Unscripted Errors – What a Beat-Up!

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

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

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

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

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

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

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

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

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

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

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

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

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

David.

HealthConnect Renamed - What To Unclear

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

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

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

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

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

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

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

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

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

David.

Smartcard Stupidity

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

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

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

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

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

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

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

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

Well done James!

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

David

Health IT and the Australian Budget

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

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

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

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

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

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

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

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

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

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

We shall see tomorrow what the budget brings.

David.

Lessons for Australia from the CCHIT

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

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

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

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

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

David

An ID Card in all but Name – For Now!

Individual identity systems are a topic of great interest for this blog. The reason for this is that patient identification is a key requirement for any form of electronic health record and that NEHTA has been working to design a patient identity management system as one of the “building blocks” for e-health.

It now seems that Australia is to have an “access card” that will be needed to be presented when accessing all Commonwealth Government payment services (Medicare, Social Services and so on – in total 17 different services).

Interesting analysis and a range of opinions are available both here and here.

It is fair to say that denial that the proposed card is an ID card is disingenuous in the extreme and is to be condemned as an attempt at concealing the fact that this proposal goes much further that the publicly rejected Australia Card of the 1980’s in terms of potential for abuse and the scope of linkages being planned.

The claim the card is voluntary is equally a nonsense. If you choose to go without healthcare and social security benefits sure you could struggle on without it for a while at considerable expense – but how long will it be before it is needed to use State run services and finally private services. It will surely become all pervasive without firm legislative limitation – which has not been announced as far as I am aware.

The Government needs to come clean and be clear just what is proposed to manage scope creep and ID fraud before any one should support it.

Lastly it will be interesting to see how the proposed smartcard interacts with the proposed NEHTA patient ID proposal. Does this announcement pre-empt, support, interact with or have any other role in the development of the Australian EHR system.

This commentator will wait and wonder!

David.

Shared Electronic Health Records are Not Easy

A day or so an interesting report appeared in the web magazine ehiprimarycare.com revealing that the plans for the Shared Electronic Health Record (SEHR) for the NHS spine had been significantly scaled back. To quote the relevant section:

"Dr Gillian Braunold, one of CfH’s national clinical leads for general practice, said major diagnoses and major procedures will no longer be included in the initial upload to the spine, a change in policy from proposals issued by CfH in the autumn.

She told EHI Primary Care: “We feel it is sensible to limit the initial record to just prescriptions and allergies because we want to make sure each set of records is fully correct. The profession felt strongly that although globally a practice might feel its records were good it was important to look at each set of records before they went up.”

This outcome can only serve to remind us just how difficult it can be to come up with a useful SEHR and to ensure the accuracy and utility of the data held as well as address all the other issues that arise (privacy, security etc).

Australia’s effort in this regard, termed HealthConnect, presently has a rather ambiguous status. While it has not officially been killed off, it now seems highly likely that it will not be built as originally conceived. This conception was of a large centralised repository which held an initial patient record (with standardised content) and then a series of “event summaries” which were created each time an individual had an encounter with the health system. Over time the event summaries were to form a longitudinal health record which lasted the patient’s life.

The key barriers to success of this project would seem to have been:

1. The lack of clarity about just what the information contents of a summary records should be to meet the benefits objectives of the project.

2. The inability to clearly recognise the importance of, and the need to standardise, the client systems which were to be the sources of the information contents for the SEHR.

3. The lack of provider and client identifier approaches as well as the lack of an agreed clinical terminology. (the need for these is now recognised six years on – and they may be available in 2-3 years)

4. The lack of properly conducted, transparent, well funded trails of the various components required to reach the 2001/2 vision.

5. The difficulty in working through the privacy and legal issues, as well as the consent issues, associated with the whole concept.

6. The lack of a properly thought through and compelling business case for the overall project – leading to a lack of budgetary commitment for the whole enterprise.

7. The lack of recognition that the quality and sophistication of the client systems was crucial to the overall justification of the project.

8. An inability on the part of the sponsors of the project to develop political and public support for the implementation of HealthConnect.

It seems clear to me the UK has been sensible in scaling back what they are attempting and to approach the whole endeavour incrementally – hopefully learning as they go on. I am firmly of the belief “big bangs” are not the way to success in Health IT.

David

The More Things Change - The More They Remain the Same

The following is an article - unchanged - I wrote in late 1999. It is amazing to see how little has changed!

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Opportunity Lost – Health Information Technology in Australia : 1970 – 1999

In 1986 I was walking home late at night from a large public hospital having just lost the battle to save the life of a young man whom my colleagues and I had been working on for a number of weeks. As I mourned the loss of this young life I, not unnaturally, wondered was there anything I should have done, I had omitted – or were there things I had done that had led to this sad ultimate outcome. A search for such certainty is a natural and appropriate activity for any responsible and caring clinician, but as I later came to realise, attainment of such certainty is ultimately not achievable, or even approachable, without automated help. As I walked I comforted myself by recalling that, while I was in charge of the Intensive Care Unit for that week, others had been in charge in previous weeks and they had all helped and offered advice and skills during the last few days. That the final outcome was not totally on my shoulders offered some comfort.

Why raise this story? The reason is that at the time of this story I was, as you might say, at the peak of my clinical powers. I had been trained for nineteen years since I had left school, had two clinical fellowships and a PhD and a little over a decade’s practical experience. But I was still unsure. As I reflected further I realised there were two elements forming my dilemma - firstly, that total certainty was impossible and secondly that the management of the knowledge of medicine, and especially its dissemination, was far less than perfect.

Move on to the present day – what do we see? We see a profession that has even less certainty and confidence than 15 years ago. There is evidence of a progressive loss of public confidence in the profession, the cost of medical professional indemnity insurance is soaring, professional satisfaction seems to be waning and all agree that the national public hospital system is in a mess. Worse still, thanks to the work of people in the field of clinical quality improvement , we now know for certain that the quality and consistency of care are far below what the ordinary man would see as acceptable levels. Indeed public expectation for perfection is now so high that when the College of Anaesthetists released their recent report on anaesthesia related deaths for the period 1994-1996 that showed some 135 deaths related to anaesthesia from over 8 million anaesthetics provided (1 per 63,000 procedures), there was intense media and public concern. That such an extraordinarily good outcome should be seen so negatively shows how far we have moved since the days, less than 50 years ago, when death rates of 1 per 2,000 procedures (Beecher & Todd, Annals of Surgery, 1954) were seen as totally unpreventable.

All this is made worse, as far as the ordinary doctor is concerned, by the escalating pressure from Government to take steps to improve quality and consistency, while reducing costs. Meanwhile, these doctors are not being provided with the supporting and enabling tools to achieve the desired outcome and are paid on a basis that provides very strong incentives to deliver quick care to maximise the doctor’s income.

In 1997, while working with the IBM Consulting Group on a study for the Commonwealth Health Department, a colleague and I analysed the benefits for the total health budget that could be realised if some small technology enabled improvements were to be implemented. We costed the impact of the fully funded introduction of a General Practice Clinicians Workbench with the sole function of providing electronic prescribing. (This involved using a computer to keep track of the medicines a patient was on and then, as required, producing prescriptions for that patient. The computer was able to both produce a neatly printed legible prescription while at the same time making sure what was being prescribed was both reasonable and safe – a side benefit for the doctor is that repeat prescriptions can be produced very quickly and easily). The cost was estimated to be in the order of $100 million over two years, with the direct cash benefits to the Government flowing from the reduction in prescribing errors and their sequelae of the order of $800 million over five years (the economic life of a desktop computer).

In addition to the benefits specifically related to Electronic Prescribing, there are a range of benefits which will flow as Electronic Prescribing is essentially the “pathfinder” application leading to the use of computers in other aspects of the patient consultation process. A now dated review (Sullivan F & Mitchell E, BMJ 311: 849 1995) of the worldwide experience, and the UK experience of the impact of the $A100+ Million the UK NHS spent almost five years ago on primary computing, reached the following conclusions based on a review of all available literature:

· On the downside, Use of a computer during consultations in the UK occurs in 55% of consultations and this use lengthens the consultation by between 48 and 90 seconds.

· But among the good news was that use of the computer improves immunisation rates between 8 and 18% and that;

· Use of a computer also improves the carrying out of other preventative tasks by up to 50% (eg mammography, Pap smears etc).

· Additionally it was found that use of the computer did not have a significant negative impact on patient satisfaction.

To obtain such major improvements in preventative activity would be of considerable importance in having Australia reach the goals set in the Health 2000 Initiative, and would represent immense overall value to the community as a whole (probably as important, if not more so, as the financial benefits identified above).

Sadly we find ourselves in a situation where, some four years after the study was given to Government, we are still moving at a glacial pace, nothing fundamental has happened and an opportunity cost of almost a billion dollars has been incurred through inaction. Even more worrying is that the present Federal Minister, Michael Wooldridge, has been saying publicly and privately that something needs to be done for at least three years and has been vociferously supported by both the AMA and the College of General Practice. Yet it appears that no coherent action has been taken or even planned.

If confirmation was required of the basic correctness of the general assertion that having doctors use computers to assist them deliver improved care, one has to look no further than the ‘Mother Country’. In the UK – a country not famous for being at the very forefront of IT Innovation – they have recently committed (September, 1998) through their strategy “Information for Health - An Information Strategy for the Modern NHS 1998 – 2005 ” to spend $A2.4 billion over seven years to achieve the following objectives:

· a lifelong Electronic Health Record for every person in the country.

· round-the-clock on-line access to patient records and support of best clinical practice, for all NHS clinicians.

· a National Electronic Library for Health to keep doctors and nurses, and other clinical professionals up to date with the latest clinical research and best practice at the time they need it.

· delivery of integrated seamless and properly co-ordinated care for patients through GPs, hospitals and community services sharing information across the NHS information highway.

· fast and convenient public access to information, advice and care through online information services and telemedicine.

· more effective use of NHS resources by providing NHS planners and managers with the information they need.

It is clear the UK sees this investment as a strategic move to dramatically upgrade the effectiveness of their national health system, and it is equally clear they would not be prepared to provide the scale of funding planned if they were not certain they would achieve major improvement both in financial and clinical outcome terms.

Back home, however, we find ourselves in a situation where we have an obvious and worsening problem – information overload for medical professionals, a ready solution in the form of automated clinical desktops, and the public in the middle are getting care of a quality and consistency considerably less than is possible. As a side issue, we also see spiralling health costs, related, in part, to a failure to leverage the efficiency and quality benefits obtainable from structured and properly planned implementation of appropriate technology. The fact that expenditure on technology to support the front line care givers may, on occasion, be dramatically more effective than simply hiring a few extra doctors, nurses or administrators, has clearly escaped many of the health system’s leaders.

So what, you may ask is actually going on, and why is the situation allowed to continue? The answer, I fear, is a combination of factors, but at the top of the list there must clearly be some degree of lack of professional and governmental leadership. Additionally, as is always the case there are some financial and structural issues as well as what may simply be termed the ‘well it doesn’t look too broke, so we won’t fix it yet’ attitude of those in the health system. This is despite the increasing concern of the public at large.

Let’s start with money. We have here an instant problem. Implementation of the systems and infrastructure to achieve the UK NHS goals would be quite expensive, probably $250+ million over 1-2 years. While a very compelling business case can be made that the money would be recovered many times over – no-one in authority seems to have a strong inclination to authorise that scale of investment. Sadly, even with an unassailable business case straightforward action in this area is not easy because of the Byzantine complexities of health funding in Australia, sourced as it isfrom federal, state, private and personal sources.

Easy you say, have each doctor pay for their computer etc as they are the user and all will be well. Maybe just sweeten it a bit with a payment or two for some specific computerised information on a monthly basis and they will all be off and running.

Think again – our health system – at the GP level – largely rewards not quality of care but rapidity of care – the faster you can get them through the more you make! Worse still, using a computer slows you down a little to boot. The final blow to GP enthusiasm for automation is, of course, that while there may be some small benefits to offset the inevitable slowdown caused by automation the major benefits derived from the system (e.g. less drug interactions caused, higher vaccination and screening rates etc) are for the Government and the patient. The doctor is no better off, except for the feeling of practising better medicine, and has all those ongoing costs – even if the initial leap, and expense, has been taken.

A third option might be to have the patient pay an extra 20 cents, or whatever, a visit to have the guarantee of being reminded when the next vaccination and screening procedures are due and being warned before taking potentially incompatible medicines.

Without denying that there are a number of GP’s who, for their own reasons, decided to computerise some aspects of their practice (50%+ with accounting and about 15% for some clinical functions), the step that will really make the difference is to ensure that there is a fair and equitable split of the benefit between Government, patient and GP. This can be most simply achieved, in my view, by developing a rebate for computerised activity on the part of the doctor and use of some appropriate federal funds to develop and appropriate secure health information network infrastructure (The Health Insurance Commission has wanted to do this for years –as have the telcos). An example may be an extra 50 cents rebate to the doctor for each patient encounter that is properly recorded in an approved computerised system. In this way the patient receives all the automated alerts and warning important for ensuring the quality of their care and the practitioner does not feel pressured to rush through the computerised parts of the consultation. As an inevitable side effect of this we reduce adverse drug events, improve vaccination and cancer screening rates, have prescriptions that pharmacists can read and have much enhanced medical record keeping which can later feed into research and teaching. I see this is a very small price to pay for a dramatic and sustained improvement in the quality and consistency of care in key priority areas.

In summary, Australia Health Information Technology is in a Mexican Standoff. Those who want the benefits don’t want to pay, for whatever reason, and those who need to use the technology for the good of their patients mostly won’t do so without some financial incentive to ensure their incomes are not reduced. The logjam needs to be cleared by some decisive leadership and development of a clear forward strategy that all stakeholders can be comfortable with and see is in their interests. Fortunately it is clear that there are a range of rational and effective national strategies that could be developed which would make all the stakeholders winners, and thus minimise implementation difficulties. The background work has all be done, it is clear the benefits are there to be had, all the pilot studies we need have been conducted and evaluated and the time for decisive coherent action has arrived. If ever my younger colleagues are to feel confident and sure of their capabilities to face the knowledge and information challenges of the new millennium the time to start is now. I hope someone will act soon, for all our sakes.

David G More – October, 1999

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The only thing that has changed is that the evidence for all the claims made above is now vastly stronger!

David