, health and social care in England.

ASSIST's submission was developed through a facilitated workshop for senior informaticians held on Wednesday 24th September 2008, with other ASSIST members contributing by correspondence. ASSIST is grateful to John Farenden and Tribal for leading the workshop, continuing Tribal's long-term support of ASSIST.

More here:

http://www.bcs.org/server.php?show=ConWebDoc.22027

View the formal submission here

Pages 12-14 are the crucial bit.

The home page for ASSIST is here(and is worth a visit):

http://www.bcs.org/server.php?show=nav.7898

This is remarkably like the conclusion of the Environmental Scan done for the Victorian E-Health Strategy.

http://www.health.vic.gov.au/ictstrategy/environment-scan.pdf

(Note this is a new, much better version of the document in terms of accessibility and searchabilty from a week ago.)

See especially pages 25 - 27.

“The Environmental Scan has identified some common critical success factors which will greatly enhance the chances of eHealth initiatives succeeding. These are:

• High level sustained commitment over several years with levels of investment of at least around 3% of Gross Operating Revenue.

• Clearly stated simple goals that can be measured.

• Manageable scop and timeframes (2-3 year planning horizon)

• Involvement of clinicians at all stages of the process.

• Enforcement of standards with some local flexibility in implementation of common systems.

From this research the following broad conclusions have been drawn with detailed examples contained within the body of this document.

1. Have a Plan

It is important to actually have a plan! The plan must be clear, simply understood by all stakeholders and offer an attractive vision of the proposed future. Additionally the plan must have the various components discussed in the introductory section. More than that the plan needs, if unintended consequences are to be avoided, to have a broad scope covering both the private and public sectors, where relevant, and also ensuring coverage of the needs of both the ambulatory, service and hospital sectors.

The plan also needs to be actively managed and reviewed every three to four years to make sure planned objectives are being met and to ensure there is a clear and current way forward.

It is clear from the cases discussed in the scan that the approach of developing an agreed plan and regular re-visitation of that plan has a beneficial effect in terms of objective progress made compared with lack of a plan.

2. Get Commitment

It vital to have high level political / managerial commitment to the key aspects of the plan. This is best achieved by creating a ‘burning platform’ based on the impact Health IT has on patient (i.e. voter) safety and the quality of care that is received or on the argument of the current sustainability of the health system as a whole (or both).

3. Be Prepared to Invest

It is clear that not providing an realistic level of funding for eHealth initiatives has very negative consequences. This means that not only is it important to have a clear plan but also to have a compelling business and operational justification for the investment. In Australia planning was undertaken for the HealthConnect initiative in the absence of such a compelling case and when the time came for the (significant) investment to be made the then Government decided it was all too hard and five years work was essentially wasted.

4. Set Reasonable Time Frames

It is important to set reasonable time frames to achieve the various milestones in the implementation plan. Implementation of a National or Regional EHealth Strategy is a complex and quite difficult task and setting over ambitious milestones can lead to loss of confidence on the part of those on the ground if too many milestones are missed. It is important to have sensible milestones in place to ensure progress is being made at an acceptable pace.

5. Recognise Change Management Constraints

There are real constraints on the scale of change that can be applied uniformly before implementation becomes unwieldy. The apparent ease with which smaller countries (with comparable levels of development) seem to make progress compared with larger ones is hard to ignore. The lesson to be drawn from this is that it is important to structure any national initiative to recognise the degree of inertia and lack of strategic and implementation flexibility that can be found in larger countries and to work to mitigate this issue.

6. Develop Incentives to Participate

There is considerable evidence that the use of incentives can assist in reducing the ‘friction of change’. As an example, in virtually all countries where there has been widespread adoption of EHRs in ambulatory care those who pay for the health system have provided some form of (usually financial) incentive to obtain widespread adoption. Examples include the Practice Incentive Payments in Australia and the provision of systems without any physician expense in the Kaiser system.

7. Tailor Plan to Existing Health IT Capability

When planning it is vital that the plan be tailored to existing Health IT capability and that gaps in the capability (be it lack an adequate number of Health Informaticians, inadequate internet connectivity, lack of appropriate standards or whatever) be identified and addressed.

8. Balance Technical Risk with Proven Technology

It is clear that there needs to be a balance struck between technical risk and complexity and the possibility of the implementation of obsolete or out of date systems. While most suggest that in ordinary times IT systems should be refreshed very five to seven years many core systems in hospitals seem to have lives measured in decades. The importance of getting system and technology selection as close to the mark as possible is obvious in these circumstances.

The other issue that needs to be considered is that if very advanced technology is utilised there is an increased risk of project delays as technological obstacles are overcome. The key in all this is a balance between ‘bleeding edge’ and ‘early possible obsolescence’.

9. Make Technology the Servant of the Health System

It is important to make sure the technology is the servant of the health system and that the technology is responsive to the needs of those who have to use the system. Experience suggests that initiatives which are driven by responding to the needs of the particular health system are the most likely to succeed.

10. Planned Incremental Approach

The deliberate adoption of a planned incremental approach that builds on earlier successes has a better likelihood of success than a ‘big bang’ approach.

Understanding the lessons of these experiences will go a long way towards avoiding repeats – especially getting the balance of local versus central control of implementations right.

Lots of food for thought in working out how Australia should proceed nationally.

David.

Some Views on Privacy and Health IT.

There has a fair bit recently appear on privacy.

Privacy obsesses lawyers, not patients

COMMENT: James Gillespie and Stephen Leeder | October 04, 2008

JUST how worried are Australians about the privacy of their health records? This question has dogged the long and tortuous history of efforts to change to electronic health record systems. If we are to have a health service where information of relevance to the care of a patient is readily available, anywhere, any time, to those caring for them, substantial changes will be needed in the way we manage medical records.

Against this, privacy concerns are regularly adduced as the reason why progress cannot be made in using data derived from the care of individuals for improving the health service. The public, it is often said, is paranoid about the privacy of personal health records. This predominantly legal concern plays into the hands of professional and bureaucratic groups who have resisted more open scrutiny of these and other data (such as Medicare) that might reveal their own shortcomings.

Do patients trust their doctors and the broader systems to keep personal, and often sensitive, records away from unauthorised view or use? Many of the problems of our healthcare system - from unnecessary deaths from medication and hospital error to the fractured management of chronic illness - have been traced to communication problems. General practitioners, pharmacists, physiotherapists and hospital-based specialists have been unable to get easy access to a patient's medical history - their medications, allergies and past encounters with the health system. The vast majority of medical communication is untouched by advances in information technology.

Yet the power of the technological imperative, as manifest in IT, will change all of this. As new, more flexible internet technologies overcome the cost and technical obstacles that blocked information sharing, faster and more effective transfer of information has raised fears, though whether in the minds of patients is rarely proved, of new assaults on the privacy of patients' health records.

So what do Australians think about privacy and their health records? The Menzies Centre for Health Policy and The Nous Group recently surveyed a representative sample of 1200 Australians aged 18-plus on their attitudes to the health system.

One group of respondents was reminded that during a period of illness, patients are frequently treated by a series of health professionals. Should those charged with the care of the patient all have direct access to their records? Or should they rely on taking a medical history from the patient each time the patient passes from one carer to another, as happens now with astonishing frequency? There was an overwhelming consensus - 90 per cent - in favour of direct access for all treating health professionals to the patient's records: one record, available to all carers.

…..

James Gillespie is deputy director and Stephen Leeder the director of the Menzies Centre for Health Policy at the University of Sydney

See full article at the Australian.

http://www.theaustralian.news.com.au/story/0,25197,24437561-23289,00.html

We have also had recently

Data privacy concerns remain as Google PHR grows

By: Rebecca Vesely/ HITS staff writer

Story posted: September 29, 2008 - 5:59 am EDT

About two years ago, lightning struck for SafeMed, a healthcare analytics software firm, when representatives from Google strolled by the fledgling company’s booth at a trade show.

“That initiated some discussions,” says Richard Noffsinger, chief executive officer of SafeMed. The San Diego-based company signed on as one of Google Health’s first partners, sprouting more growth and new clients.

“The partnership has helped us in all areas,” Noffsinger says, including lending financial stability. SafeMed also benefited from its collaboration with Google’s engineers so it could meet expected growing demand from the millions of Google users. “Having a customer of the stature of Google is incredible.”

Google Health, launched in May to much fanfare, allows users to store, organize and manage their personal health records and other information online. The concept is that the approach puts individuals in charge of their own health data and allows them to access that data when they switch providers, visit an emergency room or search for relevant health information.

The jury is still out on whether people will use Google Health or another consumer-driven online PHR, and Google has declined to release any numbers to date.

To make the product attractive to consumers and to ensure personal medical information is relevant, Google Health is relying extensively on third parties. Google is deploying the so-called “long tail” model, in which a large number of unique products or services are offered to a wide range of people with the expectation that freedom of choice will drive participation.

In applying that model to healthcare, Google Health, along with Microsoft Corp., which offers a competing product called HealthVault, are rapidly shaping the health information sphere. HealthVault, launched in fall 2007, is a formidable competitor, with more than 100 partners, including leaders in the health information technology field such as Kaiser Permanente.

Much more here:

http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20080929/REG/309299997/1029/FREE

And then we have the results of two recent surveys

Americans say EHRs worth the privacy risks

Dec. 4, 2007 —A majority of polled Americans believe EHRs have the potential to improve U.S. healthcare and that the benefits outweigh privacy risks, based on a Wall Street Journal (WSJ) Online/Harris Interactive poll.

According to poll results published in The WSJ, three-quarters of the 2,153 survey respondents agreed that patients could receive better care if doctors and researchers were able to share information using electronic systems and 63 percent agreed such record sharing could decrease errors.

Also, 55 percent agreed the transition could reduce healthcare costs, compared with 15 percent who disagree. However, about one-quarter of those polled remained unsure whether EHRs can provide these benefits.

More here:

http://www.healthimaging.com/index.php?option=com_articles&task=view&id=8917&division=hiit

and here

Few Americans confident in privacy of EHRs

By: Rebecca Vesely/ HITS staff writer

Posted: October 9, 2008 - 5:59 am EDT

Many Americans want electronic health records, and say they would access their personal health information online, but the majority are concerned about confidentiality issues, according to a survey by the Employee Benefit Research Institute, a not-for-profit, nonpartisan organization.

Fifty-five percent of those surveyed said it is extremely or very important for providers to use electronic or computer-based health records instead of paper ones. Another 25% said it is somewhat important, while 7% said it is not too important and 9% said it is not important at all. Those results are statistically unchanged from when the question was asked in 2005.

More here:

http://modernhealthcare.com/apps/pbcs.dll/article?AID=/20081009/REG/310099994

What one needs to do with all this is drill down to the next layer and talk to individuals and understand what they want and fear. The answers are a little different from what surveys tell you.

First it is true most people think electronic patient records are a good idea and should be used, especially if security and privacy can be pretty much assured.

Second most people understand that data leaks and disclosure is possible occasionally and so….

Third how worried you are about information leak depends on individual circumstances – if you have a potentially stigmatizing medical history (HIV/AIDS, Hepatitis C, Mental Illness, severe genetic risk etc) you are much more worried and might even try to keep such information secret etc – with a risk to all.

For this reason surveys that don’t deeply explore the reasons for anxieties and concerns and work out ways to address them don’t get us all that far.

I look forward to the details of the Nous Group Study.

David.

Useful and Interesting Health IT Links from the Last Week – 12/10/2008

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

These include first:

NSW hospital statistics on patients 'worth nothing'

Mike Steketee, National affairs editor | October 11, 2008

THE NSW Government has an explanation for why some public hospitals are failing to see most of their urgent patients on time -- it does not believe its own health figures.

According to the data, in January only 36 per cent of patients with an imminently life-threatening condition were seen within the required 10 minutes of arriving at the emergency department of the Royal Prince Alfred Hospital, in inner Sydney.

But the NSW Health Department says this figure and those for Westmead Hospital are wrong because of problems with collecting data, even though they are included in the performance indicators it publishes to enable people to compare hospitals.

Asked by The Weekend Australian why the Government had published incorrect figures, a spokesman for NSW Health Minister John Della Bosca said it was important to publish the information for the sake of transparency.

"Although some of the data might reflect poorly on these hospitals, we are prepared to wear that while we try to fix the teething problems," he said.

The revelations add a bizarre twist to the string of claims about fudged figures on hospital performance in NSW and Victoria.

Mostly the allegations are that data is being massaged to meet performance benchmarks. But in this case, the NSW Government claims the figures understate the true situation.

State governments have responded to dissatisfaction with public hospitals by releasing data on their performances, available on health department websites.

According to former Victorian and NSW premier's department head Ken Baxter, whose consultancy prepared a report on the funding of public hospitals earlier this year, the figures, particularly in NSW, "are not worth the paper they were written on".

There were serious doubts about the veracity of the data fed into them from hospitals. Nor were they necessarily the best indicators of performance.

"For example, waiting times for elective surgery can be manipulated for what you want out of them," Mr Baxter said.

The report by TFG International, of which Mr Baxter is chairman, found hospital data was "inconsistent, patchy and not readily comparable on a state-by-state basis".

Although the states had spent more than $2billion on information technology and data collection systems, this money had "largely been wasted".

Much more here:

http://www.theaustralian.news.com.au/story/0,,24478368-2702,00.html

This is a very worrying report and goes to the question of just how well the funds for IT in hospitals has been spent – but more importantly just how well the investments have been managed. It seems a national audit of e-Health capability and data quality should be on the agenda sooner rather than later.

Second we have:

VicRoads admits to selling database information

The Victorian roads authority has confirmed it sells information from its licence database to 190 organisations, but defended the practice as perfectly legal.

Dylan Bushell-Embling 07/10/2008 12:52:00

The Victorian roads authority, VicRoads, has admitted it sells personal information to 190 outside organisations, but has refused to name any of its customers.

The Herald Sun yesterday published the details of a secret deal, whereby companies such as Connex and Yarra Trams paid for special access to information from the VicRoads licence database.

More here:

http://www.computerworld.com.au/index.php?id=651912288&eid=-6787

Other coverage is here:

VicRoads cashes in on personal information

Article from Herald Sun

Ashley Gardiner

October 09, 2008 12:00am

VICROADS raked in $6.4 million in one year by selling the personal information on its licence and registration databases.

The Herald Sun can also reveal that Connex ticket inspectors use a verbal password for database access, a process described as "only 95 per cent secure".

VicRoads has admitted instances of inappropriate use of its databases by outside organisations.

Registration and licensing operations director Chris McNally confirmed VicRoads raised revenue through the databases.

"(This) goes towards offsetting the more than $100 million cost of running VicRoads' registration and licensing business," Mr McNally said.

Since the late 1990s, there had been a small number of incidents in relation to external access of the databases, Mr McNally said.

"One involved the inadvertent release of information to an external party and one involved the inappropriate disclosure of information," he said. "The person concerned in this case is no longer with the agency."

VicRoads now requires external agencies to provide a quarterly compliance report and an independent audit.

More here:

http://www.news.com.au/heraldsun/story/0,,24467932-5006922,00.html

This is an absolute disgrace. Trade in personal identification information is quite unacceptable and in such a pathetically insecure way as this it is just dreadful. VicRoads is to be condemned – running a license system is core business for such an entity – not a cost to be offset!

Third we have:

Just what the doctors ordered

Karen Dearne | October 07, 2008

case study | SA Heart Centres
CARDIOLOGISTS in South Australia have said goodbye to costly commercial broadband services by building a private high-speed microwave network to link their Adelaide clinics.

Dr Bill Heddle, chairman of SA Health Centres, says the practice was hampered by slow connections and he was unimpressed by the premiums charged for high-speed fixed-line links when the operation moved to electronic patient records and images.

"In the early days, we often had problems using dial-up broadband.

"The computer kept crashing and it took 20 minutes to log on," he says.

"In that time, you need to have seen at least one patient or you get behind on your appointments."

SA Heart Centres is Australia's largest cardiology group, with 17 specialists operating in six large clinics in suburban Adelaide, plus smaller clinics at Mt Gambier, Port Lincoln and in the Riverland.

"We looked for solutions to this big problem of being able to have reliable and rapid access to patient information wherever we were seeing them," Heddle says.

More here:

http://www.australianit.news.com.au/story/0,24897,24454724-24171,00.html

This story makes one wonder if the National Broadband Network – as planned – will be fast enough in 2-3 years when it finally gets built. I think 100 Mbs should be the minimum for the NBN at the end-user level.

Fourth we have:

Canberra plans unified privacy principles

Karen Dearne | October 07, 2008

SPECIAL Minister of State John Faulkner has proposed a set of unified privacy principles and protections for credit reporting and health information, following a revamp of the Privacy Act.

Senator Faulkner will also tackle abuses of data capture and usage made possible by small, cheap and versatile devices that record and transfer sound, images and data.

"Privacy is not about what we voluntarily - however unwisely - disclose of ourselves," he told a symposium at the University of NSW Cyberspace Law and Policy Centre last week.

"Privacy is our right to make that decision for ourselves.

"But new developments, whether it be the internet, the camera-phone, radio-frequency ID tags or CCTV in public places, have made it incredibly easy for others to make that decision for us."

More here:

http://www.australianit.news.com.au/story/0,24897,24456243-15319,00.html

This is good – as it seems the Senator Faulkner ‘gets it’. He is dead right – the decision about where out information goes is the one that matters and is what most worries people about e-Health proposals.

There is also good coverage here:

Privacy lags in technology rush

http://www.smh.com.au/news/technology/privacy-lags-in-technology-rush/2008/10/07/1223145356191.html

Fifth we have:

Identity fraud 'fastest-growing crime'

October 6, 2008 - 7:52PM

With identity fraud becoming the nation's fastest-growing crime, Crime Stoppers has urged Australians to stop throwing personal information into rubbish bins.

Identity fraud has claimed half-a-million victims in the last 12 months at an estimated cost of $1 billion to the national economy, says the Australian Bureau of Statistics (ABS).

And professional women in their 20s and 30s are most at risk.

Despite the danger, a Newspoll survey shows nearly 70 per cent of people throw away bank and credit card statements, social security and tax file number details, utility bills and other personal information.

Ahead of national identity fraud awareness week, Crime Stoppers has urged Australians to shred their statements and personal information, as well as digital information held on CDs, before throwing it away.

More here:

http://www.computerworld.com.au/index.php?id=293044380&eid=-255

The relevance of this report for the e-Health Domain relates to the personal identity systems and identifiers planned by NEHTA. We need to be sure these credentials are managed in such a way that they have no value to the criminal identity fraudsters. As I see it the only way this can be achieved is by having major penalties for the use of NEHTA identifiers as part of the information that can be used to establish identity for any purpose other than the expected healthcare roles. I know this has been mooted but I would like to see the actual law enacted before becoming involved in these schemes.

More information here:

No names: inside the fake identity racket

Conrad Walters

October 7, 2008

WANT to buy enough information about a stranger's credit card to steal their money? All it takes is one email and a transfer of funds through Western Union.

The Herald found it was remarkably easy to unearth the online locations where hackers conduct a global trade in stolen credit card information.

If you want the data from a standard Australian credit card, it will cost you just $US1.50 ($1.80). Rather rob from a gold card holder? That'll be $2.50, thanks.

For accounts in Britain and the United States, the salesmen claim even to be able to bypass some of the latest anti-fraud protection, including Verified by Visa. And if your needs are great, bulk deals are available.

Full investigative article is here:

http://www.smh.com.au/news/national/no-names-inside-the-fake-identity-racket/2008/10/06/1223145261821.html

and here:

http://www.smh.com.au/news/national/the-great-credit-card-swindle/2008/10/06/1223145261818.html

and here:

http://www.smh.com.au/news/technology/security-you-can-bank-on-still-elusive/2008/10/06/1223145261878.html

Last we have the slightly more technical article for the week:

Are international standards organisations no longer incorruptible?

The fight over OOXML and ODF seems to have taken another twist as the bodies continue to pile up in their wake.

Carl Jongsma 08/10/2008 12:55:00

For the last several months Microsoft has been pushing for their Office Open XML (OOXML) office suite file specification to be accepted as an international standard by ISO, presumably to help them gain traction for future government contracts (look, this file specification is an ISO standard, it must be good).

As far as ISO/IEC DIS 29500 is concerned, it continues its steady progress towards standardship, however it seems that Microsoft's push towards this goal hasn't been without its bodycount. While the ISO site lists 29500 as a deleted standard, complementary reporting shows the process is still ongoing and OOXML will soon become ISO/IEC IS 29500.

In an ideal world, standards bodies would be incorruptible and lead to the publication and adoption of consistent standards across the user communities. Anyone who has followed the OOXML progress through ISO would think otherwise. The ongoing stoush regarding Microsoft's effort to get the ODF-killer that has yet to be properly implemented through the standards body has claimed some high profile casualties, with the national Standards body of Norway effectively self-destructing after 13 of 23 members of the technical committee resigned in disgust.

More here:

http://www.computerworld.com.au/index.php?id=43917536&eid=-6787

It is amazing that we see this sort of goings on in international standardisation. There needs to be trust in these international processes if the benefits are to be achieved. Having Microsoft apparently distorting processes like this – as seems to be the case – is really not good news at all.

More information is here:

More OOXML trouble as Norwegians quit

Over half of Norway's ISO body, Standard Norway, have resigned over the country's approval for OOXML, citing Microsoft influence.

John E. Dunn (Techworld) 07/10/2008 10:03:00

Full article here:

http://www.linuxworld.com.au/index.php/id;1521592002;fp;;fpid;;pf;1

Another minor bit of news for Win XP users.

Microsoft grants Windows XP yet another reprieve

New timeline will make it possible for users to purchase XP-powered PCs through next July, just months before Microsoft plans to roll out Windows 7.

Gregg Keizer (Computerworld (US)) 07/10/2008 08:03:00

See article here:

http://www.computerworld.com.au/index.php?id=293044380&eid=-255

Finally – a small comment on the Financial Crisis – If our banks are so safe why not a time limited guarantee on all bank deposits and a guarantee of interbank cash flows so commerce can work – at least in Australia as seems to be happening all over the advanced world?

More next week.

David.

Obama and McCain on Health IT.

With less than a month to go until the US general election iHealthBeat has published a useful summary of what we can expect from each of the candidates.

Modernizing Health Care With President Obama or President McCain

by David Merritt

With only 35 days left until the presidential election, Americans have an important decision to make regarding the future of health care. With the perpetual problems of rising costs, poor quality and the uninsured, Americans must decide which candidate is better suited to help build a 21st century intelligent health system that saves lives and money for all Americans.

A critical part of any solution will be the rapid deployment of health IT. Both Sens. Barack Obama (D-Ill.) and John McCain (R-Ariz.) know the importance of modernizing our system through IT, and while some may condemn one or the other as someone who “doesn’t get it,” one point needs to be clarified: health IT is not a bipartisan issue -- it is a nonpartisan issue. Everyone agrees on its necessity. Everyone agrees on the goals we should work toward.

Where many advocates and policymakers disagree is how best to accomplish these shared objectives.

I believe that a President Obama or a President McCain will make health reform, and thus health IT, a top priority. It is just too important an issue to ignore.

So what would each man do to advance health IT specifically? Yes, we can look at their promises from the stump and read their health care plans for a general sense of how each man would advance health IT, but the reality is that campaign politics do not allow for intricate or exhaustive policy proposals, nor should the campaign trail be the place for this kind of policy development.

Much more here:

http://www.ihealthbeat.org/Perspectives/2008/Modernizing-Health-Care-With-President-Obama-or-President-McCain.aspx

At the end of the article there are relevant links.

More On The Web

• McCain’s Health IT statement
• Obama’s Health IT statement
• Center for Health Transformation

There is also a summary of the more general policy positions of the two on health in general here:

Health plans pit low-cost vs. public coverage

By TONY LEYS

leys@dmreg.com

November's presidential election offers a dramatic choice on how to attack America's health care problems.

Should the country try to hold down costs by encouraging consumers to shop for inexpensive coverage? That's what Republican John McCain proposes.

Or should the government build on the current system by offering more public insurance plans and subsidies to uninsured people, as Democrat Barack Obama wants to do?

Iowans heard a lot about the issue during last winter's caucus campaigns, in which each party's candidates quibbled with each other over relatively small variations in their health care proposals. But now, with two general-election candidates whose differences are stark, the discussion has taken a back seat to worries about the overall economy.

More here:

http://www.desmoinesregister.com/apps/pbcs.dll/article?AID=/20080929/NEWS09/809290326/-1/LIFE04

The most comprehensive analysis of the differences between the two I have so far seen is provided by the Commonwealth Fund. This is found here:

http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=707948

While it is clearly a good thing that both the candidates have expressed a view on the topic of Health IT, I must say the prospect of real money is attractive.

On page 2 of the main health policy document from Brack Obama we have:

(1) INVEST IN ELECTRONIC HEALTH INFORMATION TECHNOLOGY SYSTEMS. Most medical records are still stored on paper, which makes them difficult to use to coordinate care, measure quality, or reduce medical errors. Processing paper claims also costs twice as much as processing electronic claims. Barack Obama and Joe Biden will invest $10 billion a year over the next five years to move the U.S. health care system to broad adoption of standards-based electronic health information systems, including electronic health records. They will also phase in requirements for full implementation of health IT and commit the necessary federal resources

to make it happen. Barack Obama and Joe Biden will ensure that these systems are developed in coordination with providers and frontline workers, including those in rural and underserved areas. Barack Obama and Joe Biden will ensure that patients’ privacy is protected. A study by the Rand Corporation found that if most hospitals and doctors offices adopted electronic health records, up to $77 billion of savings would be realized each year through improvements such as reduced hospital stays, avoidance of duplicative and unnecessary testing, more appropriate drug utilization, and other efficiencies.

John McCain has the following:

INFORMATION TECHNOLOGY: Greater Use Of Information Technology To Reduce Costs. We should promote the rapid deployment of 21st century information systems and technology that allows doctors to practice across state lines.

I am afraid if I had a vote I would have to lean to the Democrats!

David.

The US National Health Information Network is Coming Together.

The following very interesting report arrived a few days ago.

NHIN goes live for a day, sort of

By Nancy Ferris

Published on September 23, 2008

The emerging Nationwide Health Information Network was put through its paces today as live operations were demonstrated before a large audience at the Health and Human Services Department and via a Webcast.

The demonstration involved records created for the test but stored in actual health systems. The exercise showed that a health care provider could easily use a Web browser to obtain basic records on a patient stored by another health care system.

“I think you have to admit that this is really cool,” said one of the participants, Dr. Robert White of the New Mexico Health Information Collaborative. “This is kind of like having a magic decoder ring in health care.”

Holt Anderson, executive director of the North Carolina Healthcare Information and Communications Alliance, quipped that the problem was that it looked too easy. Thousands of hours of work and ingenuity — a fair amount supplied by volunteers — have gone into the NHIN program and lie behind the seeming ease of retrieving records.

Using a variety of Web interfaces and authentication schemes, representatives of more than a dozen health care organizations showed how they could locate a record, retrieve it, and view important information such as the patient’s medications, diagnoses, allergies, laboratory test results and recent treatments.

…..

In mid-December, another public NHIN demonstration will feature more complex scenarios and more varied data.

Full article here:

http://www.govhealthit.com/online/news/350589-1.html?GHITNL=yes

At the same time we had the following press release.

Compuware's Covisint To Build E-Health Exchange For Minnesota

Compuware Corp. (NASDAQ: CPWR) Monday announced an agreement between its Covisint subsidiary and a public-private coalition in Minnesota to build one of the largest e-health exchanges in the nation.

The Minnesota Health Information Exchange -- being called MN HIE, which is being pronounced "Min High" -- provides a secure, electronic health information network designed to increase the safety and quality of care while decreasing costs.

Through Covisint technology, MN HIE will enable doctors at any hospital or clinic in the state to have patient-controlled access to medications and other patient information.

“This program allows providers and health plans to collaborate to provide more seamless care for patients,” said Mike Ubl, Interim Executive Director of Minnesota Health Information Exchange, LLC. “Immediate benefits for Minnesotans include real-time, point-of-care access to health information and an infrastructure to deliver future services, such as e-prescribing, lab test results, immunization records and communicable disease reporting.”

Many patients have electronic medical records, but those records are only available to doctors in a particular hospital or clinic system and not to outside providers. By using single technology platform to safely and securely exchange health information, providers across Minnesota will have immediate access to vital medical information more quickly to deliver better care.

Sponsor organizations include Blue Cross Blue Shield of Minnesota, Fairview Health Services, HealthPartners, Medica, UCare and the Minnesota Department of Human Services. The exchange is intended to go live in November.

“MN HIE is an important part of the state’s health care reform efforts,” said Minnesota Human Services Commissioner Cal Ludeman. “It will enhance patient safety, as well as quality improvement. MN HIE will also allow providers to more effectively manage and coordinate healthcare services with each other.”

Brett Furst, Covisint vice president for health care, said Minnesota is the second statewide health information exchange deal for the company. Tennessee made the first such announcement in February.

Said Furst: "We'll provide an infrastructure for securely shared health information between health plans, the largest health systems and the state, with 90 percent of the citizens, four and a half million people, on Day one."

Medication history will be the first information exchanged in November, which Furst called "a key data element for patient safety and reducing the cost of care." He said the system "will be adding more clinical and administrative transactions through the middle of next year, including laboratory information, imaging and eligibility."

Furst said Covisint will use its technology to make sure the data stays private and only available to authorized users.

He also said Covisint is in talks with several other states, including Michigan, for similiar systems.

Covisint is compensated for its work in the deal by a subscription fee paid by the system's users.

Covisint was founded in 2000 by a group of automakers seeking to bring the power of the Internet to the automotive supply chain. It later sold its business-to-business auction operations, but kept the secure communications business. The company now has 280 employees, up from 220 a year ago, and Furst said it currently has openings for developers, support staff, project managers and sales staff.

Full release here.

http://www.wwj.com/Compuware-s-Covisint-To-Build-E-Health-Exchange-Fo/2928117

Anyone who is not sure that the US is making serious progress in Health Information Exchange needs to read carefully. It is slowly, but inexorably coming together, while we have NEHTA wanting to build central repositories. Let’s get the information flows happening first! Then we can see if we really need all this IEHR stuff.

David.

A Must Read Article on Evidence Based Medicine.

I came upon the great article a few days ago.

Evidence of a Need for Change

How likely is it that you will receive treatment the medical literature says is best? Flip a coin. Evidence-based health care can improve those odds, save lives and cut health care costs dramatically.

By: Michael L. Millenson | September 19, 2008 | 07:00 AM (PDT)

High cost is the high-profile villain of American health care, and fall is the season when it sashays onto center stage. It is the time of year when employers and Medicare make annual announcements of the extra bite rising health insurance premiums will take out of next year’s paycheck or retirement income, and, this fall, it is also presidential election season. That means a spotlight on the urgent need to corral high medical costs as part of national health care reform.

Yet if the cost of insurance is an obvious concern, there is another fundamental problem in American medicine at least as disturbing in its implications for both wallet and well-being. That problem centers on what happens to patients once they are inside the doctor’s office or hospital.

One way to highlight what is at stake is with a number: 55 percent. That figure represents the chances you will receive the treatment the medical literature says is best for your illness. Put differently, it’s roughly the flip of a coin — heads, yes; tails, no. The odds for common individual conditions are hardly more encouraging. Hip fracture? Patients receive what is known as evidence-based care a dismal 23 percent of the time, according to a study in The New England Journal of Medicine. Breast cancer treatment? The disease’s high profile helped it finish at the top of the list by being evidence-based all of three-quarters of the time (76 percent).

An earlier comprehensive study of evidence-based care that used a slightly different methodology was only slightly more reassuring. While the average rate of evidence-based treatment was higher (60 percent for chronic care and 70 percent for acute care), the authors calculated that patients received “contraindicated” therapy (that’s medicalese for “Don’t do this!”) 20 percent of the time for chronic conditions and 30 percent of the time for acute ones.

If you are tempted to think, “Not my doctor,” think again. Providers in low-income areas perform more poorly on some quality measures, but the broader research shows socioeconomic status provides no sanctuary. The widespread failure to do the right thing for the right patient at the right time is egalitarian in its impact.

By comparison to health care, America’s airlines are paragons of reliable performance. In 2007, one of the worst years on record, the average airline on-time rate was about 74 percent, while the individual airline that was the worst of the bad had an on-time record of 65 percent. The rate of “contraindicated” flights (flying to the wrong city, for example) was negligible, and, perhaps most significantly, the safety record was vastly better.

Experts believe that a stunning 20 to 40 percent of the $2.4 trillion America spends on health care in 2008 will be wasted on misuse (including harmful and fatal errors), overuse (care that’s unnecessary) or underuse (effective care that’s not provided). If you take a midrange figure — let’s say 30 percent — you end up with $720 billion in savings. That’s enough in health care savings to pay the cumulative costs of the Iraq war (about $560 billion by mid-September 2008) and still have enough cash left over to pay for universal health care and the entire federal education budget. If you simply sent out a rebate check, it would come to some $2,100 for every man, woman and child in the country.

And that’s just one year of savings.

10 further pages and some great pictures here:

http://www.miller-mccune.com/article/691

This is a really excellent outline of the case for Evidence Based Medicine while identifying just how hard getting evidence based practice actually is and what the barriers are.

Health IT can help but human nature can be hard to shift!

David.

Patient Views on Health IT

I came upon this very interesting piece a few days ago

What do Patients Want?

The Commonwealth Fund has released the results of its 2008 Survey of Public Views of the U.S. Health Care System, conducted by Harris Interactive. According to a telephone survey of 1,004 random U.S. adults, 80 percent of respondents believe that the healthcare system needs either fundamental change or complete rebuilding.

Approximately one of five adults with Internet access is able to communicate electronically with their doctors (21%) or schedule appointments online (19%).

See the full blog here:

http://medseekblog.typepad.com/medseek_weblog/2008/10/what-do-patient.html

Seeing as there was a lot of discussion about Health IT I noted this and followed the link below.

The blog post provides a link to a Commonwealth Fund Survey

http://www.commonwealthfund.org/usr_doc/How_Public_Views_8-4-08.pdf?section=4039

The Abstract of the .pdf reads as follows:

Public Views on U.S. Health System Organization: A Call for New Directions

Sabrina K. H. How, Anthony Shih, Jennifer Lau, and Cathy Schoen

Abstract: On behalf of The Commonwealth Fund Commission on a High Performance Health System, Harris Interactive surveyed a random sample of 1,004 U.S. adults (age 18 and older) to determine their experiences and perspectives on the organization of the nation’s health care system and ways to improve patient care. Eight of 10 respondents agreed that the health system needs either fundamental change or complete rebuilding. Adults’ health care experiences underscore the need to organize care systems to ensure timely access, better coordination, and better flow of information among doctors and patients. There is also a need to simplify health insurance administration. There was broad agreement among survey respondents that wider use of health information systems and greater care coordination could improve patient care. The majority of adults say it is very important for the 2008 presidential candidates to seek reforms to address health care quality, access, and costs.

The key section from the perspective of this blog is the following:

Information Technology

The public strongly endorsed the use of information technology, particularly computerized medical records and information exchange across sites of care, as a way to improve patient care (Exhibit 7).

· There is strong support among adults (86%) for doctors’ use of computerized medical records.

· Nearly nine of 10 adults (89%) believe it is important for doctors to be able to access test results electronically.

· The same proportion of adults (89%) believes it is important for doctors to be able to exchange infor­mation with other doctors electronically.

. Seven of 10 adults (71%) endorse the use of electronic prescribing to improve patient care.

Strong public support for the use of health information technology stands in stark contrast to actual practice in the United States. In a 2006 survey of primary care physicians in Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States, the U.S. fell well below leading countries on use of health information systems. Only 28 percent of U.S. primary care physi­cians reported using electronic medical records in their practice, compared with 98 percent in the Netherlands, 92 percent in New Zealand, and 89 percent in the U.K.4 The percent of U.S. doctors using systems with multi­ple functions—such as electronic ordering of prescrip­tions and tests or computerized alerts about potential drug problems—was even lower. Only 19 percent of U.S. primary care practices reported having such high-capacity systems, compared with as many as 87 per­cent in leading countries.

Adults are also interested in being able to access their medical records and communicate with physicians electronically. While few adults currently have such abilities, many would be interested in man­aging their care online or via e-mail (Exhibit 8).

• Approximately one of five adults with Internet access is able to communicate electronically with their doctors (21%) or schedule appointments online (19%).
• Only one of 10 (9%) adults can access their medical records via the Internet.
• Of those who cannot access their medical records via the Internet, nearly half (49%) would like to do so. An even greater proportion of adults would like to be able schedule appointments online (57%) or communicate electronically with their doctors (58%).

--- End Quote.

As I read it what the survey is saying is that the US public think their healthcare system is broken big time and that Health IT could really help make it better.

The full report is well worth a read.

David.

NEHTA Confirms it Failed To Make Any Progress at COAG.

The following report in today’s Australian Financial Review tells the story.

Credit crisis takes patient records off the agenda

Monday, 06 October 2008 | The Australian Financial Review | Ben Woodhead

The health sector is shifting its hopes for the approval of a new plan to make the health records of every Australian resident available online to November after the issue was pushed to the sidelines at the Council of Australian Governments meeting last week.

Health-care providers and clinicians were anticipating that state and federal ministers would review a National e-Health Transition Authority (NEHTA) business case for a national, individual electronic health record (IEHR) at COAG.

However, turmoil in the global economy dominated discussions, leaving the health industry left to hope that the business case will be considered at the next COAG meeting on November 17.

A November 28 meeting of the Australian Health Ministers Conference in Brisbane is also likely to be a target for clinicians and technologists who are increasingly eager to have elements of a national IEHR in place by the end of 2012.

A spokeswoman for NEHTA on Friday confirmed that the authority's business case did not make the COAG agenda amid discussions of the pall spreading throughout worldwide financial markets.

“So far no new date has been set for COAG discussions around an individual electronic health record and NEHTA funding arrangements" the spokeswoman wrote in an emailed response.

She declined to comment further, but it is understood that NEHTA staff and the organisation's board are disappointed that the business case was not discussed as COAG had loomed large on the organisation's calendar for much of the year.

Much more here:

http://www.misaustralia.com/viewer.aspx?EDP://20081006000030389252

There are a few things to be said here.

First, maybe if NEHTA actually made the non-commercial parts of their case public – along with the Benefits Case developed by the Allen Consulting Group - there might be an opportunity for the various interested parties to support the proposal. Not knowing just what is proposed and what it might roughly cost makes any rational support difficult.

Second the article wrongly suggests the Deloittes Study is being developed on behalf of the Victorian Health Department – the work is a National e-Health Strategy being developed for the Australian Health Ministers Advisory Council.

Third there is a separate Victorian Health ICT Strategy 2009-13 which was mentioned yesterday in the blog.

See:

http://www.health.vic.gov.au/ictstrategy/news.htm

Fourth there is also work on e-Health happening is pretty secret ways by the National Health and Hospitals Reform Commission –another one of those activities that won’t gain support without more public awareness and review.

All in all this NEHTA Business Case run up has been totally hopelessly managed – thinking glossy spin rather than substance will persuade a group like COAG. The Premiers may not be the ‘sharpest tool in the shed’ but they can easily detect when a proposal has not been adequately reviewed and discussed by relevant stakeholders and where consensus has not been really developed.

Let’s hope the new NEHTA CEO can come up to speed and understand that a much better explanation and communication approach is critical to success. Of course, he also needs to work out if he is really convinced the IEHR is the right way to go. Blog readers will know I am deeply sceptical it is the right thing to be doing at this point but then with the proposal being secret how can one really form a truly informed view?

David.