Just Who Do They Think They are Fooling?

Earlier this week an eight page brochure entitled “e-Health NewsLetter” June 2006 appeared in my e-mail inbox. A nicely produced eight page brochure which was suggesting all was absolutely wonderful with all the e-health projects being sponsored by the (what was thought to be up until now the defunct) HealthConnect program.

Oh joy…all will be well in e-health I thought – such a professional polished brochure can only contain good and exciting news.

Sadly it is not the case. What is in fact contained in the Newsletter, which for some odd reason was not found with a Google search for ["e-health newsletter" healthconnect] on July 2, 2006, is a sad illustrated repeat of all the failures and lack of progress we have seen over the last six years.

I finally located an on line copy at http://www.health.gov.au/ehealth/. It was made available on 28 June, 2006 according to the download page. Quite odd that there is not even a pointer to it on the HealthConnect web site itself. Clearly this brochure is meant to be very low key indeed in its public exposure.

What do we learn from the contents?

Firstly we discover the national consumer health information line (Healthinsite), after 5 plus years of operation receives less that 12,000 unique visitors a day. Hardly usage that Google or Yahoo would see as a commercial threat. (I must say however the site is valuable and really should be much better marketed to the public – pity the good work is not more widely known.)

Secondly we hear that a few months ago the Council of Australian Governments provided $130 million over 3-4 years to identify patients and health providers and progress clinical terminologies. Still no idea how the identity systems will relate to the proposed Access card of course.

Next we get a recital of all the various HealthConnect Trials that have been conducted over the last 4-5 years.

We discover that South Australia is implementing a proof of concept care co-ordination system because SA has the oldest patients in the country and need it most. No specific technology, patient groups, time lines, outcomes etc are discussed so we will all just have to wait and see.

In the Northern Territory is seems the Shared EHR has been such a success that it has needed to be supplemented with point to point (P2P) messaging of clinical information (i.e. secure e-mail between doctors). The discussion also has real issues regarding tense. Part of the document implies a lot is up and working and then further on there are comments saying that what is being done will comply with yet to be finalised standards. I know the evaluation of the initial NT trials were very negative and have no certainty much is really happening at present either.

The latest news from the Townsville trial is that everyone thought it was a good idea. Again, no discussion of what difference it made, how many better outcomes achieved etc

From NSW we hear that the Health-E-Link project began a pilot implementation in March and is a great success because only five percent of patients have opted out. Commentary recently suggests the trial is not going all that well technically – and certainly there have been no public claims of progress I have seen. Again we need to wait and see – a franker discussion of numbers enrolled, access made to records would provide a few facts to support the brochure assertions.

In Victoria and Western Australia there have been broadband implementations which may improve regional communications and provide VoIP and e-mail etc. Clinical benefits are not yet apparent and the costs of service provision are a major issue in the WA project continuing after Commonwealth Funding ends.

Lastly, in Tasmania Hospital Systems have been modified to send an e-mail or fax, based on patient administrative system data, when a patient is admitted or discharged. Possibly useful – but rather a far cry from the Shared EHR vision which HealthConnect was meant to be about.

In essence this brochure is simply an admission of failure, after what is said to be $200 Million spent, to demonstrate a single improved clinical outcome.

It is really quite serious when a government publication is so carefully crafted to conceal the lack of progress and to provide quotes and commentary which are frankly untrue.

David.

An Interesting Week for Australian Health IT

It has been an interesting week for Australian Health IT. First big bit of news was that there seems now to have emerged some concern from our political masters, at least on the opposition side, that Australia’s progress with e-health leaves a good deal to be desired.

As reported in the Australian a few days ago, in an article colourfully entitled “E-Health on Life Support says Labor”, Ms Julia Gillard delivers a withering attack on the performance of the government in the e-health arena.

Among other things she points out:

"We have to face the fact that a national e-health system is at least a decade off"

"Responsibilities have shifted, programs have changed names and the plethora of committees and advisory groups continues to grow," she said.

"In Senate estimates, we learnt that Human Services Minister Joe Hockey had made the decision in May - unannounced - to scrap the Medicare smartcard.

"We also learned that HealthConnect no longer exists as a program, leaving only three small initiatives running in South Australia, the Northern Territory and Tasmania.

"Indeed, HealthConnect has disappeared from the Health Department's lexicon, and there is some revisionist history at work."

The only legacy after four years and $200 million spent on HealthConnect was a "lessons learned" report in 2005 that identified a lack of "the underlying infrastructure and connectivity" critical to a successful implementation, she said.”

The lack of apparent co-ordination between the planned Services Access Card and the NEHTA Individual Health Identifier initiative were also strongly criticised - seeming as they do to duplicate each other's function to a large degree.

Of course she is right… the whole thing has deteriorated into a visionless fiasco. I only hope when, at some time in the future, Labor comes to Government these comments will be remembered and something constructive and properly considered be done.

For a little good news, in contrast, we also learned this week that, despite some delays and difficulties the UK NHS Connecting for Health initiative is actually making some significant progress. This is very good news and offers just a tiny sliver of hope for us south of the equator! It is worth reproducing the summary of the report made by iHealthBeat.

“Report Notes Achievements, Delays in NHS IT Program
by Colleen Egan, iHealthBeat Associate Editor
June 20, 2006

The United Kingdom's National Health Service has been under scrutiny since 2002 when it launched in its National Program for IT, which was intended to modernize the NHS' computer systems in an effort to improve care quality. The National Audit Office in a new report looks at the IT program's advances and shortcomings, and makes recommendations for future progress.

According to a report, which was issued last week, the massive IT program's "scope, vision and complexity is wider and more extensive than any ongoing or planned health care IT program in the world, and it represents the largest single IT investment in the UK to date."

The report, "The National Program for IT in the NHS," which was submitted to the House of Commons last week, assesses the state of the IT program, including:

• Progress being made in comparison to the program's original plans and costs;
• Steps being taken to implement the program;
• How the IT systems have been procured; and
• How the NHS is preparing to use the systems.

Schedule and Budget Status

The main goal of the IT program is to "improve services rather than reduce costs," and availability of the IT program's services have "largely exceeded contractual goals," according to the report. As of April 2006, the "Choose and Book" electronic scheduling system was being used for 12% of appointments, and the electronic prescribing program is being used at about 15% of physician offices and pharmacies. In addition, 80,000 active users and 168,000 staff members have registered with the NHS' e-mail system, called NHSmail.

Despite progress on some aspects of the IT program, other components have been postponed. For example, the National Data Spine was up and running on time, but some parts intended to enhance functionality have been delayed, according to the report. Also delayed are the first phases of the NHS Care Records Service, which will make certain parts of a patient's medical records available to caregivers.

The IT program is working to control costs by fostering "vigorous competition" among vendors and by using its buying power to negotiate reduced prices, according to the report. For example, NHS will renew its license for Microsoft desktop product prices for the "lowest prices in the world," according to the report. Overall savings from these types of agreements are estimated at about $1.6 billion.

The report estimates gross spending on the IT program over the 10-year timeframe (2004-2005 to 2013-2014) will be about $22.8 billion. However, Lord Warner, the minister of state for reform who is responsible for the program, in May estimated the total expenditure on NHS IT over 10 years at close to $36.8 billion.

Moving Forward

As the NHS proceeds with the IT program, the report states that successful implementation hinges on three areas:

• Making sure IT suppliers deliver on time systems that meet the NHS' needs;
• Ensuring that NHS organizations participate in implementing the program's systems; and
• Getting the support of NHS staff and the public to use the technology.

The report recommends that the NHS and the Department of Health focus on communication, training, management and evaluation as the departments further their IT plans. For example, the Department of Health and NHS Connecting for Health, which is an agency of the Department of Health, inform NHS organizations and staff as to when certain parts of the IT program will be delivered, and NHS organizations should tell members and staff how the implementation schedule will affect them, according to the report.

Also, NHS Connecting for Health should "continue its strong management of suppliers' performance" to make sure vendors are delivering components of the IT program on time, a process that includes imposing contractual penalties, the report states. In addition, the report recommends that the Department of Health, NHS Connecting for Health and the NHS develop training and development programs for staff and commission studies to evaluate the impact of the IT program and the experiences of organizations that have implemented the technology. ”

I hope our Government is watching and seeing how far they are slipping behind to the cost “in both blood and treasure” of the Australian population.

David.

Clinical Decision Support - A Major Contribution

Informatics group outlines clinical decision-support 'road map'

Supportive policy and new financial incentives are needed to increase healthcare's adoption of clinical decision-support systems, according to a report produced by the American Medical Informatics Association. The report said that providers are often reluctant to purchase clinical decision-support systems because doing so might increase liability, not be cost-efficient, and privacy regulations hinder them from accessing patient data.

The report also said that a lack of sharing best practices and providing feedback to vendors has stymied the development of adequate systems that are easy to customize. "Thus, lessons learned in clinical use, which could be used to greatly improve the efficiency, acceptability, and value of CDS (clinical decision support) tools, are translated into improved products and implementation strategies very slowly, if at all." Moreover, there is "no mechanism for post-marketing surveillance" and that prevents improvement. The AMIA report suggests that demonstration projects should be launched by 2008, and they could lead to the development of better systems that are more widely used. In 2005, the federal government's Office of the National Coordinator for Health Information Technology commissioned the association to write the report. The association is an organization that studies the development of medical informatics and has 3,000 members made up of providers and researchers. Read the Roadmap for National Action on Clinical Decision Support.

By Joseph Mantone / HITS staff writer

Go here and read - this is vital and important stuff and it is crucial the recommendations get adopted!

http://www.amia.org/inside/initiatives/cds/

David.

An Australian e-Health Strategy - The Outline

As the sole reader (nod to Crikey.com) of this blog is aware I have been saying for a while now that Australia is being badly short changed by the lack of a coherent national e-health strategy and implementation plan to frame and put in context both NEHTA and the various State and Commonwealth initiatives.

While developing relatively more comprehensive documentation for publication initially in a different forum, it has occurred to me that what I feel is required can be very simply summarised. In summary what is needed is a two prong approach :

1. The NEHTA work plan to be supported and advanced and where possible and useful increased investment made. In saying this I am recognising that NEHTA will not deliver much of practical use until 2008/9 by its own estimation and that NEHTA will need to operate for a good deal longer (in perpetuity actually) and that reaching its apparent goals may take a good deal longer than a “transition” timeframe.

2. There should be a separate national initiative to get in place nationwide proven health information systems that are known, already to be both practical and to make a real difference to the quality and safety of health care delivery.

I see there are five areas such an initiative should cover.

a. General Practice and relevant office based Specialists should be encouraged and provided with incentives to obtain and use advanced ambulatory EHR systems with sophisticated Clinical Decision Support.

b. Secure Clinical Messaging should be established between Laboratories, Radiology Practices, Hospitals and GPs with documents to be exchanged to include discharge summaries, specialist letters and pathology and radiology reports (and maybe images)

c. Public and Private Hospitals should all implement appropriate clinical and patient management systems including Clinical Physician Order Entry, Nursing Documentation and Medication Management using “closed loop” drug administration control.

d. Health Insurers and Medicare should offer their clients Personal Electronic Health Records where individual can record important health information for use, by those they authorise, in their care.

e. There should be a concerted push by the Commonwealth to establish appropriate disease pattern incidence and monitoring systems for monitoring epidemic disease outbreaks and bioterrorism.

All this is totally feasible today using commercially available and in some cases ‘open source’ software. The only block to major progress in the short term and a better long term future is a strategic vision and the appropriate funds. The paralytic inactivity of the Commonwealth in not setting such an proven and doable agenda is a public scandal I believe.

This is all so obvious I am alarmed some one did not think of it ages ago!

David.

The Road to e-Health Success – What’s Missing?

This article suggests that the National E-Health Transition Authority (NEHTA) has lost its rationale and reason for being, if, indeed, it ever had it. I accept that this is a fairly large call, so how do I justify it?

The premise on which NEHTA is based is that the provision of relevant, timely and accurate information needed by those who deliver and manage patient care will improve patient safety and reduce clinical accidents, thereby allowing us all to live happier, longer and more productive lives.

NEHTA is the offspring of a Boston Consulting Group Report which was delivered to the Australian Health Information Council (AHIC) and Health Ministers in April 2004. This report recommended, among other things, that an entity (that subsequently became NEHTA) be established and that its focus be on development of e-health connectivity and standards at a National level. It also recommended work to advance Electronic Health Records and Clinical Information Systems but this suggestion was not followed up if the funding allocations from COAG are to be believed (see below).

Later in 2004 NEHTA was established with Dr Ian Reinecke as its CEO. As at June 2006 the organisation has more than thirty staff scattered across offices in a number of States befitting its role as a cross-jurisdictional entity. A little under twelve months ago NEHTA was incorporated as NEHTA Ltd with its board being made up of each of the jurisdictional Health Department CEOs and some Commonwealth representation.

About three months ago the Council of Australian Governments (COAG) provided NEHTA with $131 Million in funding over three years for initiatives in the areas of clinical terminology and patient and provider identification. The timetable for these initiatives to be operational extends to 2009. In the meantime, in terms of meeting the implicit goals of the premise identified above not much seems to be happening, and indeed it could be claimed, with some justification, that a wet blanket of indecision and uncertainty has been cast over the Australian e-Health Space. The fact that NEHTA says it is determining the National Standards to be used in e-Health in Australia, but has yet to decide what they should be, is not helpful to most participants in the sector.

This has been made worse by the approach NEHTA has adopted to its communications with stakeholders. These stakeholders include medical practitioners, pharmacists, nurses, patients, the medical software industry, health system managers and others. It would be fair to say that outside the e-health cogniscenti NEHTA is virtually unknown and that the public in general are totally unaware of its existence. Worse still, is that despite being publicly funded and having accumulated a great deal of valuable intellectual capital over the last two years, essentially none of this material has been shared with the specialists working in the e-health space or the community in general.

Parties impacted by this authoritarian vacuum have essentially responded by moving forward as best they can, not asking permission but recognising at some point they may have to seek forgiveness. Consequently, we have seen emerging the use of an increasing variety of clinical communication systems and tools from multiple providers, be they pathology or radiology service providers or local hospitals, wanting to communicate with local GPs. Each has tried to service the needs of their customers within the known Standards.

Further we see a patchwork of potentially non-harmonised hospital systems being purchased and implemented by the different States as well as a progressively fragmented market in the private hospital sector.

It seems that over the last few decades there has been a significant trend towards acceptance of the idea that it is managers and experts, rather than clinicians, who know what is best in the running of hospitals and the delivery of patient care. The consequences of this ‘managerialist’ approach has been amply demonstrated in the outcomes seen recently in Queensland Health, where ultimately a Health Minister had to apologise to a physician who was wrongly disciplined by departmental bureaucrats.

NEHTA appears to have only one practicing clinician among its publicly acknowledged 30+ staff and no clinicians on its Board. This is a recipe leading to a profound clinical ‘disconnect’ and loss of a proper appreciation of NEHTA’s raison d’etre.

What is needed, is for NEHTA to get back to servicing its stakeholders – the clinicians and their patients. To achieve this it needs to continue with the work already initiated and at the same time start developing and making public a road-map; one that is focussed on meeting the objective of getting systems that make a difference into the hands of clinicians as soon as possible. What is needed by clinicians is well known. Indeed, a full description has been publicly available in detailed reports for over a decade!

If this is not done very soon we will find ourselves with a health system that is not properly wired, that will be more unsafe than it should be, and which will be inefficient and unnecessarily costly. The six year HealthConnect experiment was finally put out of its misery in the 2006 Budget papers (disappearing without trace!). The NEHTA experiment has now been running for two years and as best anyone can tell not a single patient has benefited from its work. It is time NEHTA explained to the public and to the caring professions how NEHTA is going to address the information needs of the Health System and when we can expect to see some substantive change. Lives are being lost as NEHTA cogitates in secret.

David.

Identity Management - What's Happening?

I must say this is all getting pretty confusing. In the late 1980’s an initial attempt to introduce an identity card for the Australian population was rolled by the Privacy Lobby. This experience of public revolt scarred many politicians and bureaucrats and the “Australia” card remained off the agenda for a good 20 years.

After 9/11 there was a recognition that a review of the management of citizen’s identity could be valuable and this led to a number of proposals beginning to circulate within Government. At around the same time the HealthConnect program was recognising the need for patient identification as one of the key infrastructure pieces for the then proposed National Shared Electronic Health Record. When HealthConnect programs were transferred to NEHTA the work on patient (and provider) identification were key initial elements.

Consulting reports addressing this area were commissioned after COAG Meeting in July 2004 recommended the development of a National Patient Identifier System and the report was delivered in early February 2005. The report has not been made public but it seems likely some of that work has informed the Individual Health Identifier (IHI) which is being developed with funding from the March 2006 COAG Meeting. This identifier is planned to be voluntary, i.e. all health services will be available without its use, and the individual will have easy access to the information held under the identifier (e.g Name, Address etc). Registered Health Providers will also have access.

So far so good. However in the recent Federal Budget it was announced that there was to be a National Services Access Card developed – at a cost of $1.1Billion Dollars. This card is to be a Smartcard which will have to be produced to access any Commonwealth (and possibly State Based) payments for Health and Social Services. For most citizens this will make this card “about as voluntary as breathing” as it has been put by more than one commentator.

We also have in the mix the Document Verification Service (operated by the Attorney General’s Department) and up until a few days we had the Medicare SmartCard that was announced by Minister Abbott in 2004. We discovered a day or so ago – as the Senate Estimates Hearings that this project had been cancelled after $4.4M had been spent – and presumably wasted. The adoption of the card in the Pilot Area of Tasmania over the two years had been of the order of 1% of the population. Clearly a remarkable success with the Tasmanian Community.

Lastly, of course we have the identity management systems currently used by Medicare and Centre Link as well, of course, as the database used by the Passport Office running out of the Department of Foreign Affairs and Trade (DFAT).

It seems to this humble observer we have a large number of right and left hands ignorant of each other’s activities, objectives and requirements. Expect this mess to cost us all dearly both in financial failed system terms and in lack of progress with the e-health agenda.

David.

Who Pays the Piper

In the last few weeks I have been reflecting on the rather sad series of outcomes we have seen in the e-health space in Australia and wondering just what can be done to change the present situation for the better.

The first thing that is obvious is that there is no quick and easy fix. Standing back from the day to day fray a little I think most would accept that what the desired end state is clinicians (covering doctors, nurses and others providing patient care) being able to access the information and decision support they need to do their job well and safely.

It is clear that without this end-state being reached clinical error of both commission and omission will continue and patients will be injured or die as a result. It is thus clear that what is needed is a national infrastructure that provides these services to the clinicians. (Note: this analysis leaves aside for now the thorny issue of how to achieve use of the technology once it is available at the point of care delivery for use).

There are thus two issues – the first is who pays, and the second is how to obtain adoption and use of the technology once there is no longer the “elephant in the room” that blocks adoption – viz. that the clinician user is expected to pay personally for benefits to be harvested by others.

The Australian Health Care System has a powerful, built-in, disincentive to the use of technology in the delivery of clinical care – that is that not only do you have to spend your money to obtain the technology but that, because your financial rewards are linked to patient throughput, once you have the technology in place you will see your income drop as you use the technology to do a better but unrewarded better job (at the very least for the first few months of use).

For reasons that totally escape me the Department of Health and Aging are of the view that clinicians (who are essentially small businesses) will adopt technology and pay for it on the basis of warm feelings in their nether regions that they are doing the “right thing”. This is clearly rubbish.

Automation of clinical practice provides the bulk of its benefits to the payers (i.e. the Medicare system) and the patients through less quality poor care and reduced cost of care. It is these sector that need to pay. The policy question for Government is how best to deliver the funding – not to place it’s head firmly in the sand and hope something will happen as if by magic.

Once the issue of the “financial friction” is addressed we can then start to use the appropriate change management approaches to foster uptake. Without the first step we might as well just forget it and look for other windmills at which to tilt.

David.

Oh Wonder of Wonders – NEHTA Recognises We Need an e-Health Vision.

Dr Zoran Milosevic is obviously a smart man. With the job of managing the NEHTA Interoperability Framework you would need to be!

Further evidence of his talent is revealed in a recent e-mail which was published in the Australian College of Health Informatics (ACHI) e-mail list. Among a range of comments came the following:

“5. Regarding your comment on the lack of national vision, I believe that this is now prime time for us all (NEHTA, jurisdictions, clinical experts, clinical informatics people, and many other stakeholders) to work on such a national vision while leveraging the past efforts, including HealthConnect.”

Implicit in this comment is the acknowledgement that such a vision, and associated plans does not exist at present. One must wonder if Dr Milosevic had cleared this comment with his CEO or is it just possible that Dr Reinecke agrees?

I certainly hope so, as while there were many aspects of the Interoperability Framework I was not happy with (See the Blog entry of April 4 for details) the key deficiency that concerned me was that the document did not provide details of the strategic context and environment for which it was intended.

Clearly I wish all power to Dr Milosevic’s arm! If he can persuade NEHTA to undertake the consultative and open process he seems to foresee to develop a National e-health Vision (and subsequent Strategy and Implementation Plan) he will be the friend of many.

While he is at it he might also like to suggest the other components of NEHTA’s work are also opened up to similar discussion and review. Were that to be achieved we would all be encouraged progress was really possible.

David.