Writing earlier this year on the demise of HealthConnect as it was initially planned in an article in New Matilda in early 2006 I noted in passing
“There are other worrying portents of the Commonwealth Government vacating the e-health space. Firstly, the formal role of the Australian Health Information Council (AHIC) to undertake national e-health planning was withdrawn after the AHMAC meeting in late 2005.”
What I wrote seems to be truer than I could have imagined.
AHIC was initially set up by Health Ministers in July 2003. AHIC, it was said “works closely with the National Health Information Group in to increase the effectiveness of IT investment in the health sector.”
After little practical outcome from the Council after two years, it was reviewed by the Australian Government (in secret it would seem as there was no public report I am aware of ever announced or released) and its role was changed.
The new role was described as follows:
“The revised operating arrangements for AHIC are based on an independent review of the Council commissioned by the Australian Government. These arrangements will enable AHIC to focus on providing strategic advice to Health Ministers about the more effective and efficient use of information management and information communications technology (IM&ICT) in the health sector.”
At the same time as this was done (November 2005) all references to a proposed National E-Health Strategy disappeared from the AHIC web-site. I am told that despite twelve months consultation and work by the AHIC secretariat the strategy produced was so bad as to not be appropriate for release and so the whole idea of developing a National E-Health Strategy was abandoned. Since that time administrative transfers, changes and resignations have ensured that any expertise and skills in the e-health domain that may have existed have been largely dissipated.
It now seems that the last rites have been administered to the last representative Australian e-Health peak body – with the web site (www.ahic.org.au or www.ahic.gov.au) now having disappeared as of the time of writing (6th September, 2006).
The days of open consultative development of e-Health Policy in Australia would now seem to be over given we now have nothing other than private discussions determining the Heath Ministers decisions and NEHTA having advisory groups whose membership seems to be a state secret.
It seems unaccountable bureaucracy rules! All in all a sad day.
David.
Wednesday, September 06, 2006
Saturday, September 02, 2006
What’s the Secret? - Political Comments – Part 2.
A few months ago I discovered your humble correspondent had made a minute contribution to the Smartcard debate by providing a quote that permitted the Labor Party Spokesman on the Smartcard Project to ask a question, with notice, of Minister Joe Hockey regarding the costs of the project.
The question and the responses are as follows:
Mr Kelvin Thomson asked the Minister for Human Services, in writing, on 14 June 2006:
(1) Is the estimated cost of $100 million to register Australians for the Smartcard, attributed to consultant Dr David More in The Australian on 13 June 2006, accurate; if not, what is the correct sum.
(2) Does the $1.1 billion allocated for the Smartcard project in the 2006 Budget include a sum for Smartcard registration; if so, what sum has been allocated for that purpose.
(3) Is the estimated cost of $100 million to provide the Smartcard cards, attributed to consultant Dr David More in The Australian on 13 June 2006, accurate; if not, what is the correct sum.
(4) Does the $1.1 billion allocated for the Smartcard project in the 2006 Budget include a sum for provision of the Smartcard cards; if so, what sum has been allocated for that purpose.
(5) Is there an intention to allow private businesses use of Smartcard infrastructure.
(6) Has he, or the Smartcard Taskforce, received advice to the effect that the creation of a more valuable, single proof of identity instrument will increase the appeal and practice of identity theft.
(7) Does he, or the Smartcard Taskforce, plan to endow department or agency staff with the power to (a) confiscate and/or (b) deactivate a Smartcard; if so, (i) who will have that power, and (ii) will the exercise of that power be subject to appeal by the cardholder.
Mr Hockey—The answer to the honourable member’s question is as follows:
(1) The cost of establishing the access card system is $1.09 billion over four years. For commercial reasons, detailed information regarding costs, including the cost of registering Australians for the Health and Social Services (HSS) access card is not publicly available.
(2) Yes, the cost of $1.09 billion over four years to introduce the HSS access card includes funding for the registration of Australians for the access card. However, as noted in the response to question (1), information regarding the estimated cost of registration is not publicly available.
(3) See response to question (1).
(4) See response to question (2).
(5) The Government does not intend to build all Smartcard infrastructure such as cards, readers and microchips. This is not core government business. Therefore it is obvious that the private sector will need to service its equipment.
(6) Advice that the introduction of the HSS access card will increase the appeal and practice of identity theft has not been received by the Minister for Human Services, the Smart Technologies and Services Taskforce or the Access Card Consumer and Privacy Taskforce.
Indeed, as the KPMG Health and Social Services Smart Card Initiative, Volume 1: Business Case notes:
“KPMG considers that greater trust in the overall system will be strengthened by consumers being confident that their card cannot be used by someone else. Having a photograph on the card and all the other securities in place, in our view, is likely to strengthen that confidence.” (Public Extract, Page 18).
(7) The abilities of staff from the Department of Human Services or its agencies to confiscate or deactivate access cards is not yet determined, this will be the subject of detailed design work and the advice of the Lead Advisor and Chief Technology
Architect.
To prepare this answer it has taken approximately 2 hours and 21 minutes at an estimated cost of $137."
I would suggest you would have to score this answer 2/10 for provision of useful information and 9/10 for stonewalling.
What amazes me is why a breakdown at the level of enrolment costs and smartcard costs could not be provided. Details that might compromise the tendering process for the cards it is reasonable to withhold until such tendering is complete and pricing is determined, but providing estimates to the nearest 10-20 million (as the Government must have to provide the precise total cost of $1.09billion over 4 years) seems secretive in the extreme. It is, after all, a lot of public money and it would seem reasonable for the public to know a little more than just to total cost.
The response to question 5 is really bizarre. The Government would be not be expected to build any of the equipment involved – given there is not even a microchip fabrication plant in the country and it simply has neither the staff or capability to manufacture such products. But this was not the question. The question asked sought to understand if any Government infrastructure would be accessible or usable by the private sector i.e. if a new Government network is to be built to support Smartcard services will be private sector be able to use it.
The answer reveals a very poor understanding on the part of the public servant who drafted the response as to just what was being asked and what the implications were.
In fact, what is virtually certain, is that either a beefed up Medicare Australia network will be used or the private sector will provision the Access Card requirements for a fee which will most likely be transaction or usage based. The cards and readers will simply be purchased or leased commercially on behalf of the Government.
The response to question 6 is equally unsatisfactory. The question was going to the issue of the robustness of the identity services to be implemented to prevent identity fraud. Clearly what was needed in the answer were the reasons how the new card would reduce ID theft and evidence that backed that assertion. It should be noted that systems such as the Access Card are only as robust as their weakest link and the events of the last week or two surrounding the security of Government tax and Centrelink records make it clear where one potentially major weakness lies.
All in all an opportunity wasted for the Government to re-assure the public regarding the Access Card, its costs, its security and its workings.
David.
The question and the responses are as follows:
Mr Kelvin Thomson asked the Minister for Human Services, in writing, on 14 June 2006:
(1) Is the estimated cost of $100 million to register Australians for the Smartcard, attributed to consultant Dr David More in The Australian on 13 June 2006, accurate; if not, what is the correct sum.
(2) Does the $1.1 billion allocated for the Smartcard project in the 2006 Budget include a sum for Smartcard registration; if so, what sum has been allocated for that purpose.
(3) Is the estimated cost of $100 million to provide the Smartcard cards, attributed to consultant Dr David More in The Australian on 13 June 2006, accurate; if not, what is the correct sum.
(4) Does the $1.1 billion allocated for the Smartcard project in the 2006 Budget include a sum for provision of the Smartcard cards; if so, what sum has been allocated for that purpose.
(5) Is there an intention to allow private businesses use of Smartcard infrastructure.
(6) Has he, or the Smartcard Taskforce, received advice to the effect that the creation of a more valuable, single proof of identity instrument will increase the appeal and practice of identity theft.
(7) Does he, or the Smartcard Taskforce, plan to endow department or agency staff with the power to (a) confiscate and/or (b) deactivate a Smartcard; if so, (i) who will have that power, and (ii) will the exercise of that power be subject to appeal by the cardholder.
Mr Hockey—The answer to the honourable member’s question is as follows:
(1) The cost of establishing the access card system is $1.09 billion over four years. For commercial reasons, detailed information regarding costs, including the cost of registering Australians for the Health and Social Services (HSS) access card is not publicly available.
(2) Yes, the cost of $1.09 billion over four years to introduce the HSS access card includes funding for the registration of Australians for the access card. However, as noted in the response to question (1), information regarding the estimated cost of registration is not publicly available.
(3) See response to question (1).
(4) See response to question (2).
(5) The Government does not intend to build all Smartcard infrastructure such as cards, readers and microchips. This is not core government business. Therefore it is obvious that the private sector will need to service its equipment.
(6) Advice that the introduction of the HSS access card will increase the appeal and practice of identity theft has not been received by the Minister for Human Services, the Smart Technologies and Services Taskforce or the Access Card Consumer and Privacy Taskforce.
Indeed, as the KPMG Health and Social Services Smart Card Initiative, Volume 1: Business Case notes:
“KPMG considers that greater trust in the overall system will be strengthened by consumers being confident that their card cannot be used by someone else. Having a photograph on the card and all the other securities in place, in our view, is likely to strengthen that confidence.” (Public Extract, Page 18).
(7) The abilities of staff from the Department of Human Services or its agencies to confiscate or deactivate access cards is not yet determined, this will be the subject of detailed design work and the advice of the Lead Advisor and Chief Technology
Architect.
To prepare this answer it has taken approximately 2 hours and 21 minutes at an estimated cost of $137."
I would suggest you would have to score this answer 2/10 for provision of useful information and 9/10 for stonewalling.
What amazes me is why a breakdown at the level of enrolment costs and smartcard costs could not be provided. Details that might compromise the tendering process for the cards it is reasonable to withhold until such tendering is complete and pricing is determined, but providing estimates to the nearest 10-20 million (as the Government must have to provide the precise total cost of $1.09billion over 4 years) seems secretive in the extreme. It is, after all, a lot of public money and it would seem reasonable for the public to know a little more than just to total cost.
The response to question 5 is really bizarre. The Government would be not be expected to build any of the equipment involved – given there is not even a microchip fabrication plant in the country and it simply has neither the staff or capability to manufacture such products. But this was not the question. The question asked sought to understand if any Government infrastructure would be accessible or usable by the private sector i.e. if a new Government network is to be built to support Smartcard services will be private sector be able to use it.
The answer reveals a very poor understanding on the part of the public servant who drafted the response as to just what was being asked and what the implications were.
In fact, what is virtually certain, is that either a beefed up Medicare Australia network will be used or the private sector will provision the Access Card requirements for a fee which will most likely be transaction or usage based. The cards and readers will simply be purchased or leased commercially on behalf of the Government.
The response to question 6 is equally unsatisfactory. The question was going to the issue of the robustness of the identity services to be implemented to prevent identity fraud. Clearly what was needed in the answer were the reasons how the new card would reduce ID theft and evidence that backed that assertion. It should be noted that systems such as the Access Card are only as robust as their weakest link and the events of the last week or two surrounding the security of Government tax and Centrelink records make it clear where one potentially major weakness lies.
All in all an opportunity wasted for the Government to re-assure the public regarding the Access Card, its costs, its security and its workings.
David.
The e-Health Fiasco in Australia Is Now Recognised – What Should be Done?
Finally at least one side of politics has recognised there is a major problem with the Australian e-health strategy (or lack of it) and has pointed out the “waste and mismanagement” that has been bedevilling the area for years.
The following is the Sydney Morning Herald’s report of the Opposition Spokeswoman for Health.
http://www.smh.com.au/news/National/National-health-record-system-stalled/2006/08/29/1156816880858.html
“National health record system 'stalled'
August 29, 2006 - 1:29PM
The government has wasted hundreds of millions of dollars in stalled and failed attempts to introduce a national electronic health record system, Labor says.
Opposition health spokeswoman Julia Gillard said on Tuesday it was widely considered that using information technology to integrate patients health records could help prevent over-referrals, over-prescribing and minimise medical mistakes.
But the government had scrapped the Medicare Smart Card and its new proposed $1.1 billion Smartcard would not provide access to patient medical records, Ms Gillard said.
The much-lauded e-health records system HealthConnect no longer existed as a program and had all but disappeared, she said.
"Recent developments suggest that our national e-health strategy has not only stalled, but is dangerously close to being considered an expensive failure," Ms Gillard said in a speech to the Australian College of Health Services Executives in Adelaide.
HealthConnect - a national health information network designed to integrate patient records from hospitals, doctor surgeries, nursing homes, medical laboratories and pharmacies - was launched in 2000 with claims it could reduce accidental mishaps in treatment by as much as 30 per cent.
But Ms Gillard said "just a handful" of small HealthConnect initiatives were currently running in some states.
"And there do not appear to be any reports about what we have learned from those projects, how they might be further extended or why they succeeded or failed," she said.
"In terms of a coordinated national initiative, we are not much further advanced in this area than we were back in April 1999.
"The problem is that hundreds of millions of dollars have been spent on programs launched with much fanfare and then allowed to die."
Ms Gillard said changing the health care management and delivery system was not an easy task, but the government had missed some opportunities and made some obvious mistakes.
She said states and territories have started their own e-health efforts, raising fears of a fragmented and disconnected system.
Australia now had to face the reality that a national e-health system was at least a decade off, Ms Gillard said.
"To fix the problem we will need a national, collaborative approach and strong national leadership," she said.
Health Minister Tony Abbott in 2003 said the health system would be in "systemic paralysis" if a smart card carrying an individual's medical history was not available within five years.
But the federal government said the HealthConnect project was on track and a major agreement had been made at the most recent Council of Australian Governments (COAG) meeting.”
Ms Gillard made a number of points which were, in my view, absolutely spot on.
These key ones were:
1. “To fix the problem we will need a national, collaborative approach and strong national leadership.”
2. “In terms of a coordinated national initiative, we are not much further advanced in this area than we were back in April 1999.”
3. “The government has wasted hundreds of millions of dollars in stalled and failed attempts to introduce a national electronic health record system.”
The Government’s response to this considered and utterly accurate assessment of the current e-health state of play was that the most recent COAG meeting “had agreed to have a work schedule in place by 2009, a "considerable" step involving consensus about protocols and terminology had been taken with the provision of “an additional $130 million to be invested in the National E-Health Transition Authority, the body responsible for developing the electronic records”.
It also made the utterly ludicrous claim that “HealthConnect is still operational and on track and we are learning some very valuable lessons from the trials that have been going on in Tasmania and the Northern Territory”. This is a barefaced untruth as has been widely reported and thoroughly documented, if in no other place, in this blog. The development of HealthConnect has been totally downscaled and essentially defunded.
The sole element of the minister’s comments I can agree with is that “the minister has expressed his frustration with how slow things are moving, but it is very complicated, and it's moving ahead”.
I would suggest that it is time to say that the HealthConnect centralised model for e-health service delivery has failed in Australia and that what is needed is a radical re-think of approach.
This is implicitly recognised in the timeframes now being talked of by NEHTA for delivery of the Shared EHR Concept of Operations and Version 2.0 of the Interoperability Framework (Both now apparently due some time in 2007).
Evidence would seem to be emerging globally that centralised approaches bring with them high cost, high risk and excessive complexity. Witness the problems being experienced in the UK NHS Connecting for Health Program.
Equally it is now becoming clear that there are models for regional health information sharing that are becoming both technically as well as financially viable. Witness the successes seen in Scandinavia and in some of the nascent Regional Health Information Organisations in the USA.
As I have argued previously there are e-health projects that can make a difference, are affordable and which offer considerable benefit for both clinicians and their patients that could be undertaken in Australia. These include provision of effective General Practice and Specialist Practitioner computerisation, the automation of Acute and Long Term Hospitals, the computerised support of pharmacy, radiology and laboratory practice and the introduction of a common interoperable form of secure health messaging.
That would be a major two to three year agenda that could be sponsored and delivered by either side of national politics with enough will, understanding and determination. One can only hope that both Ms Gillard and Mr Abbott can recognise the value of such an approach – as well as the lower political risk to themselves personally, and move towards having NEHTA adopt such an approach, while possibly continuing some of the important long term infrastructure work they have in their work plan. To just do the latter, without the former, delays benefits to all Australians and carries a high risk of virtually total failure with the associated need to start again in 2010 or so. A quite unacceptable outcome.
David.
The following is the Sydney Morning Herald’s report of the Opposition Spokeswoman for Health.
http://www.smh.com.au/news/National/National-health-record-system-stalled/2006/08/29/1156816880858.html
“National health record system 'stalled'
August 29, 2006 - 1:29PM
The government has wasted hundreds of millions of dollars in stalled and failed attempts to introduce a national electronic health record system, Labor says.
Opposition health spokeswoman Julia Gillard said on Tuesday it was widely considered that using information technology to integrate patients health records could help prevent over-referrals, over-prescribing and minimise medical mistakes.
But the government had scrapped the Medicare Smart Card and its new proposed $1.1 billion Smartcard would not provide access to patient medical records, Ms Gillard said.
The much-lauded e-health records system HealthConnect no longer existed as a program and had all but disappeared, she said.
"Recent developments suggest that our national e-health strategy has not only stalled, but is dangerously close to being considered an expensive failure," Ms Gillard said in a speech to the Australian College of Health Services Executives in Adelaide.
HealthConnect - a national health information network designed to integrate patient records from hospitals, doctor surgeries, nursing homes, medical laboratories and pharmacies - was launched in 2000 with claims it could reduce accidental mishaps in treatment by as much as 30 per cent.
But Ms Gillard said "just a handful" of small HealthConnect initiatives were currently running in some states.
"And there do not appear to be any reports about what we have learned from those projects, how they might be further extended or why they succeeded or failed," she said.
"In terms of a coordinated national initiative, we are not much further advanced in this area than we were back in April 1999.
"The problem is that hundreds of millions of dollars have been spent on programs launched with much fanfare and then allowed to die."
Ms Gillard said changing the health care management and delivery system was not an easy task, but the government had missed some opportunities and made some obvious mistakes.
She said states and territories have started their own e-health efforts, raising fears of a fragmented and disconnected system.
Australia now had to face the reality that a national e-health system was at least a decade off, Ms Gillard said.
"To fix the problem we will need a national, collaborative approach and strong national leadership," she said.
Health Minister Tony Abbott in 2003 said the health system would be in "systemic paralysis" if a smart card carrying an individual's medical history was not available within five years.
But the federal government said the HealthConnect project was on track and a major agreement had been made at the most recent Council of Australian Governments (COAG) meeting.”
Ms Gillard made a number of points which were, in my view, absolutely spot on.
These key ones were:
1. “To fix the problem we will need a national, collaborative approach and strong national leadership.”
2. “In terms of a coordinated national initiative, we are not much further advanced in this area than we were back in April 1999.”
3. “The government has wasted hundreds of millions of dollars in stalled and failed attempts to introduce a national electronic health record system.”
The Government’s response to this considered and utterly accurate assessment of the current e-health state of play was that the most recent COAG meeting “had agreed to have a work schedule in place by 2009, a "considerable" step involving consensus about protocols and terminology had been taken with the provision of “an additional $130 million to be invested in the National E-Health Transition Authority, the body responsible for developing the electronic records”.
It also made the utterly ludicrous claim that “HealthConnect is still operational and on track and we are learning some very valuable lessons from the trials that have been going on in Tasmania and the Northern Territory”. This is a barefaced untruth as has been widely reported and thoroughly documented, if in no other place, in this blog. The development of HealthConnect has been totally downscaled and essentially defunded.
The sole element of the minister’s comments I can agree with is that “the minister has expressed his frustration with how slow things are moving, but it is very complicated, and it's moving ahead”.
I would suggest that it is time to say that the HealthConnect centralised model for e-health service delivery has failed in Australia and that what is needed is a radical re-think of approach.
This is implicitly recognised in the timeframes now being talked of by NEHTA for delivery of the Shared EHR Concept of Operations and Version 2.0 of the Interoperability Framework (Both now apparently due some time in 2007).
Evidence would seem to be emerging globally that centralised approaches bring with them high cost, high risk and excessive complexity. Witness the problems being experienced in the UK NHS Connecting for Health Program.
Equally it is now becoming clear that there are models for regional health information sharing that are becoming both technically as well as financially viable. Witness the successes seen in Scandinavia and in some of the nascent Regional Health Information Organisations in the USA.
As I have argued previously there are e-health projects that can make a difference, are affordable and which offer considerable benefit for both clinicians and their patients that could be undertaken in Australia. These include provision of effective General Practice and Specialist Practitioner computerisation, the automation of Acute and Long Term Hospitals, the computerised support of pharmacy, radiology and laboratory practice and the introduction of a common interoperable form of secure health messaging.
That would be a major two to three year agenda that could be sponsored and delivered by either side of national politics with enough will, understanding and determination. One can only hope that both Ms Gillard and Mr Abbott can recognise the value of such an approach – as well as the lower political risk to themselves personally, and move towards having NEHTA adopt such an approach, while possibly continuing some of the important long term infrastructure work they have in their work plan. To just do the latter, without the former, delays benefits to all Australians and carries a high risk of virtually total failure with the associated need to start again in 2010 or so. A quite unacceptable outcome.
David.
Tuesday, August 29, 2006
iSoft – A Problem for More than the NHS!
In November 2005, I had the opportunity to review, in some considerable detail, the Hospital Information System which was being offered to an international client as a solution to provide advanced computer services for a three hundred bed tertiary private hospital.
It was clear at that time that the iSoft Lorenzo software suite was little more than ‘foilware’. The system was a concocted blend of old and new components, was obviously un-integrated and lacked any common utility in its user interface.
Needless to say I recommended that no further engagement be had with iSoft and that alternative providers of the necessary HIS software be considered.
The following headlines from the London Financial Times over the last week say it all!
Isoft receives bid approaches
Isoft, the beleaguered software supplier to the £6.2bn National Health Service IT project in the UK, has received several informal approaches from both private equity firms and trade rivals.
Isoft refinances after posting £343.8m loss
Isoft, the troubled healthcare software company being investigated by the FSA for issuing potentially misleading statements, has reported a full year pre-tax loss of £343.8m.
Isoft duo present a catalogue of horrors
For the two men charged with delivering one of the most eagerly awaited earnings statements of the year, Isoft's John Weston and Gavin James appeared remarkably fresh...
Questions linger over plan to build electronic patient record
Ministers and officials yesterday breathed a collective sigh of relief that iSoft, one of the principal suppliers to the National Health Service's £12bn computer..
There is one crucial lesson to be learnt from this. That is that buying software futures is a fool’s game, especially with complex systems like a HIS. If you can’t see, touch and feel the software operating live in at least 2-3 reference sites, exactly as you need it to operate, then to make any purchase is folly!
In the Australian today Karen Dearne makes the point there are potential Australian implications.
“Health group's fall may hit here
Karen Dearne
August 29, 2006
TROUBLED health software developer iSoft's shock loss of almost £400 million last year has destabilised Britain's £10 billion ($24.9 billion) Connecting for Health IT program and may hit local projects, including Victoria's $323 million HealthSmart.
While iSoft clutched a straw offered by its British bankers, the company faces investigations by financial regulators, problems with current implementations and questions over the long-promised Lorenzo web-based product.
The debacle has grabbed front-page attention in Britain, with reports that iSoft's three founders have become millionaires while the company's market value has plummeted from more than £1 billion at its peak to just £97 million.
Reports say the late Roger Dickens (iSoft chairman until late 2003), sold shares worth about £10 million; former chief executive Patrick Cryne received about £40 million; and Stephen Graham, currently suspended, about £30 million.
Former chief executive Tim Whiston resigned in June, reportedly with a golden handshake. The release of iSoft's results ended months of speculation over alleged accounting irregularities that saw its share price fall 90 per cent to just 40p last week.”
It looks to me that iSoft’s failure is inevitable, given the comments made a week or so ago in the audit of their progress in delivery of Lorenzo that they “lacked a credible plan” for its delivery any time in the next few years.
Additionally, there is no point holding obsolete software in escrow. All that does is provide a false sense of security that something can be done when iSoft fails. All that can be done with the escrowed software is maybe fix the occasional critical ‘bug’ while buying time to identify new software to replace the now doomed iSoft system.
Those in NSW and Victoria who have purchased iSoft software on the basis of future promises have clearly let their respective health systems down very badly and should consider their ongoing roles in their present positions. This is a huge mess both here and in the UK. Those in both the UK and Australia affected by this have my sympathy, but they should have known better.
David.
It was clear at that time that the iSoft Lorenzo software suite was little more than ‘foilware’. The system was a concocted blend of old and new components, was obviously un-integrated and lacked any common utility in its user interface.
Needless to say I recommended that no further engagement be had with iSoft and that alternative providers of the necessary HIS software be considered.
The following headlines from the London Financial Times over the last week say it all!
Isoft receives bid approaches
Isoft, the beleaguered software supplier to the £6.2bn National Health Service IT project in the UK, has received several informal approaches from both private equity firms and trade rivals.
Isoft refinances after posting £343.8m loss
Isoft, the troubled healthcare software company being investigated by the FSA for issuing potentially misleading statements, has reported a full year pre-tax loss of £343.8m.
Isoft duo present a catalogue of horrors
For the two men charged with delivering one of the most eagerly awaited earnings statements of the year, Isoft's John Weston and Gavin James appeared remarkably fresh...
Questions linger over plan to build electronic patient record
Ministers and officials yesterday breathed a collective sigh of relief that iSoft, one of the principal suppliers to the National Health Service's £12bn computer..
There is one crucial lesson to be learnt from this. That is that buying software futures is a fool’s game, especially with complex systems like a HIS. If you can’t see, touch and feel the software operating live in at least 2-3 reference sites, exactly as you need it to operate, then to make any purchase is folly!
In the Australian today Karen Dearne makes the point there are potential Australian implications.
“Health group's fall may hit here
Karen Dearne
August 29, 2006
TROUBLED health software developer iSoft's shock loss of almost £400 million last year has destabilised Britain's £10 billion ($24.9 billion) Connecting for Health IT program and may hit local projects, including Victoria's $323 million HealthSmart.
While iSoft clutched a straw offered by its British bankers, the company faces investigations by financial regulators, problems with current implementations and questions over the long-promised Lorenzo web-based product.
The debacle has grabbed front-page attention in Britain, with reports that iSoft's three founders have become millionaires while the company's market value has plummeted from more than £1 billion at its peak to just £97 million.
Reports say the late Roger Dickens (iSoft chairman until late 2003), sold shares worth about £10 million; former chief executive Patrick Cryne received about £40 million; and Stephen Graham, currently suspended, about £30 million.
Former chief executive Tim Whiston resigned in June, reportedly with a golden handshake. The release of iSoft's results ended months of speculation over alleged accounting irregularities that saw its share price fall 90 per cent to just 40p last week.”
It looks to me that iSoft’s failure is inevitable, given the comments made a week or so ago in the audit of their progress in delivery of Lorenzo that they “lacked a credible plan” for its delivery any time in the next few years.
Additionally, there is no point holding obsolete software in escrow. All that does is provide a false sense of security that something can be done when iSoft fails. All that can be done with the escrowed software is maybe fix the occasional critical ‘bug’ while buying time to identify new software to replace the now doomed iSoft system.
Those in NSW and Victoria who have purchased iSoft software on the basis of future promises have clearly let their respective health systems down very badly and should consider their ongoing roles in their present positions. This is a huge mess both here and in the UK. Those in both the UK and Australia affected by this have my sympathy, but they should have known better.
David.
The Perfect Storm Intensifies!
Just when you thought it would not get much worse, it has. Added to the litany of computer assisted privacy violations perpetrated by Government custodians of “your personal information” we now find yet another and separate agency involved in more poor behaviour.
As Ben Woodhead reports in today’s Australian:
“Tax office sacks 'spies'
Ben Woodhead
August 29, 2006
A SECOND government agency has been forced to sack staff for spying on client records, with the Australian Taxation Office taking action against 27 workers for breaches of privacy.
The tax office took action against 24 employees over inappropriate access to taxpayer files last financial year, with another three cases detected this year.
ATO first assistant commissioner for people and place, Anne Ellison, said 12 of the staff caught spying last year resigned on the spot. Four were sacked, two were fined and six had their salaries reduced or were demoted.
Two were ultimately prosecuted for breaches of the Tax Administration Act, with one sentenced to community service and the other fined."
The article then goes on to point out that there is considerable suspicion that leaked tax details of a range of celebrities may be linked to these unauthorised intrusions and searches.
Even more alarming are the comments from “Medicare Australia spokesman Peter Sexton said that agency had also had talks with Centrelink as part of a review of its privacy systems.
"We have engaged a consultant to review a number of our processes including audit logging, access profiles and risk assessments," Dr Sexton said. "There is swift disciplinary or legal action taken whenever a case of fraud or unauthorised access is detected."
This confirms what we already knew. Right now the security of your Medicare records (among others) is inadequate. Why else would consultants be asked to help and sort things out?
The points made in the earlier article are just confirmed. Public trust is on the way down and the effect of these ongoing problems not only confirms their right to be concerned but enhances it!
One has to ask why it is only now, with all these reviews having been underway for the last years, do we know what has been and continues to go on. The present system is clearly just not working.
If the public confidence in electronic health records is not going to be destroyed it seems time that a few of the senior managers of these “sticky beaks” who browse and leak information need to be faced with the ultimate disciplinary sanction and terminated. Maybe, then, we would see the cultural change that is so obviously required.
David
As Ben Woodhead reports in today’s Australian:
“Tax office sacks 'spies'
Ben Woodhead
August 29, 2006
A SECOND government agency has been forced to sack staff for spying on client records, with the Australian Taxation Office taking action against 27 workers for breaches of privacy.
The tax office took action against 24 employees over inappropriate access to taxpayer files last financial year, with another three cases detected this year.
ATO first assistant commissioner for people and place, Anne Ellison, said 12 of the staff caught spying last year resigned on the spot. Four were sacked, two were fined and six had their salaries reduced or were demoted.
Two were ultimately prosecuted for breaches of the Tax Administration Act, with one sentenced to community service and the other fined."
The article then goes on to point out that there is considerable suspicion that leaked tax details of a range of celebrities may be linked to these unauthorised intrusions and searches.
Even more alarming are the comments from “Medicare Australia spokesman Peter Sexton said that agency had also had talks with Centrelink as part of a review of its privacy systems.
"We have engaged a consultant to review a number of our processes including audit logging, access profiles and risk assessments," Dr Sexton said. "There is swift disciplinary or legal action taken whenever a case of fraud or unauthorised access is detected."
This confirms what we already knew. Right now the security of your Medicare records (among others) is inadequate. Why else would consultants be asked to help and sort things out?
The points made in the earlier article are just confirmed. Public trust is on the way down and the effect of these ongoing problems not only confirms their right to be concerned but enhances it!
One has to ask why it is only now, with all these reviews having been underway for the last years, do we know what has been and continues to go on. The present system is clearly just not working.
If the public confidence in electronic health records is not going to be destroyed it seems time that a few of the senior managers of these “sticky beaks” who browse and leak information need to be faced with the ultimate disciplinary sanction and terminated. Maybe, then, we would see the cultural change that is so obviously required.
David
Saturday, August 26, 2006
Is Australian E-Health Facing a Perfect Storm?
Reference to Wikipedia describes a “Perfect Storm” as follows:
“The phrase perfect storm refers to a simultaneous occurrence of events which, taken individually, would be far less powerful than the result of their chance combination. Such occurrences are, by their very nature, rare, and so even a slight change in any one event contributing to a ‘perfect storm’ would be sufficient to lessen the overall power of the final event.”
In this short article I am suggesting that the future of e-Health may be facing just such a storm. Why? Because it seems there are a number of forces and events coalescing to greatly damage the progress of the implementation of e-Health nationally.
Firstly we have the revelations that following a two year investigation (one wonders why it took that long) some six hundred Centrelink staff have been found browsing Centrelink client records inappropriately – despite there being clear warnings to all stuff that such activity will be dealt with very harshly (over 100 apparently no longer work for the organisation).
It seems this is not the first incidence of such behaviour among public servants – with a major breach, rather worryingly, having occurred at the Commonwealth Child Support Agency a year or so back.
Secondly we have all sorts of incidents being reported from all over the world where patient details are being accidentally provided to third parties through everything from stolen laptops to web-based accidental patient information publication.
The most recent was reported a few days ago.
“Laptop computer with home-care patient data stolen in Michigan
Beaumont Home Care on Tuesday asked the public to help it recover a laptop computer filled with three years worth of personal patient information that was stolen with an employee's car.
Beaumont said the information was encrypted and password-protected and is related only to home-health patients. Beaumont Hospital inpatients’ or outpatients' information was not included and centralized registration and medical records of Beaumont are not at risk. But the laptop belonged to a new employee who had stored the ID access code and password with the computer.
Home-care staff use laptop computers to document patient care. The stolen information included patients' names, addresses, birth dates and Social Security numbers. Medical- insurance and personal-health information was also included. Home-care patients have been apprised of the theft and Beaumont is arranging enrollment in a credit-reporting service as well, the Royal Oak, Mich.-based system said in a news release.
"We are taking aggressive measures to protect their personal and health information and to lessen the impact of the computer theft on them," said Chris Hengstebeck, security director at Beaumont in Troy, Mich. The hospital system is offering a reward for the recovery of the Dell Latitude D-400 laptop, serial No. 5MZ1F61, WBH Tag No. 218242.
Crain's Detroit Business”
Note that this problem would simply not have arisen without the records being computerised.
Third we have Minister Hockey, the minister for Centrelink, claiming the information held for the proposed Commonwealth Services Access SmartCard will be handled differently. How much credibility can such a claim have in the public’s mind?
Fourth we have NEHTA suggesting that the basis of its privacy approach is to be technologically agnostic. As I wrote a few months ago,
“talk of privacy neutrality is naïve. It is critically necessary to distinguish between conceptual privacy neutrality and practical (or privacy as it is actually implemented) neutrality. Preserving the privacy of a patient’s written record is a very different thing from preserving the privacy of a patient’s record when stored, typically with hundreds of others, in a computer system. The threats from leakage and exposure are different as are the methods of auditing access and use. These differences must be clearly recognised and effectively addressed. An example is the ease with which 10,000 records can be stolen on a USB key compared with the same ‘truck-requiring’ effort with paper records.”
The essence of my concern in all this is that unless public trust is manifestly justified, through leaks of sensitive personal information being made extraordinarily rare or non-existent, implementation of e-health technology and solutions will be effectively blocked by security and privacy concerns before it can even get underway.
It is up to those working, not only in health, but those handling all sorts of personally identifiable information (e.g. banks, insurance companies, diagnostic laboratories, police etc) to understand clearly that while mistakes will always happen, it requires a computer to really make a massive series of mistakes. In the wrong hands computer data-bases can disclose vast amounts of sensitive information far more quickly and efficiently than any paper based system can!
The key message is simple. To prevent there being great difficulty with the adoption of e-health technology and solutions, great care has to be taken to address, not only the technical, but also the cultural, human and organisational issues that permit un-authorised disclosure of private information. It is a problem for all of us!
David.
“The phrase perfect storm refers to a simultaneous occurrence of events which, taken individually, would be far less powerful than the result of their chance combination. Such occurrences are, by their very nature, rare, and so even a slight change in any one event contributing to a ‘perfect storm’ would be sufficient to lessen the overall power of the final event.”
In this short article I am suggesting that the future of e-Health may be facing just such a storm. Why? Because it seems there are a number of forces and events coalescing to greatly damage the progress of the implementation of e-Health nationally.
Firstly we have the revelations that following a two year investigation (one wonders why it took that long) some six hundred Centrelink staff have been found browsing Centrelink client records inappropriately – despite there being clear warnings to all stuff that such activity will be dealt with very harshly (over 100 apparently no longer work for the organisation).
It seems this is not the first incidence of such behaviour among public servants – with a major breach, rather worryingly, having occurred at the Commonwealth Child Support Agency a year or so back.
Secondly we have all sorts of incidents being reported from all over the world where patient details are being accidentally provided to third parties through everything from stolen laptops to web-based accidental patient information publication.
The most recent was reported a few days ago.
“Laptop computer with home-care patient data stolen in Michigan
Beaumont Home Care on Tuesday asked the public to help it recover a laptop computer filled with three years worth of personal patient information that was stolen with an employee's car.
Beaumont said the information was encrypted and password-protected and is related only to home-health patients. Beaumont Hospital inpatients’ or outpatients' information was not included and centralized registration and medical records of Beaumont are not at risk. But the laptop belonged to a new employee who had stored the ID access code and password with the computer.
Home-care staff use laptop computers to document patient care. The stolen information included patients' names, addresses, birth dates and Social Security numbers. Medical- insurance and personal-health information was also included. Home-care patients have been apprised of the theft and Beaumont is arranging enrollment in a credit-reporting service as well, the Royal Oak, Mich.-based system said in a news release.
"We are taking aggressive measures to protect their personal and health information and to lessen the impact of the computer theft on them," said Chris Hengstebeck, security director at Beaumont in Troy, Mich. The hospital system is offering a reward for the recovery of the Dell Latitude D-400 laptop, serial No. 5MZ1F61, WBH Tag No. 218242.
Crain's Detroit Business”
Note that this problem would simply not have arisen without the records being computerised.
Third we have Minister Hockey, the minister for Centrelink, claiming the information held for the proposed Commonwealth Services Access SmartCard will be handled differently. How much credibility can such a claim have in the public’s mind?
Fourth we have NEHTA suggesting that the basis of its privacy approach is to be technologically agnostic. As I wrote a few months ago,
“talk of privacy neutrality is naïve. It is critically necessary to distinguish between conceptual privacy neutrality and practical (or privacy as it is actually implemented) neutrality. Preserving the privacy of a patient’s written record is a very different thing from preserving the privacy of a patient’s record when stored, typically with hundreds of others, in a computer system. The threats from leakage and exposure are different as are the methods of auditing access and use. These differences must be clearly recognised and effectively addressed. An example is the ease with which 10,000 records can be stolen on a USB key compared with the same ‘truck-requiring’ effort with paper records.”
The essence of my concern in all this is that unless public trust is manifestly justified, through leaks of sensitive personal information being made extraordinarily rare or non-existent, implementation of e-health technology and solutions will be effectively blocked by security and privacy concerns before it can even get underway.
It is up to those working, not only in health, but those handling all sorts of personally identifiable information (e.g. banks, insurance companies, diagnostic laboratories, police etc) to understand clearly that while mistakes will always happen, it requires a computer to really make a massive series of mistakes. In the wrong hands computer data-bases can disclose vast amounts of sensitive information far more quickly and efficiently than any paper based system can!
The key message is simple. To prevent there being great difficulty with the adoption of e-health technology and solutions, great care has to be taken to address, not only the technical, but also the cultural, human and organisational issues that permit un-authorised disclosure of private information. It is a problem for all of us!
David.
Interactive Electronic Decision Support Benefits - Keys to the Literature
As a follow-up to the material presented last week it seemed to me it would be useful to provide some references and abstracts from the current literature to confirm my views regarding the importance of interactive clinical decision support.
A very useful slightly earlier review by Professor Enrico Coiera, that is readily available on the web, can be found at the following URL.
http://www.coiera.com/aimd.htm
Four key recent references are as follows:
Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success
Kensaku Kawamoto , Caitlin A Houlihan , E Andrew Balas , David F Lobach
Objective: To identify features of clinical decision support systems critical for improving clinical practice.
Design: Systematic review of randomised controlled trials.
Data sources: Literature searches via Medline, CINAHL, and the Cochrane Controlled Trials Register up to 2003; and searches of reference lists of included studies and relevant reviews.
Study selection Studies had to evaluate the ability of decision support systems to improve clinical practice.
Data extraction: Studies were assessed for statistically and clinically significant improvement in clinical practice and for the presence of 15 decision support system features whose importance had been repeatedly suggested in the literature.
Results: Seventy studies were included. Decision support systems significantly improved clinical practice in 68% of trials. Univariate analyses revealed that, for five of the system features, interventions possessing the feature were significantly more likely to improve clinical practice than interventions lacking the feature. Multiple logistic regression analysis identified four features as independent predictors of improved clinical practice: automatic provision of decision support as part of clinician workflow (P<0.00001), provision of recommendations rather than just assessments (P=0.0187), provision of decision support at the time and location of decision making (P=0.0263), and computer based decision support (P=0.0294). Of 32 systems possessing all four features, 30 (94%) significantly improved clinical practice. Furthermore, direct experimental justification was found for providing periodic performance feedback, sharing recommendations with patients, and requesting documentation of reasons for not following recommendations.
Conclusions: Several features were closely correlated with decision support systems' ability to improve patient care significantly. Clinicians and other stakeholders should implement clinical decision support systems that incorporate these features whenever feasible and appropriate.
Source:
http://bmj.bmjjournals.com/cgi/content/abstract/bmj.38398.500764.8Fv1
BMJ, doi:10.1136/bmj.38398.500764.8F (published 14 March 2005)
Effects of Computerized Clinical Decision Support Systems on Practitioner Performance and Patient Outcomes
A Systematic Review
Amit X. Garg, MD; Neill K. J. Adhikari, MD; Heather McDonald, MSc; M. Patricia Rosas-Arellano, MD, PhD; P. J. Devereaux, MD; Joseph Beyene, PhD; Justina Sam, BHSc; R. Brian Haynes, MD, PhD
JAMA. 2005;293:1223-1238.
Context: Developers of health care software have attributed improvements in patient care to these applications. As with any health care intervention, such claims require confirmation in clinical trials.
Objectives: To review controlled trials assessing the effects of computerized clinical decision support systems (CDSSs) and to identify study characteristics predicting benefit.
Data Sources: We updated our earlier reviews by searching the MEDLINE, EMBASE, Cochrane Library, Inspec, and ISI databases and consulting reference lists through September 2004. Authors of 64 primary studies confirmed data or provided additional information.
Study Selection We included randomized and nonrandomized controlled trials that evaluated the effect of a CDSS compared with care provided without a CDSS on practitioner performance or patient outcomes.
Data Extraction: Teams of 2 reviewers independently abstracted data on methods, setting, CDSS and patient characteristics, and outcomes.
Data Synthesis One hundred studies met our inclusion criteria. The number and methodologic quality of studies improved over time. The CDSS improved practitioner performance in 62 (64%) of the 97 studies assessing this outcome, including 4 (40%) of 10 diagnostic systems, 16 (76%) of 21 reminder systems, 23 (62%) of 37 disease management systems, and 19 (66%) of 29 drug-dosing or prescribing systems. Fifty-two trials assessed 1 or more patient outcomes, of which 7 trials (13%) reported improvements. Improved practitioner performance was associated with CDSSs that automatically prompted users compared with requiring users to activate the system (success in 73% of trials vs 47%; P = .02) and studies in which the authors also developed the CDSS software compared with studies in which the authors were not the developers (74% success vs 28%; respectively, P = .001).
Conclusions: Many CDSSs improve practitioner performance. To date, the effects on patient outcomes remain understudied and, when studied, inconsistent.
Source:
http://jama.ama-assn.org/cgi/content/abstract/293/10/1223
Systematic Review: Impact of Health Information Technology on Quality, Efficiency, and Costs of Medical Care
Basit Chaudhry, MD; Jerome Wang, MD; Shinyi Wu, PhD; Margaret Maglione, MPP; Walter Mojica, MD; Elizabeth Roth, MA; Sally C. Morton, PhD; and Paul G. Shekelle, MD, PhD
16 May 2006 | Volume 144 Issue 10 | Pages 742-752
Background: Experts consider health information technology key to improving efficiency and quality of health care.
Purpose: To systematically review evidence on the effect of health information technology on quality, efficiency, and costs of health care.
Data Sources: The authors systematically searched the English-language literature indexed in MEDLINE (1995 to January 2004), the Cochrane Central Register of Controlled Trials, the Cochrane Database of Abstracts of Reviews of Effects, and the Periodical Abstracts Database. We also added studies identified by experts up to April 2005.
Study Selection: Descriptive and comparative studies and systematic reviews of health information technology.
Data Extraction: Two reviewers independently extracted information on system capabilities, design, effects on quality, system acquisition, implementation context, and costs.
Data Synthesis: 257 studies met the inclusion criteria. Most studies addressed decision support systems or electronic health records. Approximately 25% of the studies were from 4 academic institutions that implemented internally developed systems; only 9 studies evaluated multifunctional, commercially developed systems. Three major benefits on quality were demonstrated: increased adherence to guideline-based care, enhanced surveillance and monitoring, and decreased medication errors. The primary domain of improvement was preventive health. The major efficiency benefit shown was decreased utilization of care. Data on another efficiency measure, time utilization, were mixed. Empirical cost data were limited.
Limitations: Available quantitative research was limited and was done by a small number of institutions. Systems were heterogeneous and sometimes incompletely described. Available financial and contextual data were limited.
Conclusions: Four benchmark institutions have demonstrated the efficacy of health information technologies in improving quality and efficiency. Whether and how other institutions can achieve similar benefits, and at what costs, are unclear.
Source:
http://www.annals.org/cgi/content/short/144/10/742
Costs and Benefits of Health Information Technology.
Shekelle PG, Morton SC, Keeler EB.
Evidence Report/Technology Assessment No. 132. (Prepared by the Southern California Evidence-based Practice Center under Contract No. 290-02-0003.) AHRQ Publication No. 06-E006. Rockville, MD: Agency for Healthcare Research and Quality. April 2006.
Abstract
Objectives: An evidence report was prepared to assess the evidence base regarding benefits and costs of health information technology (HIT) systems, that is, the value of discrete HIT functions and systems in various healthcare settings, particularly those providing pediatric care.
Data Sources: PubMed®, the Cochrane Controlled Clinical Trials Register, and the Cochrane Database of Reviews of Effectiveness (DARE) were electronically searched for articles published since 1995. Several reports prepared by private industry were also reviewed.
Review Methods: Of 855 studies screened, 256 were included in the final analyses. These included systematic reviews, meta-analyses, studies that tested a hypothesis, and predictive analyses. Each article was reviewed independently by two reviewers; disagreement was resolved by consensus.
Results: Of the 256 studies, 156 concerned decision support, 84 assessed the electronic medical record, and 30 were about computerized physician order entry (categories are not mutually exclusive). One hundred twenty four of the studies assessed the effect of the HIT system in the outpatient or ambulatory setting; 82 assessed its use in the hospital or inpatient setting. Ninety seven studies used a randomized design. There were 11 other controlled clinical trials, 33 studies using a pre-post design, and 20 studies using a time series. Another 17 were case studies with a concurrent control. Of the 211 hypothesis-testing studies, 82 contained at least some cost data.
We identified no study or collection of studies, outside of those from a handful of HIT leaders, that would allow a reader to make a determination about the generalizable knowledge of the study’s reported benefit. Beside these studies from HIT leaders, no other research assessed HIT systems that had comprehensive functionality and included data on costs, relevant information on organizational context and process change, and data on implementation.
A small body of literature supports a role for HIT in improving the quality of pediatric care. Insufficient data were available on the costs or cost-effectiveness of implementing such systems.
The ability of Electronic Health Records (EHRs) to improve the quality of care in ambulatory care settings was demonstrated in a small series of studies conducted at four sites (three U.S. medical centers and one in the Netherlands). The studies demonstrated improvements in provider performance when clinical information management and decision support tools were made available within an EHR system, particularly when the EHRs had the capacity to store data with high fidelity, to make those data readily accessible, and to help translate them into context specific information that can empower providers in their work.
Despite the heterogeneity in the analytic methods used, all cost-benefit analyses predicted substantial savings from EHR (and health care information exchange and interoperability) implementation: The quantifiable benefits are projected to outweigh the investment costs.
However, the predicted time needed to break even varied from three to as many as 13 years.
Conclusions: HIT has the potential to enable a dramatic transformation in the delivery of health care, making it safer, more effective, and more efficient. Some organizations have already realized major gains through the implementation of multifunctional, interoperable HIT systems built around an EHR. However, widespread implementation of HIT has been limited by a lack of generalizable knowledge about what types of HIT and implementation methods will improve care and manage costs for specific health organizations. The reporting of HIT development and implementation requires fuller descriptions of both the intervention and the organizational/economic environment in which it is implemented.
Note: This abstract is for the full report, which was summarised in the Annals of Internal Medicine article above which was published at close to the same time.
Source:
http://www.ahrq.gov/downloads/pub/evidence/pdf/hitsyscosts/hitsys.pdf
Taken together these review provide compelling evidence for the key importance of interactive CDS
Note: a Google search for (benefits "clinical decision support") yields 158,000 English language pages. That of itself says something!
David.
A very useful slightly earlier review by Professor Enrico Coiera, that is readily available on the web, can be found at the following URL.
http://www.coiera.com/aimd.htm
Four key recent references are as follows:
Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success
Kensaku Kawamoto , Caitlin A Houlihan , E Andrew Balas , David F Lobach
Objective: To identify features of clinical decision support systems critical for improving clinical practice.
Design: Systematic review of randomised controlled trials.
Data sources: Literature searches via Medline, CINAHL, and the Cochrane Controlled Trials Register up to 2003; and searches of reference lists of included studies and relevant reviews.
Study selection Studies had to evaluate the ability of decision support systems to improve clinical practice.
Data extraction: Studies were assessed for statistically and clinically significant improvement in clinical practice and for the presence of 15 decision support system features whose importance had been repeatedly suggested in the literature.
Results: Seventy studies were included. Decision support systems significantly improved clinical practice in 68% of trials. Univariate analyses revealed that, for five of the system features, interventions possessing the feature were significantly more likely to improve clinical practice than interventions lacking the feature. Multiple logistic regression analysis identified four features as independent predictors of improved clinical practice: automatic provision of decision support as part of clinician workflow (P<0.00001), provision of recommendations rather than just assessments (P=0.0187), provision of decision support at the time and location of decision making (P=0.0263), and computer based decision support (P=0.0294). Of 32 systems possessing all four features, 30 (94%) significantly improved clinical practice. Furthermore, direct experimental justification was found for providing periodic performance feedback, sharing recommendations with patients, and requesting documentation of reasons for not following recommendations.
Conclusions: Several features were closely correlated with decision support systems' ability to improve patient care significantly. Clinicians and other stakeholders should implement clinical decision support systems that incorporate these features whenever feasible and appropriate.
Source:
http://bmj.bmjjournals.com/cgi/content/abstract/bmj.38398.500764.8Fv1
BMJ, doi:10.1136/bmj.38398.500764.8F (published 14 March 2005)
Effects of Computerized Clinical Decision Support Systems on Practitioner Performance and Patient Outcomes
A Systematic Review
Amit X. Garg, MD; Neill K. J. Adhikari, MD; Heather McDonald, MSc; M. Patricia Rosas-Arellano, MD, PhD; P. J. Devereaux, MD; Joseph Beyene, PhD; Justina Sam, BHSc; R. Brian Haynes, MD, PhD
JAMA. 2005;293:1223-1238.
Context: Developers of health care software have attributed improvements in patient care to these applications. As with any health care intervention, such claims require confirmation in clinical trials.
Objectives: To review controlled trials assessing the effects of computerized clinical decision support systems (CDSSs) and to identify study characteristics predicting benefit.
Data Sources: We updated our earlier reviews by searching the MEDLINE, EMBASE, Cochrane Library, Inspec, and ISI databases and consulting reference lists through September 2004. Authors of 64 primary studies confirmed data or provided additional information.
Study Selection We included randomized and nonrandomized controlled trials that evaluated the effect of a CDSS compared with care provided without a CDSS on practitioner performance or patient outcomes.
Data Extraction: Teams of 2 reviewers independently abstracted data on methods, setting, CDSS and patient characteristics, and outcomes.
Data Synthesis One hundred studies met our inclusion criteria. The number and methodologic quality of studies improved over time. The CDSS improved practitioner performance in 62 (64%) of the 97 studies assessing this outcome, including 4 (40%) of 10 diagnostic systems, 16 (76%) of 21 reminder systems, 23 (62%) of 37 disease management systems, and 19 (66%) of 29 drug-dosing or prescribing systems. Fifty-two trials assessed 1 or more patient outcomes, of which 7 trials (13%) reported improvements. Improved practitioner performance was associated with CDSSs that automatically prompted users compared with requiring users to activate the system (success in 73% of trials vs 47%; P = .02) and studies in which the authors also developed the CDSS software compared with studies in which the authors were not the developers (74% success vs 28%; respectively, P = .001).
Conclusions: Many CDSSs improve practitioner performance. To date, the effects on patient outcomes remain understudied and, when studied, inconsistent.
Source:
http://jama.ama-assn.org/cgi/content/abstract/293/10/1223
Systematic Review: Impact of Health Information Technology on Quality, Efficiency, and Costs of Medical Care
Basit Chaudhry, MD; Jerome Wang, MD; Shinyi Wu, PhD; Margaret Maglione, MPP; Walter Mojica, MD; Elizabeth Roth, MA; Sally C. Morton, PhD; and Paul G. Shekelle, MD, PhD
16 May 2006 | Volume 144 Issue 10 | Pages 742-752
Background: Experts consider health information technology key to improving efficiency and quality of health care.
Purpose: To systematically review evidence on the effect of health information technology on quality, efficiency, and costs of health care.
Data Sources: The authors systematically searched the English-language literature indexed in MEDLINE (1995 to January 2004), the Cochrane Central Register of Controlled Trials, the Cochrane Database of Abstracts of Reviews of Effects, and the Periodical Abstracts Database. We also added studies identified by experts up to April 2005.
Study Selection: Descriptive and comparative studies and systematic reviews of health information technology.
Data Extraction: Two reviewers independently extracted information on system capabilities, design, effects on quality, system acquisition, implementation context, and costs.
Data Synthesis: 257 studies met the inclusion criteria. Most studies addressed decision support systems or electronic health records. Approximately 25% of the studies were from 4 academic institutions that implemented internally developed systems; only 9 studies evaluated multifunctional, commercially developed systems. Three major benefits on quality were demonstrated: increased adherence to guideline-based care, enhanced surveillance and monitoring, and decreased medication errors. The primary domain of improvement was preventive health. The major efficiency benefit shown was decreased utilization of care. Data on another efficiency measure, time utilization, were mixed. Empirical cost data were limited.
Limitations: Available quantitative research was limited and was done by a small number of institutions. Systems were heterogeneous and sometimes incompletely described. Available financial and contextual data were limited.
Conclusions: Four benchmark institutions have demonstrated the efficacy of health information technologies in improving quality and efficiency. Whether and how other institutions can achieve similar benefits, and at what costs, are unclear.
Source:
http://www.annals.org/cgi/content/short/144/10/742
Costs and Benefits of Health Information Technology.
Shekelle PG, Morton SC, Keeler EB.
Evidence Report/Technology Assessment No. 132. (Prepared by the Southern California Evidence-based Practice Center under Contract No. 290-02-0003.) AHRQ Publication No. 06-E006. Rockville, MD: Agency for Healthcare Research and Quality. April 2006.
Abstract
Objectives: An evidence report was prepared to assess the evidence base regarding benefits and costs of health information technology (HIT) systems, that is, the value of discrete HIT functions and systems in various healthcare settings, particularly those providing pediatric care.
Data Sources: PubMed®, the Cochrane Controlled Clinical Trials Register, and the Cochrane Database of Reviews of Effectiveness (DARE) were electronically searched for articles published since 1995. Several reports prepared by private industry were also reviewed.
Review Methods: Of 855 studies screened, 256 were included in the final analyses. These included systematic reviews, meta-analyses, studies that tested a hypothesis, and predictive analyses. Each article was reviewed independently by two reviewers; disagreement was resolved by consensus.
Results: Of the 256 studies, 156 concerned decision support, 84 assessed the electronic medical record, and 30 were about computerized physician order entry (categories are not mutually exclusive). One hundred twenty four of the studies assessed the effect of the HIT system in the outpatient or ambulatory setting; 82 assessed its use in the hospital or inpatient setting. Ninety seven studies used a randomized design. There were 11 other controlled clinical trials, 33 studies using a pre-post design, and 20 studies using a time series. Another 17 were case studies with a concurrent control. Of the 211 hypothesis-testing studies, 82 contained at least some cost data.
We identified no study or collection of studies, outside of those from a handful of HIT leaders, that would allow a reader to make a determination about the generalizable knowledge of the study’s reported benefit. Beside these studies from HIT leaders, no other research assessed HIT systems that had comprehensive functionality and included data on costs, relevant information on organizational context and process change, and data on implementation.
A small body of literature supports a role for HIT in improving the quality of pediatric care. Insufficient data were available on the costs or cost-effectiveness of implementing such systems.
The ability of Electronic Health Records (EHRs) to improve the quality of care in ambulatory care settings was demonstrated in a small series of studies conducted at four sites (three U.S. medical centers and one in the Netherlands). The studies demonstrated improvements in provider performance when clinical information management and decision support tools were made available within an EHR system, particularly when the EHRs had the capacity to store data with high fidelity, to make those data readily accessible, and to help translate them into context specific information that can empower providers in their work.
Despite the heterogeneity in the analytic methods used, all cost-benefit analyses predicted substantial savings from EHR (and health care information exchange and interoperability) implementation: The quantifiable benefits are projected to outweigh the investment costs.
However, the predicted time needed to break even varied from three to as many as 13 years.
Conclusions: HIT has the potential to enable a dramatic transformation in the delivery of health care, making it safer, more effective, and more efficient. Some organizations have already realized major gains through the implementation of multifunctional, interoperable HIT systems built around an EHR. However, widespread implementation of HIT has been limited by a lack of generalizable knowledge about what types of HIT and implementation methods will improve care and manage costs for specific health organizations. The reporting of HIT development and implementation requires fuller descriptions of both the intervention and the organizational/economic environment in which it is implemented.
Note: This abstract is for the full report, which was summarised in the Annals of Internal Medicine article above which was published at close to the same time.
Source:
http://www.ahrq.gov/downloads/pub/evidence/pdf/hitsyscosts/hitsys.pdf
Taken together these review provide compelling evidence for the key importance of interactive CDS
Note: a Google search for (benefits "clinical decision support") yields 158,000 English language pages. That of itself says something!
David.
Sunday, August 20, 2006
Paths to Benefits – A Clearway or Not?
We have a new document from NEHTA. It is entitled “PATHS TO BENEFITS. NEHTA’s approach to modelling the benefits of investment in national e-health infrastructure - Version 1.0 — 20 August 2006 - For Comment”
According to the document’s introduction “The purpose of this document is to describe the approach NEHTA is using to model the benefits realisable from investment in national e-health infrastructure. In order to model the benefits realisable from national e-health infrastructure investment, it is necessary to examine both the most likely approaches to developing Australia's e-health infrastructure and the quality of evidence supporting these approaches. The document also outlines the technical approach to modelling costs and benefits being used by NEHTA for the Benefits Realisation Study.”
I have endeavoured to approach this document with a positive mind-set and in the hope that something useful will come from the modelling and associated efforts outlined. Sadly the more I have read, the more I am concerned.
The first issue that occurs to me concerns the second sentence of the introduction quoted above and relates to the admission that NEHTA does not know what the national e-health infrastructure approach is and so it is going to model some likely approaches. NEHTA has been in existence for just over two years having been authorised by Health Ministers on July 29, 2004 to commence immediate operations. For NEHTA to still not know the approach that will be adopted to the establishment of a National E-Health Infrastructure two years after its founding would be hilarious if it were not so dreadfully serious. What on earth are they being paid to do?
It is clear that what is needed, before benefits analysis is undertaken, let alone before benefits realisation is undertaken, is a clear statement of the technology and e-health functionality assumptions and directions being assessed. Appendix 1 suggests there are eighteen NEHTA initiatives & deliverables that “Contributes to >0.5 Billion annual benefit”. Such assertions are simply not credible unless there is a clear articulation of just what is referred to in each and (hopefully) what the cost of each might be. It is just not possible to model the cost-benefit of system Y or infrastructure X without knowing, in some functional and technical detail, what it is!
Secondly there is to me a fundamental issue with the context of this document. Benefits Realisation is a process that is undertaken as part of the planning of and implementation of new business processes and supporting or enabling computer systems. Before it begins there are a few prior steps which NEHTA has omitted which render the present document problematic. These prior steps include identification of problems to be addressed, development of a strategy to address the problems and the subsequent development of a business case (with costs and benefits) to justify the planned investments and activity. Only once this is agreed should implementation planning and business realisation (of the identified benefits) be undertaken. The work covered here, in the absence of the pre-work, is clearly a cart put much before the horse.
It should be noted that in the US (ONCHIT Plans), the UK (Information for Health) and Canada (Health Infoway) the national plan and approach has been developed first and costed and analysed for benefits before implementation is begun. In Australia a plan (HealthConnect) was in development for five years, but having not been funded has largely gone nowhere, while we now see NEHTA making infrastructure investments without either a National Plan or a National Business Case and in the absence of a clear view of what is being built towards!.
A third concern relates to the nature of Business Cases for Infrastructure Investment. In developing the various identification initiatives and SNOMED CT, it seems to me NEHTA is adopting a “build it and they will come” mentality, which may or may not turn out to be true. Additionally it is widely recognised that there is seldom a business case for infrastructure development that, of itself, is positive. Building a railway can only be justified when one knows how many trains of what type will use it and what they can be charged. The same with NEHTA infrastructure. NEHTA does not know who (GPs, Specialists, Hospitals, Pathologists etc) will use its planned infrastructure, what their needs will be and how much they are prepared to pay. The central issue is that while NEHTA has some understanding of the needs of the Jurisdictions which own it, it would seem to have little information and understanding of the needs of the private sectors comprising GP, Specialist and Private Hospitals. Any approach to examining the benefits of e-Healthand to developing a business case for investment, must review the Health Sector as a whole and not serve just the sectoral concerns of NEHTA’s owners.
Fourthly it is clear that the lack of interest in, and understanding of, the office practice needs and requirements has led to substantial imbalance in the benefits being sought and a denial that anything needs to be done in these areas. An example is the discussion of decision support (Section 3.2.1)
"3.2.1 Role of decision support
The diagram highlights the important role of decision support in the realisation of quantifiable clinical benefits. Information from the shared electronic health record, clinical evidence and evidence arising from the monitoring of health services utilisation (such as the monitoring of the under use or overuse of specific medications, trends in laboratory results and regional variation in access to specific elective procedures) are used to present to both health consumers and healthcare providers sophisticated decision support tools designed to assist health consumers and healthcare providers make better decisions when choosing to access specific healthcare services.(13)
In the case of health consumers, decision support is primarily designed to assist self management of clinical conditions and to assist a health consumer in making choices concerning the most appropriate healthcare services to meet their needs, given their clinical, cultural and geographical context.(14) Decision support for healthcare providers is primarily targeted at improving the appropriateness of prescribing and referral for specific consultations, procedures or investigations in order to reduce misuse, overuse and under use of individual healthcare services. (15-18)”
It is well known that the key driver of Health Sector costs are medical activities. These activities are notoriously difficult to change and the only good evidence for causing change in behaviour centres around decision support and alerts provided at the point of clinical decision making. Non-interactive reporting back to doctors, weeks or months later, of what they were doing inappropriately runs a very poor second in effectiveness – yet this is really the only type explored in the report. Why one asks? NEHTA simply does not want to address the issues of quality and functionality of the client systems which may use its infrastructure. This is a real “head in the sand” approach which means any assessment of benefits will be pure guesswork without explicit assumptions as to the capabilities of the client systems being modelled.
Let us be quite clear on this – it is interactive, point of care, advanced clinical decision support and alert systems that offer the largest opportunity for benefit realisation from e-health. The fact this point is not emphasised in this report provides evidence that the document is lacking an appropriate direction and focus.
Next the report notes, without giving adequate emphasis, the issue of the distribution of benefits and the place of incentives in obtaining the adoption and use of Health IT. This issue has been explored in a previous note (Who pays the Piper? May 28,2006) but the essential truth is that small business people (as GPs and Specialists are) will not adopt any technology that reduces their net income. Time and time again it has been demonstrated altruism is not enough and it won’t be here as well. Any modelling will need to carefully analyse the source and recipients of the benefits. NEHTA would be well advised to workshop the suggested provider benefits with a range of practitioners as I know few who would see many of the claimed benefits affecting them and many who could foresee much increased cost and time expenses.
A mystifying omission from the potential benefits of secure messaging is the use of such a service for the transmission of Specialist’s Letters. If ever there is a considered reliable document produced regarding a patient it is such letters (much more so than discharge summaries) and priority should be given to their communication. Their omission is another reflection of the lack of a whole-of-health system perspective in the document.
Another concern is that many of the benefits are predicated on a Shared EHR that is not yet being built, is not funded and in the present climate, realistically, never will be. It is mentioned in the document that NEHTA has recently published a “Concept of Operations” document for the SEHR. This document has been under development for over a year and has yet to see the public “light of day”. It would be useful if this were made available as soon as possible to assist in providing comments to NEHTA on the present document.
It is this commentators belief that the key benefits that can be derived from e-Health will occur from the provision of quality information and advice at the point of clinical care. To not focus on the high quality delivery of these services is a major strategic omission from both this report and NEHTA’s overall agenda.
Lastly the following from Section 7.1 is telling. “It is intended to circulate, for comment, a Study findings document outlining the major Study findings prior to completion of the final Study report. In reporting the findings, it is intended to group benefits (and costs) for NEHTA’s current COAG funded initiatives, (foundation services, identifiers and clinical information structure/terminologies) separately from the shared electronic health record benefits.” It may be that NEHTA is hoping to provide the basis of a business case for the SEHR in a form which will be accepted by Government for funding. If so it will be crucial to address the issues raised here. Benefits studies for HealthConnect have been done previously and have been ignored, one can hope maybe this one won’t be ignored but I for one will not be holding my breath.
In summary this project is the wrong project at the wrong time with the wrong scope. What is needed is a National e-Health Strategy and Business Plan (covering the whole Health Sector) based on the modelling of a considered, agreed and realistic implementation approach. The benefits realisation comes after we have decided to invest and implement and want to ensure success.
David.
Small Nits Appendix:
1. Why is the document so badly formatted?
2. Why is the role of the private sector in Health Services Delivery so underplayed?
3. Is the ASTM Clinical Care Record (rather than HL7 CDA) now on the NEHTA agenda?
Enquiring minds would like to know!
Note - the original report is found at:
http://www.nehta.gov.au/component/option,com_docman/task,cat_view/gid,141/Itemid,139/
D.
According to the document’s introduction “The purpose of this document is to describe the approach NEHTA is using to model the benefits realisable from investment in national e-health infrastructure. In order to model the benefits realisable from national e-health infrastructure investment, it is necessary to examine both the most likely approaches to developing Australia's e-health infrastructure and the quality of evidence supporting these approaches. The document also outlines the technical approach to modelling costs and benefits being used by NEHTA for the Benefits Realisation Study.”
I have endeavoured to approach this document with a positive mind-set and in the hope that something useful will come from the modelling and associated efforts outlined. Sadly the more I have read, the more I am concerned.
The first issue that occurs to me concerns the second sentence of the introduction quoted above and relates to the admission that NEHTA does not know what the national e-health infrastructure approach is and so it is going to model some likely approaches. NEHTA has been in existence for just over two years having been authorised by Health Ministers on July 29, 2004 to commence immediate operations. For NEHTA to still not know the approach that will be adopted to the establishment of a National E-Health Infrastructure two years after its founding would be hilarious if it were not so dreadfully serious. What on earth are they being paid to do?
It is clear that what is needed, before benefits analysis is undertaken, let alone before benefits realisation is undertaken, is a clear statement of the technology and e-health functionality assumptions and directions being assessed. Appendix 1 suggests there are eighteen NEHTA initiatives & deliverables that “Contributes to >0.5 Billion annual benefit”. Such assertions are simply not credible unless there is a clear articulation of just what is referred to in each and (hopefully) what the cost of each might be. It is just not possible to model the cost-benefit of system Y or infrastructure X without knowing, in some functional and technical detail, what it is!
Secondly there is to me a fundamental issue with the context of this document. Benefits Realisation is a process that is undertaken as part of the planning of and implementation of new business processes and supporting or enabling computer systems. Before it begins there are a few prior steps which NEHTA has omitted which render the present document problematic. These prior steps include identification of problems to be addressed, development of a strategy to address the problems and the subsequent development of a business case (with costs and benefits) to justify the planned investments and activity. Only once this is agreed should implementation planning and business realisation (of the identified benefits) be undertaken. The work covered here, in the absence of the pre-work, is clearly a cart put much before the horse.
It should be noted that in the US (ONCHIT Plans), the UK (Information for Health) and Canada (Health Infoway) the national plan and approach has been developed first and costed and analysed for benefits before implementation is begun. In Australia a plan (HealthConnect) was in development for five years, but having not been funded has largely gone nowhere, while we now see NEHTA making infrastructure investments without either a National Plan or a National Business Case and in the absence of a clear view of what is being built towards!.
A third concern relates to the nature of Business Cases for Infrastructure Investment. In developing the various identification initiatives and SNOMED CT, it seems to me NEHTA is adopting a “build it and they will come” mentality, which may or may not turn out to be true. Additionally it is widely recognised that there is seldom a business case for infrastructure development that, of itself, is positive. Building a railway can only be justified when one knows how many trains of what type will use it and what they can be charged. The same with NEHTA infrastructure. NEHTA does not know who (GPs, Specialists, Hospitals, Pathologists etc) will use its planned infrastructure, what their needs will be and how much they are prepared to pay. The central issue is that while NEHTA has some understanding of the needs of the Jurisdictions which own it, it would seem to have little information and understanding of the needs of the private sectors comprising GP, Specialist and Private Hospitals. Any approach to examining the benefits of e-Healthand to developing a business case for investment, must review the Health Sector as a whole and not serve just the sectoral concerns of NEHTA’s owners.
Fourthly it is clear that the lack of interest in, and understanding of, the office practice needs and requirements has led to substantial imbalance in the benefits being sought and a denial that anything needs to be done in these areas. An example is the discussion of decision support (Section 3.2.1)
"3.2.1 Role of decision support
The diagram highlights the important role of decision support in the realisation of quantifiable clinical benefits. Information from the shared electronic health record, clinical evidence and evidence arising from the monitoring of health services utilisation (such as the monitoring of the under use or overuse of specific medications, trends in laboratory results and regional variation in access to specific elective procedures) are used to present to both health consumers and healthcare providers sophisticated decision support tools designed to assist health consumers and healthcare providers make better decisions when choosing to access specific healthcare services.(13)
In the case of health consumers, decision support is primarily designed to assist self management of clinical conditions and to assist a health consumer in making choices concerning the most appropriate healthcare services to meet their needs, given their clinical, cultural and geographical context.(14) Decision support for healthcare providers is primarily targeted at improving the appropriateness of prescribing and referral for specific consultations, procedures or investigations in order to reduce misuse, overuse and under use of individual healthcare services. (15-18)”
It is well known that the key driver of Health Sector costs are medical activities. These activities are notoriously difficult to change and the only good evidence for causing change in behaviour centres around decision support and alerts provided at the point of clinical decision making. Non-interactive reporting back to doctors, weeks or months later, of what they were doing inappropriately runs a very poor second in effectiveness – yet this is really the only type explored in the report. Why one asks? NEHTA simply does not want to address the issues of quality and functionality of the client systems which may use its infrastructure. This is a real “head in the sand” approach which means any assessment of benefits will be pure guesswork without explicit assumptions as to the capabilities of the client systems being modelled.
Let us be quite clear on this – it is interactive, point of care, advanced clinical decision support and alert systems that offer the largest opportunity for benefit realisation from e-health. The fact this point is not emphasised in this report provides evidence that the document is lacking an appropriate direction and focus.
Next the report notes, without giving adequate emphasis, the issue of the distribution of benefits and the place of incentives in obtaining the adoption and use of Health IT. This issue has been explored in a previous note (Who pays the Piper? May 28,2006) but the essential truth is that small business people (as GPs and Specialists are) will not adopt any technology that reduces their net income. Time and time again it has been demonstrated altruism is not enough and it won’t be here as well. Any modelling will need to carefully analyse the source and recipients of the benefits. NEHTA would be well advised to workshop the suggested provider benefits with a range of practitioners as I know few who would see many of the claimed benefits affecting them and many who could foresee much increased cost and time expenses.
A mystifying omission from the potential benefits of secure messaging is the use of such a service for the transmission of Specialist’s Letters. If ever there is a considered reliable document produced regarding a patient it is such letters (much more so than discharge summaries) and priority should be given to their communication. Their omission is another reflection of the lack of a whole-of-health system perspective in the document.
Another concern is that many of the benefits are predicated on a Shared EHR that is not yet being built, is not funded and in the present climate, realistically, never will be. It is mentioned in the document that NEHTA has recently published a “Concept of Operations” document for the SEHR. This document has been under development for over a year and has yet to see the public “light of day”. It would be useful if this were made available as soon as possible to assist in providing comments to NEHTA on the present document.
It is this commentators belief that the key benefits that can be derived from e-Health will occur from the provision of quality information and advice at the point of clinical care. To not focus on the high quality delivery of these services is a major strategic omission from both this report and NEHTA’s overall agenda.
Lastly the following from Section 7.1 is telling. “It is intended to circulate, for comment, a Study findings document outlining the major Study findings prior to completion of the final Study report. In reporting the findings, it is intended to group benefits (and costs) for NEHTA’s current COAG funded initiatives, (foundation services, identifiers and clinical information structure/terminologies) separately from the shared electronic health record benefits.” It may be that NEHTA is hoping to provide the basis of a business case for the SEHR in a form which will be accepted by Government for funding. If so it will be crucial to address the issues raised here. Benefits studies for HealthConnect have been done previously and have been ignored, one can hope maybe this one won’t be ignored but I for one will not be holding my breath.
In summary this project is the wrong project at the wrong time with the wrong scope. What is needed is a National e-Health Strategy and Business Plan (covering the whole Health Sector) based on the modelling of a considered, agreed and realistic implementation approach. The benefits realisation comes after we have decided to invest and implement and want to ensure success.
David.
Small Nits Appendix:
1. Why is the document so badly formatted?
2. Why is the role of the private sector in Health Services Delivery so underplayed?
3. Is the ASTM Clinical Care Record (rather than HL7 CDA) now on the NEHTA agenda?
Enquiring minds would like to know!
Note - the original report is found at:
http://www.nehta.gov.au/component/option,com_docman/task,cat_view/gid,141/Itemid,139/
D.
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