Its getting to the time of the year when the Health bureaucrat starts to think of all things Christmas and congratulate themselves on a year well spent.
How is the report card looking this year I wonder?
In this context I guess it would be about time to remind Minister Abbott of what he said to the Sydney Morning Herald on September 6, 2005 and to use that as a benchmark.
See:
http://www.smh.com.au/news/next/erecords--a-healthy-chart-buster/2005/09/05/1125772438601.html
“Abbott's patience runs out
Federal Health Minister Tony Abbott admits to "a great deal of slippage" with the Federal Government's $128million national electronic medical records program but says he is working to ensure that patients get benefits within 12 months.
"I will do everything I can to meet these deadlines and I will be disappointed if we don't," he says.
His comments come after he told a breakfast briefing at Parliament House that he was "sick of trials and studies and working groups", and wanted to see electronic health records making a difference in patients' lives by the middle of next year.”
What do we see 14 month later?
A Department of Health and Ageing Report Card
Well it has been a year of focused but quite secret activity. The E-health Program from DoHA seems to be divided into five areas:
1. E-Health Business Development.
The emphasis here is on Managed Health Network Grants for development of health networking. They were announced December 2005 and the funds must be spent by June 30, 2007. Sadly no winners have yet been announced so the spend fest is likely to be amazing.
The earlier Eastern Goldfields Regional Reference Site, where amazingly expensive broadband access was provided to practitioners. The viability of the network is now questionable without the government subsidy
2. E-Health communications
This provides access to the HealthConnect Archive which has been pretty stable since February 2006. The June 2006 E-Health Newsletter has been reviewed earlier.
3. E-Health Governance
Progress here has been that the Council of Australian Governments (COAG) has announced that:
“From February 2006, governments will accelerate work on a national electronic health records system to improve safety for patients and increase efficiency for health care providers by developing the capacity for health providers, with their patient’s consent, to communicate safely and securely with each other electronically about patients and their health. This requires:
• developing, implementing and operating systems for an individual health identifier, a healthcare provider identifier and agreed clinical terminologies; and
• promoting compliance with nationally-agreed standards in future government procurement related to electronic health systems and in areas of healthcare receiving government funding.”
The strength of this commitment was emphasised by the disappearance of the Australian Health Information Council which is meant to be the peak advisory body to COAG on such matters. Clearly E-Health governance isn’t actually happening as best one can tell.
4. E-Health Major Programs
There are four major programs:
1. Broadband for Health.
Giving practitioners broadband internet access – clearly practitioners can’t find the $40 per month to pay for it them selves (tax deductible business expense of actually less).
2. HealthConnect
Said to be as follows:
“HealthConnect is an overarching national change management strategy to improve safety and quality in healthcare by establishing and maintaining a range of standardised electronic health information products and services for healthcare providers and consumers.”
Not much change seems to be happening federally (I will review the State HealthConnect initiatives in a separate post) and no one knows, or at least I don’t, what the “standardised electronic health information products and services for healthcare providers and consumers” are.
As most know, the E-Health Implementation Branch (previously responsible for all this including HealthConnect) has been wound down, after Dr Brian Richards and then Tam Shepherd left. Now it is being led Lisa McGlynn (who is ex NSW Health – but not an expert e-health or technology I am told).
I am also told all the original staff (with any corporate knowledge of e-health which they may have built up) have moved on, and the incoming staff are all people who have never worked in health and know nothing about e-health or IT. Apparently the States and Territories can’t get any sense out of them at all now. Many commentators have suggested to me they think that this tactic is deliberate to wind down the branch to nothing.
3. HealthInsite.
An excellent idea and well implemented. By far the best initiative of DoHA. Pity they have not had a few more good ideas since this service began in mid 2002.
4. NEHTA.
It is very hard to comment on NEHTA since it is a privatisation of Government accountability to ensure that if it does not work the Minister can't be blamed and that the truth will never be known as Freedom Of Information does not apply.
Sadly NEHTA is not an outsourced e-Health Government strategy - or the Government would have had an outsourcing contract with all the usual performance hurdles and rewards.
The NEHTA Directors must be hoping some concrete results will be delivered soon since the organisation now has over sixty staff and, as yet, it is hard to see that much has been delivered other the FUD (Fear, Uncertainty and Doubt) on the part of all the other actors in the E-Health space.
My view is that unless there are some really useful and practical outcomes within the next six months (i.e. having been in action for just on three years (Authorised by COAG July 2004)serious questions will start being asked. The opportunity cost of all this inactivity is really astronomical in terms of patient suffering and lives lost.
5. E-Health Strategic Policy.
This section comes direct from the DoHA web site
“Information regarding e-Health strategic policy and how it is being implemented is found in this area of the website.
Strategic policy alignment takes a strong focus on the monitoring and analysis of trends and technology, in order to drive the Australian Governments' e-Health agenda. The work involves the provision of advice on Departmental, other government and independent e-Health related activity and the establishment of appropriate regulatory frameworks to enable e-Health nationally. Much of this work is linked with the National E-Health Transition Authority (NEHTA) work program. Further information about NEHTA and the work program can be found at the following site: www.nehta.gov.au
Page last modified: 21 April, 2006”
Sadly there is not a word about policy other than it has been passed to NEHTA, and can be understood as a work-program!
What does this all amount to?
I would contend it amounts to a virtually total abdication of central government involvement in E-Health. We have seen no significant concrete progress and the National E-Health Strategy, Business Case and Implementation Plans remain non-existent and the relevant Federal bureaucracy seems to have essentially imploded.
I hope next November I can write a happier report. I suspect our Health Minister must be very disappointed and frustrated in the progress made in the last twelve months!
David.
Tuesday, November 21, 2006
Sunday, November 19, 2006
The Drug Pricing Scandal and How the Sick are Ripped off in Australia.
First, apologies to the die hard Health IT readers. For once I am going to stray from the chosen Health IT path, due to a deep sense of gob smacked outrage.
In the last week or so we have had the Federal Health Minister – Mr Tony Abbott – claiming he has just done a wonderful job negotiating a great reduction of the cost of generic prescription medicines and how grateful we all should be.
Without putting too fine a point on it that was just total codswallop.
A day or so the Wall Street Journal made available the pricing for Generic Prescription Medicine from Wal-Mart – the US retail chain. I grabbed the seven page price list document to see just what was on offer.
Essentially what is available is one months supply of a very large range of life saving medicines in a wide range of therapeutic classes for $US4.00 – i.e. $A5.30 per month.
Included in the list are Anti-Allergy, Anti-Inflammatory, Anti-Anxiety, Anti- Depressant Anti-Psychotic and so on medicines. Also included are a wide range of antibiotics (including Penicillin, Amoxycillin, Bactrim, Cephalosporins and even Ciprofloxin), 2 statins drugs, some hormones (e.g. Thyroid Replacement Therapy and Prednisone) and even multi-vitamins and Prozac.
The only major class of drug I could not find were the proton pump inhibitors for which the H2 Receptor Antagonists are nearly as good and just as safe. The PPIs will be off patent very soon I am sure (They are in Australia I believe) or it might be they are a bit more costly to manufacture.
The stand out saving for me was that Meloxicam – an anti-inflammatory for osteo-arthritis that I take was available for $5.30 a month rather than the $29.50 I presently pay! Without going into details my monthly $100 prescription costs could be adjusted down to about $20 a month with little or no change in the quality or safety of my treatment.
This really is a huge con with the drug companies and the pharmacists getting rich off the back of those unlucky enough to need prescription medicine. With this fix in a huge number of people are being ripped off and many, I am sure, are missing out on effective medicines that could make a great difference to the quality and quantity of their lives due to costs they may not be able to afford.
Our much vaunted Pharmaceutical Benefits Scheme looks to like a wonderful cosy drug company – pharmacist – government cartel to me. Transparent it certainly is not and how – with these sort of savings possible – one can justify keeping the supermarkets out of the area is beyond belief.
We will now return to our usual program with that off my chest.
David.
Note – Please e-mail me if you want a copy of the list – its only about 50Kbyte so easy to e-mail.
In the last week or so we have had the Federal Health Minister – Mr Tony Abbott – claiming he has just done a wonderful job negotiating a great reduction of the cost of generic prescription medicines and how grateful we all should be.
Without putting too fine a point on it that was just total codswallop.
A day or so the Wall Street Journal made available the pricing for Generic Prescription Medicine from Wal-Mart – the US retail chain. I grabbed the seven page price list document to see just what was on offer.
Essentially what is available is one months supply of a very large range of life saving medicines in a wide range of therapeutic classes for $US4.00 – i.e. $A5.30 per month.
Included in the list are Anti-Allergy, Anti-Inflammatory, Anti-Anxiety, Anti- Depressant Anti-Psychotic and so on medicines. Also included are a wide range of antibiotics (including Penicillin, Amoxycillin, Bactrim, Cephalosporins and even Ciprofloxin), 2 statins drugs, some hormones (e.g. Thyroid Replacement Therapy and Prednisone) and even multi-vitamins and Prozac.
The only major class of drug I could not find were the proton pump inhibitors for which the H2 Receptor Antagonists are nearly as good and just as safe. The PPIs will be off patent very soon I am sure (They are in Australia I believe) or it might be they are a bit more costly to manufacture.
The stand out saving for me was that Meloxicam – an anti-inflammatory for osteo-arthritis that I take was available for $5.30 a month rather than the $29.50 I presently pay! Without going into details my monthly $100 prescription costs could be adjusted down to about $20 a month with little or no change in the quality or safety of my treatment.
This really is a huge con with the drug companies and the pharmacists getting rich off the back of those unlucky enough to need prescription medicine. With this fix in a huge number of people are being ripped off and many, I am sure, are missing out on effective medicines that could make a great difference to the quality and quantity of their lives due to costs they may not be able to afford.
Our much vaunted Pharmaceutical Benefits Scheme looks to like a wonderful cosy drug company – pharmacist – government cartel to me. Transparent it certainly is not and how – with these sort of savings possible – one can justify keeping the supermarkets out of the area is beyond belief.
We will now return to our usual program with that off my chest.
David.
Note – Please e-mail me if you want a copy of the list – its only about 50Kbyte so easy to e-mail.
Wednesday, November 15, 2006
Clinical Software Certification – What’s Practical, Necessary and What Makes Sense?
In the last few months there has been some correspondence in the Medical Journal of Australia and elsewhere on the topic of the safety of clinical software and the possible need for certification of such software.
In this commentary I want to consider this suggestion from a range of perspectives including practicality, barriers to implementation, likely impact on quality of care and so on. I would also like to point out that from my perspective, while I believe it is vital, certification of clinical software is likely to prove clinically challenging, technically complex as well as commercially contentious.
Before going any further it is important to say that I recognise the inherent difficulty and complexity of the topic and need to take a perspective that ignores the system user – recognising the unreality of pretending areas such as user skill, attention, competence and experience are not important in the overall outcome. What I seek to achieve here is to try and identify the different components of an approach that may address the issues around having the practitioner be confident that the system they are using is providing the best possible aid and support for their care delivery.
What attributes are needed for the purchaser and user to be sure this to be so?
I would suggest the following are important.
1. Data Model
The target system needs to have a sufficiently rich data model to support both the usual data capture required in a clinical EHR system as well as the detailed – and hopefully structured information required for automated decision support. This means that at the very least crucial laboratory results (e.g Haemoglobin, Creatinine etc) will be captured in atomic form.
Clearly there is also the need to address coding / terminology in appropriate areas (e.g. diagnoses, medications etc) to ensure useful values are held and are computable to support clinical decision making.
2. Functionality
The functionality of the EHR system that is required for quality care delivery has been the subject of much work over the years and is quite well understood. The requirements contained in the General Practice Computing Report in Australia and the HL7 and CCHIT specifications for the US provide quite reasonable guidance in this area.
Clearly the full scope of these requirements including clinical decision support and clinical pathway management and tracking are required.
3. Knowledge Database(s)
While vital, here we arrive at a major difficulty. This is at least one area where the quality, scope and depth of what is required is likely to prove less than straight-forward to define.
4. Interoperability
As attractive as ‘vendor lock in’ may or may not be to commercial software providers it is anathema to software customers and users. For this reason all information stored in the EHR should be exportable in a standard – and preferably standardised form to any certified competing product.
5. A Commercial Future
With use over time the value of the information held in a clinical system becomes progressively larger. The purchaser / selector of a system, which will be expected to be operational for ten years or longer, needs to be confident of the commercial viability of the software provider in terms of maintenance, updates, recurrent costs and so on.
6. Messaging and Communications Capability
Systems these days do not live in a vacuum and they need to be able to securely transmit and receive both clinical and administrative information in a seamless and standardised fashion.
7. Usability
It is important any systems should be engineered to be both easy to use and also to be designed using the principles applied to aircraft-cockpit design where the important information cannot be overlooked easily or without warning.
It should be noted that while the emphasis in this article has been on ambulatory systems all the forgoing is just as relevant to the hospital and other larger provider sectors.
The next issue is how is assurance obtained that these attributes are indeed present and are of the quality etc required.
Given the current political situation it seems to me that what is required is a CCHIT (Certification Commission for Healthcare Information Technology in the USA) like organisation, funded by, but at arms length from, Government that can work with users and all the other stakeholders to develop the requirements and criteria in each of these areas and then offer incremental and reasonably in-expensive paths to certification.
The CCHIT approach of developing roadmaps of requirements and capabilities to be delivered over a known time-frame I see as remarkably sensible and pragmatic and well worth adoption.
Clearly the Australian CCHIT would need to work collaboratively with both system developers, academia, clinicians and standards bodies to develop and then assess systems against the agreed criteria. This said it would also be important to have very professional leadership of the commission in place to ensure there is no easy route for less than high quality systems to be certified. A half baked process would be far worse than no process at all.
My guess this would be of the order of a five year project to get where we need to be with initial certifications possible in two to three years.
To not go down this path will leave individual purchasers and vendors possibly, indeed almost inevitably, liable for possible errors of omission or commission. The Government must really act to provide appropriate coverage for all those in the E-Health sector.
The other step I believe is required is that there be financial incentives for the clinical users to both install and then use the advanced systems as we know from the study reported yesterday that it is only the actual use of capable quality systems that makes a real quality and safety difference.
The business case for the Commonwealth to do this in the Ambulatory Sector I am sure would be totally compelling!
David.
In this commentary I want to consider this suggestion from a range of perspectives including practicality, barriers to implementation, likely impact on quality of care and so on. I would also like to point out that from my perspective, while I believe it is vital, certification of clinical software is likely to prove clinically challenging, technically complex as well as commercially contentious.
Before going any further it is important to say that I recognise the inherent difficulty and complexity of the topic and need to take a perspective that ignores the system user – recognising the unreality of pretending areas such as user skill, attention, competence and experience are not important in the overall outcome. What I seek to achieve here is to try and identify the different components of an approach that may address the issues around having the practitioner be confident that the system they are using is providing the best possible aid and support for their care delivery.
What attributes are needed for the purchaser and user to be sure this to be so?
I would suggest the following are important.
1. Data Model
The target system needs to have a sufficiently rich data model to support both the usual data capture required in a clinical EHR system as well as the detailed – and hopefully structured information required for automated decision support. This means that at the very least crucial laboratory results (e.g Haemoglobin, Creatinine etc) will be captured in atomic form.
Clearly there is also the need to address coding / terminology in appropriate areas (e.g. diagnoses, medications etc) to ensure useful values are held and are computable to support clinical decision making.
2. Functionality
The functionality of the EHR system that is required for quality care delivery has been the subject of much work over the years and is quite well understood. The requirements contained in the General Practice Computing Report in Australia and the HL7 and CCHIT specifications for the US provide quite reasonable guidance in this area.
Clearly the full scope of these requirements including clinical decision support and clinical pathway management and tracking are required.
3. Knowledge Database(s)
While vital, here we arrive at a major difficulty. This is at least one area where the quality, scope and depth of what is required is likely to prove less than straight-forward to define.
4. Interoperability
As attractive as ‘vendor lock in’ may or may not be to commercial software providers it is anathema to software customers and users. For this reason all information stored in the EHR should be exportable in a standard – and preferably standardised form to any certified competing product.
5. A Commercial Future
With use over time the value of the information held in a clinical system becomes progressively larger. The purchaser / selector of a system, which will be expected to be operational for ten years or longer, needs to be confident of the commercial viability of the software provider in terms of maintenance, updates, recurrent costs and so on.
6. Messaging and Communications Capability
Systems these days do not live in a vacuum and they need to be able to securely transmit and receive both clinical and administrative information in a seamless and standardised fashion.
7. Usability
It is important any systems should be engineered to be both easy to use and also to be designed using the principles applied to aircraft-cockpit design where the important information cannot be overlooked easily or without warning.
It should be noted that while the emphasis in this article has been on ambulatory systems all the forgoing is just as relevant to the hospital and other larger provider sectors.
The next issue is how is assurance obtained that these attributes are indeed present and are of the quality etc required.
Given the current political situation it seems to me that what is required is a CCHIT (Certification Commission for Healthcare Information Technology in the USA) like organisation, funded by, but at arms length from, Government that can work with users and all the other stakeholders to develop the requirements and criteria in each of these areas and then offer incremental and reasonably in-expensive paths to certification.
The CCHIT approach of developing roadmaps of requirements and capabilities to be delivered over a known time-frame I see as remarkably sensible and pragmatic and well worth adoption.
Clearly the Australian CCHIT would need to work collaboratively with both system developers, academia, clinicians and standards bodies to develop and then assess systems against the agreed criteria. This said it would also be important to have very professional leadership of the commission in place to ensure there is no easy route for less than high quality systems to be certified. A half baked process would be far worse than no process at all.
My guess this would be of the order of a five year project to get where we need to be with initial certifications possible in two to three years.
To not go down this path will leave individual purchasers and vendors possibly, indeed almost inevitably, liable for possible errors of omission or commission. The Government must really act to provide appropriate coverage for all those in the E-Health sector.
The other step I believe is required is that there be financial incentives for the clinical users to both install and then use the advanced systems as we know from the study reported yesterday that it is only the actual use of capable quality systems that makes a real quality and safety difference.
The business case for the Commonwealth to do this in the Ambulatory Sector I am sure would be totally compelling!
David.
Tuesday, November 14, 2006
A Vision of E-Health Nirvana - We Know What is Needed!
It seems that, given my advanced age and galloping decrepitude, that I will not last to ever see the E-Health nirvana. However, today, HIMSS Analytics has published the report that will allow me to slip off to the grave a “very happy Vegemite” knowing, at least, nirvana is possible!
Today, the following appeared in the overnight issue of the Health IT Strategist (HITS) – the Health IT publication from Modern Medicine in the US.
"Greater benefits seen in advanced apps: study
There are few substantial correlations between improved healthcare outcomes and "incomplete" electronic medical-records systems, according to a new white paper from the Healthcare Information and Management Systems Society and its not-for-profit subsidiary HIMSS Analytics, but the more sophisticated the EMR system, the more it improves the quality of care.
"Perhaps it’s appropriate to borrow a line from the addiction-recovery industry," the report stated. "When it comes to the electronic medical record, it appears that half measures avail us nothing."
On the other hand, along with improving quality of care, the white paper stated that advanced applications such as computerized practitioner-order entry and clinical documentation can also increase hospital revenues related to pay-for-performance initiatives.
The findings are based on a study of 107 University HealthSystem Consortium hospitals that looked at how well hospitals did on 63 quality measures developed by the Agency for Healthcare Research and Quality and how advanced the hospitals’ EMR systems were. The study split the EMR systems into eight different stages of implementation, but no hospital in the study had implemented a system in the highest stage, and less than 1% had implantations in the levels five or six. In fact, most hospitals were still in stages zero, one and two.
The report concluded that there was a significant increase in quality scores between the 39 level-three hospitals and the 22 level-four hospitals. A main difference between the two levels is that level-four hospitals have implemented CPOE. According to the report, stage-three hospitals had six slight positive correlations between their EMRs and AHRQ’s quality measures and only one strong positive. Level-four hospitals, however, had nine strong positive correlations and 11 slight positives. The strong correlations included the areas of acute stroke, heart failure in-hospital mortality percentages and gastrointestinal hemorrhage in-hospital mortality percentages.
-- by Andis Robeznieks / HITS staff writer"
The report, which makes very interesting reading, and draws, I must say, quite conservative conclusions, can be found at the following URL.
http://www.himss.org/content/files/UHCresearch.pdf
The core conclusion, re-stated is that to make a real difference with clinical systems what is needed is both Clinical Physician Order Entry and Clinical Decision Support based – not just on simple error checking but on ensuring that evidence based clinical protocols are being adhered to as frequently as possible. Obviously this makes perfect intuitive sense and supports the studies mentioned previously on the blog that show at the real benefits of clinical computerisation are really only to be had when advanced systems are deployed. (See the blog article Saturday, August 26, 2006 Interactive Electronic Decision Support Benefits - Keys to the Literature).
The findings of the report have a number of important implications.
1. There is more to assessing the value of a clinical EMR system than Return on Investment (ROI).
2. We are further assured that the major investments suggested by this blog are, in fact, necessary and that half measures are a waste of time and money. The UK has it right to at least attempt a quantum leap in the level of health system automation – the debate now is only really around are they going about it the right way!
3. The identification of the need for advanced systems to achieve real clinical outcome improvements makes a mockery of the penny pinching approach to Health IT being adopted by the present Australian Government.
4. The transformation task to get Australia from where we are now to where we need to be to really improve health outcomes and patient safety is a really, really big one that is not being helped by the lack of a National E-Health Strategy.
5. It is largely pointless attempting to develop benefits models and benefits realization approaches unless you make clear assumptions about the advanced nature of the systems required and ensure the business case recognises the scale of both the cost and the benefits.
6. It is no longer sensible to not have clear guidelines as to the capabilities and functionality that should be delivered to ambulatory (GP and Specialist) and hospital practice.
NEHTA needs to change focus and really start addressing these implications if it is not to become part of the problem rather than part of the solution.
David.
Today, the following appeared in the overnight issue of the Health IT Strategist (HITS) – the Health IT publication from Modern Medicine in the US.
"Greater benefits seen in advanced apps: study
There are few substantial correlations between improved healthcare outcomes and "incomplete" electronic medical-records systems, according to a new white paper from the Healthcare Information and Management Systems Society and its not-for-profit subsidiary HIMSS Analytics, but the more sophisticated the EMR system, the more it improves the quality of care.
"Perhaps it’s appropriate to borrow a line from the addiction-recovery industry," the report stated. "When it comes to the electronic medical record, it appears that half measures avail us nothing."
On the other hand, along with improving quality of care, the white paper stated that advanced applications such as computerized practitioner-order entry and clinical documentation can also increase hospital revenues related to pay-for-performance initiatives.
The findings are based on a study of 107 University HealthSystem Consortium hospitals that looked at how well hospitals did on 63 quality measures developed by the Agency for Healthcare Research and Quality and how advanced the hospitals’ EMR systems were. The study split the EMR systems into eight different stages of implementation, but no hospital in the study had implemented a system in the highest stage, and less than 1% had implantations in the levels five or six. In fact, most hospitals were still in stages zero, one and two.
The report concluded that there was a significant increase in quality scores between the 39 level-three hospitals and the 22 level-four hospitals. A main difference between the two levels is that level-four hospitals have implemented CPOE. According to the report, stage-three hospitals had six slight positive correlations between their EMRs and AHRQ’s quality measures and only one strong positive. Level-four hospitals, however, had nine strong positive correlations and 11 slight positives. The strong correlations included the areas of acute stroke, heart failure in-hospital mortality percentages and gastrointestinal hemorrhage in-hospital mortality percentages.
-- by Andis Robeznieks / HITS staff writer"
The report, which makes very interesting reading, and draws, I must say, quite conservative conclusions, can be found at the following URL.
http://www.himss.org/content/files/UHCresearch.pdf
The core conclusion, re-stated is that to make a real difference with clinical systems what is needed is both Clinical Physician Order Entry and Clinical Decision Support based – not just on simple error checking but on ensuring that evidence based clinical protocols are being adhered to as frequently as possible. Obviously this makes perfect intuitive sense and supports the studies mentioned previously on the blog that show at the real benefits of clinical computerisation are really only to be had when advanced systems are deployed. (See the blog article Saturday, August 26, 2006 Interactive Electronic Decision Support Benefits - Keys to the Literature).
The findings of the report have a number of important implications.
1. There is more to assessing the value of a clinical EMR system than Return on Investment (ROI).
2. We are further assured that the major investments suggested by this blog are, in fact, necessary and that half measures are a waste of time and money. The UK has it right to at least attempt a quantum leap in the level of health system automation – the debate now is only really around are they going about it the right way!
3. The identification of the need for advanced systems to achieve real clinical outcome improvements makes a mockery of the penny pinching approach to Health IT being adopted by the present Australian Government.
4. The transformation task to get Australia from where we are now to where we need to be to really improve health outcomes and patient safety is a really, really big one that is not being helped by the lack of a National E-Health Strategy.
5. It is largely pointless attempting to develop benefits models and benefits realization approaches unless you make clear assumptions about the advanced nature of the systems required and ensure the business case recognises the scale of both the cost and the benefits.
6. It is no longer sensible to not have clear guidelines as to the capabilities and functionality that should be delivered to ambulatory (GP and Specialist) and hospital practice.
NEHTA needs to change focus and really start addressing these implications if it is not to become part of the problem rather than part of the solution.
David.
Monday, November 13, 2006
Identity Management – The References.
It occurs to me, following a couple of e-mails from some of those interested, it might be worth providing a few pointers to where some useful further information can be found for further research and reading.
The topics and URLs are as follows:
1. Australian Office of the Access Card
http://www.accesscard.gov.au/
This is a new site and has the work of Professor Fels and his taskforce as a sub area at the following URL
http://www.accesscard.gov.au/consumer_privacy_task_force.html
The full press release is worth a careful read as is the Government’s response which is also available at the site.
Media Release
Access Card Consumer and Privacy Taskforce Recommends Safeguards
08 November 2006
Safeguards to protect personal privacy and security and to maximise consumer convenience have been recommended by the Access Card Consumer and Privacy Taskforce.
“Comprehensive legislation to define and regulate the role of the card and associated databases is needed. This will build public trust and confidence, and establish safeguards regarding current and any new future government uses of the card”, Professor Allan Fels AO, Chairman of the Taskforce and Dean of the Australia and New Zealand School of Government said.
“The card is a health and social services access card. It should not be allowed to develop into a national identity card by virtue of “function creep”. Legislation should ensure the card is not a national identity card nor an electronic health record nor have any link with tax records nor be required to be carried by individuals.
The legislation should also prohibit anyone requiring individuals to produce the card (except when they are accessing defined Commonwealth benefits and services).
“The legislation needs to define what the card will and won’t be”, Professor Fels said. More details of the recommended legislation are in the report of the Taskforce.
“Function creep” can be minimised by requiring any new future government uses only being permissible by legislation. Function creep can also be reduced by limiting the ultimate capacity of the card.
Australians should own the card. This will give individuals better control and limit the scope for government and others to determine future uses. There should, however, be some limitations on inappropriate usage of the card e.g. tampering with it, or altering prescribed information on the card.
Card holders should not be required to have their legal name on the face of the card if they have a preferred name they commonly use. There are legitimate reasons why consumers would want to have a name displayed on the card which differs from their legal name such as those who use Australianised names, middle names, changes of name in indigenous communities and maiden names. Their legal name, however, would be stored on the chip and on the register.
The Taskforce accepts that there needs to be a photo on the face of the card (as well as in the chip and stored in the secure customer registration system). This will minimise fraud, increase convenience for card users and government agencies and improve its capability for proof of identity (where consumers choose to use it for that purpose).
“Regarding the storage of the photo on a national photographic database, there is merit in considering the storage in the form of a template rather than in the form of real photos. This would reduce possibilities of fraud and misuse”, he said.
“However, this must be weighed up against cardholder and government convenience. If a card is lost, as frequently happens, the cardholder would have to be rephotographed if the photo was not stored in real form”, he said.
“If there is to be a real photographic database, it is critical that there be maximum security precautions. This should be held separately, within the register, from other cardholder data and there should be stringent special controls to prevent unauthorised access and improper usage”, he said.
The Taskforce is sceptical for the need for a digitised signature to appear on the card. The signature seems to be of limited use and it increases the dangers of identity theft and fraud. Again, whatever the outcome, digitised signatures should be subject to rigorous controls to prevent unauthorised access and improper usage.
The Taskforce accepts that there needs to be a number associated with each card, even though this means that each cardholder then has a unique number assigned to them.
“The taskforce considers that the number should not appear on the reverse of the card”, he said. If the card number is not displayed it reduces the risks of the card slowly developing into a “unique personal identifier” number for the Australian population (that is, each Australian eventually has a unique number assigned to them). Also, if the card number is displayed it increases the risk of fraud. This risk outweighs some advantages for government administration and user convenience. In the alternative the government should give consideration to making the inclusion of a unique number on the reverse of the card a matter of genuine choice for the card holder.
When consumers register for their card they will bring documentation to verify their identity. Should copies be taken of these documents and retained on file in accordance with existing practice?
The argument for the copying and retention of proof of identity (POI) documentation relates to measures taken to detect and control fraud.Such records are accessed by relevant Departments where there is some suspicion of illegal behaviour or identity fraud, or in cases where original documents are subsequently lost or destroyed. Such a procedure may, in some instances, also be required under statute.
The Taskforce supports capturing proof of identity documentation for the purposes of establishing identity and verifying their authenticity but has recommended that they should not be scanned, copied or kept on file after they have been verified.
The Taskforce notes statements by the Government that the card is only to be used for access to health and welfare services. The Taskforce notes that the Government is also in the process of considering the adoption of a National Identity Security Strategy which aims to require a very high (“Gold Standard”) proof of identity.
However, the Taskforce does not believe that the ‘Gold Standard’ being considered for a National Identity Security Strategy is necessarily appropriate for use by to facilitate delivery of health and social services benefits. The most disadvantaged and marginalised members of the community who may be unable to provide sufficient documentation to establish their identity should not be unnecessarily burdened by this process.
The Taskforce has recommended an extensive public information campaign explaining the nature of the card.
The Taskforce makes a number of recommendations to the Government for the ongoing design and implementation of elements of the card. Fundamental to further consideration of these elements by Government is the continued process of consultation that needs to occur between the Taskforce, the Government’s Lead Advisor and Chief Technology Architect.
The Taskforce is committed to ensuring that the views of all Australians feed into the design of the access card system.
The Taskforce is currently working on the second discussion paper, which will consider the Registration process and will seek to ensure that there is continued consultation with consumer and interested groups. This paper is expected to be released for discussion in November 2006.
The Consumer and Privacy Taskforce
The Consumer and Privacy Taskforce, was established in May 2006 to report on consumer and privacy issues arising from the Government’s announced plans to introduce a new health and social services access card.
The Taskforce released an initial discussion paper released on 16 June 2006. The Taskforce has met with 120 representative groups and received over 100 written submissions.
The Taskforce’s believes that all decisions about the design of the card should be made in as transparent a fashion as possible and be informed by public consultation.
The Report makes 26 recommendations.
A copy of the report can be found at www.australia.gov.au/accesscard. The report is titled Issues and Recommendations in Relation to Architecture Questions of the Access Card.
The Government response is found here:
http://www.accesscard.gov.au/publications.html
2. Report from the UK House of Commons: Identity Card Technologies: Scientific Advice, Risk and Evidence
This can be found at the following URL.
www.publications.parliament.uk/pa/cm200506/cmselect/cmsctech/1032/1032.pdf
3. A Blog on Identity by Kim Cameron.
Kim Cameron is Architect of Identity and Access in the Connected Systems Division at Microsoft, where he drives evolution of Active Directory, Federation Services, Identity Integration Services, CardSpace and Microsoft’s other Identity Metasystem products.
See http://www.identityblog.com/
Of particular interest are the Laws of Identity found here.
http://www.identityblog.com/?page_id=354
In very brief high level summary these seven laws are.
1. User Control and Consent:
Digital identity systems must only reveal information identifying a user with the user’s consent.
2. Limited Disclosure for Limited Use
The solution which discloses the least identifying information and best limits its use is the most stable, long-term solution.
3. The Law of Fewest Parties
Digital identity systems must limit disclosure of identifying information to parties having a necessary and justifiable place in a given identity relationship.
4. Directed Identity
A universal identity metasystem must support both “omnidirectional” identifiers for use by public entities and “unidirectional” identifiers for private entities, thus facilitating discovery while preventing unnecessary release of correlation handles.
5. Pluralism of Operators and Technologies:
A universal identity metasystem must channel and enable the interworking of multiple identity technologies run by multiple identity providers.
6. Human Integration:
A unifying identity metasystem must define the human user as a component integrated through protected and unambiguous human-machine communications.
7. Consistent Experience Across Contexts:
A unifying identity metasystem must provide a simple consistent experience while enabling separation of contexts through multiple operators and technologies.
4. The Australian Attorney General’s release on Identity Theft of May 2006 which refers to the still unpublished National Identity Security Strategy (NISS).
http://www.ag.gov.au/agd/WWW/ncphome.nsf/Page/Identity_Theft
5. The Information Commissioner’s Office of the UK Government.
Has a broad range of material on privacy, ID fraud, identity cards and surveillance including the very recent and terrifying report revealing there is now one CCTV camera for every 14 UK citizens.
http://www.ico.gov.uk/
6. The Office of the Australian Privacy Commissioner.
This is a vital site which in the last year or two under Karen Curtis is really producing some excellent work in my view
http://www.privacy.gov.au/
7. The Australian Privacy Foundation.
Putting the case that the Access Card is just a stealth ID card. It is unclear at this point of Minister Hockey or Ms Anna Johnston are winning the debate. Probably the peak Australian privacy lobby group.
http://www.privacy.org.au/
8. Roger Clarke’s Dataveillance and Information Privacy Home-Page.
A well thought out set of Australian resources from an academic who has been thinking about this area for many years.
http://www.anu.edu.au/people/Roger.Clarke/DV/
I hope these are useful.
David.
The topics and URLs are as follows:
1. Australian Office of the Access Card
http://www.accesscard.gov.au/
This is a new site and has the work of Professor Fels and his taskforce as a sub area at the following URL
http://www.accesscard.gov.au/consumer_privacy_task_force.html
The full press release is worth a careful read as is the Government’s response which is also available at the site.
Media Release
Access Card Consumer and Privacy Taskforce Recommends Safeguards
08 November 2006
Safeguards to protect personal privacy and security and to maximise consumer convenience have been recommended by the Access Card Consumer and Privacy Taskforce.
“Comprehensive legislation to define and regulate the role of the card and associated databases is needed. This will build public trust and confidence, and establish safeguards regarding current and any new future government uses of the card”, Professor Allan Fels AO, Chairman of the Taskforce and Dean of the Australia and New Zealand School of Government said.
“The card is a health and social services access card. It should not be allowed to develop into a national identity card by virtue of “function creep”. Legislation should ensure the card is not a national identity card nor an electronic health record nor have any link with tax records nor be required to be carried by individuals.
The legislation should also prohibit anyone requiring individuals to produce the card (except when they are accessing defined Commonwealth benefits and services).
“The legislation needs to define what the card will and won’t be”, Professor Fels said. More details of the recommended legislation are in the report of the Taskforce.
“Function creep” can be minimised by requiring any new future government uses only being permissible by legislation. Function creep can also be reduced by limiting the ultimate capacity of the card.
Australians should own the card. This will give individuals better control and limit the scope for government and others to determine future uses. There should, however, be some limitations on inappropriate usage of the card e.g. tampering with it, or altering prescribed information on the card.
Card holders should not be required to have their legal name on the face of the card if they have a preferred name they commonly use. There are legitimate reasons why consumers would want to have a name displayed on the card which differs from their legal name such as those who use Australianised names, middle names, changes of name in indigenous communities and maiden names. Their legal name, however, would be stored on the chip and on the register.
The Taskforce accepts that there needs to be a photo on the face of the card (as well as in the chip and stored in the secure customer registration system). This will minimise fraud, increase convenience for card users and government agencies and improve its capability for proof of identity (where consumers choose to use it for that purpose).
“Regarding the storage of the photo on a national photographic database, there is merit in considering the storage in the form of a template rather than in the form of real photos. This would reduce possibilities of fraud and misuse”, he said.
“However, this must be weighed up against cardholder and government convenience. If a card is lost, as frequently happens, the cardholder would have to be rephotographed if the photo was not stored in real form”, he said.
“If there is to be a real photographic database, it is critical that there be maximum security precautions. This should be held separately, within the register, from other cardholder data and there should be stringent special controls to prevent unauthorised access and improper usage”, he said.
The Taskforce is sceptical for the need for a digitised signature to appear on the card. The signature seems to be of limited use and it increases the dangers of identity theft and fraud. Again, whatever the outcome, digitised signatures should be subject to rigorous controls to prevent unauthorised access and improper usage.
The Taskforce accepts that there needs to be a number associated with each card, even though this means that each cardholder then has a unique number assigned to them.
“The taskforce considers that the number should not appear on the reverse of the card”, he said. If the card number is not displayed it reduces the risks of the card slowly developing into a “unique personal identifier” number for the Australian population (that is, each Australian eventually has a unique number assigned to them). Also, if the card number is displayed it increases the risk of fraud. This risk outweighs some advantages for government administration and user convenience. In the alternative the government should give consideration to making the inclusion of a unique number on the reverse of the card a matter of genuine choice for the card holder.
When consumers register for their card they will bring documentation to verify their identity. Should copies be taken of these documents and retained on file in accordance with existing practice?
The argument for the copying and retention of proof of identity (POI) documentation relates to measures taken to detect and control fraud.Such records are accessed by relevant Departments where there is some suspicion of illegal behaviour or identity fraud, or in cases where original documents are subsequently lost or destroyed. Such a procedure may, in some instances, also be required under statute.
The Taskforce supports capturing proof of identity documentation for the purposes of establishing identity and verifying their authenticity but has recommended that they should not be scanned, copied or kept on file after they have been verified.
The Taskforce notes statements by the Government that the card is only to be used for access to health and welfare services. The Taskforce notes that the Government is also in the process of considering the adoption of a National Identity Security Strategy which aims to require a very high (“Gold Standard”) proof of identity.
However, the Taskforce does not believe that the ‘Gold Standard’ being considered for a National Identity Security Strategy is necessarily appropriate for use by to facilitate delivery of health and social services benefits. The most disadvantaged and marginalised members of the community who may be unable to provide sufficient documentation to establish their identity should not be unnecessarily burdened by this process.
The Taskforce has recommended an extensive public information campaign explaining the nature of the card.
The Taskforce makes a number of recommendations to the Government for the ongoing design and implementation of elements of the card. Fundamental to further consideration of these elements by Government is the continued process of consultation that needs to occur between the Taskforce, the Government’s Lead Advisor and Chief Technology Architect.
The Taskforce is committed to ensuring that the views of all Australians feed into the design of the access card system.
The Taskforce is currently working on the second discussion paper, which will consider the Registration process and will seek to ensure that there is continued consultation with consumer and interested groups. This paper is expected to be released for discussion in November 2006.
The Consumer and Privacy Taskforce
The Consumer and Privacy Taskforce, was established in May 2006 to report on consumer and privacy issues arising from the Government’s announced plans to introduce a new health and social services access card.
The Taskforce released an initial discussion paper released on 16 June 2006. The Taskforce has met with 120 representative groups and received over 100 written submissions.
The Taskforce’s believes that all decisions about the design of the card should be made in as transparent a fashion as possible and be informed by public consultation.
The Report makes 26 recommendations.
A copy of the report can be found at www.australia.gov.au/accesscard. The report is titled Issues and Recommendations in Relation to Architecture Questions of the Access Card.
The Government response is found here:
http://www.accesscard.gov.au/publications.html
2. Report from the UK House of Commons: Identity Card Technologies: Scientific Advice, Risk and Evidence
This can be found at the following URL.
www.publications.parliament.uk/pa/cm200506/cmselect/cmsctech/1032/1032.pdf
3. A Blog on Identity by Kim Cameron.
Kim Cameron is Architect of Identity and Access in the Connected Systems Division at Microsoft, where he drives evolution of Active Directory, Federation Services, Identity Integration Services, CardSpace and Microsoft’s other Identity Metasystem products.
See http://www.identityblog.com/
Of particular interest are the Laws of Identity found here.
http://www.identityblog.com/?page_id=354
In very brief high level summary these seven laws are.
1. User Control and Consent:
Digital identity systems must only reveal information identifying a user with the user’s consent.
2. Limited Disclosure for Limited Use
The solution which discloses the least identifying information and best limits its use is the most stable, long-term solution.
3. The Law of Fewest Parties
Digital identity systems must limit disclosure of identifying information to parties having a necessary and justifiable place in a given identity relationship.
4. Directed Identity
A universal identity metasystem must support both “omnidirectional” identifiers for use by public entities and “unidirectional” identifiers for private entities, thus facilitating discovery while preventing unnecessary release of correlation handles.
5. Pluralism of Operators and Technologies:
A universal identity metasystem must channel and enable the interworking of multiple identity technologies run by multiple identity providers.
6. Human Integration:
A unifying identity metasystem must define the human user as a component integrated through protected and unambiguous human-machine communications.
7. Consistent Experience Across Contexts:
A unifying identity metasystem must provide a simple consistent experience while enabling separation of contexts through multiple operators and technologies.
4. The Australian Attorney General’s release on Identity Theft of May 2006 which refers to the still unpublished National Identity Security Strategy (NISS).
http://www.ag.gov.au/agd/WWW/ncphome.nsf/Page/Identity_Theft
5. The Information Commissioner’s Office of the UK Government.
Has a broad range of material on privacy, ID fraud, identity cards and surveillance including the very recent and terrifying report revealing there is now one CCTV camera for every 14 UK citizens.
http://www.ico.gov.uk/
6. The Office of the Australian Privacy Commissioner.
This is a vital site which in the last year or two under Karen Curtis is really producing some excellent work in my view
http://www.privacy.gov.au/
7. The Australian Privacy Foundation.
Putting the case that the Access Card is just a stealth ID card. It is unclear at this point of Minister Hockey or Ms Anna Johnston are winning the debate. Probably the peak Australian privacy lobby group.
http://www.privacy.org.au/
8. Roger Clarke’s Dataveillance and Information Privacy Home-Page.
A well thought out set of Australian resources from an academic who has been thinking about this area for many years.
http://www.anu.edu.au/people/Roger.Clarke/DV/
I hope these are useful.
David.
Sunday, November 12, 2006
The Australian National Identity Security Strategy – Unknown, Critical and Possibly Flawed!
In the November / December issue of the IEEE Internet Computing Journal Daniel J. Weitzner from MIT has written what I see as a very important article entitled “In Search of Manageable Identity Systems”.
The DOI Bookmark is: http://doi.ieeecomputersociety.org/10.1109/MIC.2006.127
The key insights and the reason why I think the article is important is contained in the following two paragraphs from the paper.
“Although no doubt exists about current identity mechanisms’ weaknesses, our efforts to design and successfully deploy network-based identity management systems have been so frustratingly unsuccessful that a new approach seems necessary. Elements of the new approach come into view when we compare Internet identity protocol designs with systems used in financial services.
Traditional computer security systems begin with a nearly metaphysical design goal of associating a single identifier with a single identity (whether a person’s name or pseudonym). Once the system verifies the identifier, all privileges associated with it become available to whoever possesses that identity. Rather than taking this unitary approach, however, credit-card authorization systems take a composite approach, in which the binding between an identifier (a credit-card number) and the associated privileges (access to credit) is established only after the system has completed statistically based antifraud checks. In other words, you aren’t actually recognized as the card holder simply for presenting the card or even after verification that the card token itself is genuine. You’re recognized as an authorized party only on the basis of traditional security checks combined with statistical verification that you’re likely to be who you say you are.”
What is being said here and in the rest of the paper is that the simple concepts of a unique identifier may not be appropriate or workable in the networked world in which we now find ourselves. Indeed the paper suggests we do not yet have “manageable identity systems” as yet.
The paper describes how, in real time we now have credit card providers, having been given an identifier (the card number and expiry date etc), running sophisticated analysis on the card’s transaction history to ensure the purchase looks to fit within the individuals known spending patterns as so on. Unexpected transactions (larger than normal, bigger than normal, from an unexpected location) are either flagged for later review or declined.
It is easy to see how such technology (were it to become widespread) could also be applied to verification of a health or social service identifier, of the sort now being proposed in the Access Card, before a benefit is paid or a clinical record is linked with others.
I wonder are such approaches part of the technology architecture being developed for the various Government identity initiatives?
In late 2005 the following announcement came from the Council of Australian Government.
http://www.coag.gov.au/meetings/270905/
“Identity Security
The preservation and protection of a person's identity is a key concern and right of all Australians. COAG agreed to the development and implementation of a National Identity Security Strategy better to protect the identities of Australians. The strategy will enhance identification and verification processes and develop other measures to combat identity crime. The strategy will be underpinned by an inter-governmental agreement.
COAG also agreed to:
• the development and implementation of a national document verification service to combat the misuse of false and stolen identities; and
• investigate the means by which reliable, consistent and nationally interoperable biometric security measures could be adopted by all jurisdictions.”
Further clarification came in May, 2006 in a press release from the Attorney General.
“The national strategy aims to strengthen identity security through rigorous enrolment and authentication processes while ensuring personal privacy. The national strategy is based on a cross-jurisdictional, whole-of-government approach to maximise its effectiveness and interoperability across all governments.
The key objectives of the strategy include:
• improved standards and procedures for enrolment and registration including identifying key Proof of Identity (POI) documents to be used by all appropriate organisations for the purposes of identifying and registering clients for services;
• enhancing the security features on these documents to reduce the risk of incidence of forgery;
• establishing mechanisms to enable organisations to verify the data on key POI documents provided by clients when registering for services;
• improving the accuracy of personal identity information held on organisations’ databases;
• enabling greater confidence in the authentication of individuals using online services; and
• providing appropriate legislative support.”
It is understood that this strategy relies on the concept of a “gold standard” proof of identity - via the so called Document Verification System – where Proof of Identity (POI) is established by confirmation of the validity (via checks of relevant sources such as Births Deaths and Marriage Registers etc) of the documents presented to confirm the POI.
Were this to be the case one is forced to wonder just how sophisticated the approaches being adopted are and whether there is the risk of the waste of a great deal of money in pursuit of a “gold standard” of identity proof which turns out to be chimera.
A number of things seem clear.
1. Even if an identifier is available and has been obtained with extreme levels of verification that may not be enough to provide certainty as compromise is always possible.
2. The level of certainty required for different transactions is different in different circumstances. (e.g. borrowing a video requires less certainty than linking clinical patient records).
3. Judgements as to the required level of certainty as to identity should be made on a pragmatic and reasonable ‘fit for purpose’ basis.
4. The approaches planned by the Access Card team, the NEHTA Identifier Team and those in the DVS team really need to be aligned, made consistent and fit for purpose and suitable to the application planned. It is hard to see how they are at present.
5. For at least some in the community POI will be very difficult to achieve and any systems implemented need to be sensitive to that fact.
Professor Fels makes relevant points in his November 8, 2006 press release entitled “Access Card Consumer and Privacy Taskforce Recommends Safeguards”
“The Taskforce notes statements by the Government that the card is only to be used for access to health and welfare services. The Taskforce notes that the Government is also in the process of considering the adoption of a National Identity Security Strategy which aims to require a very high (“Gold Standard”) proof of identity. However, the Taskforce does not believe that the ‘Gold Standard’ being considered for a National Identity Security Strategy is necessarily appropriate for use by to facilitate delivery of health and social services benefits. The most disadvantaged and marginalised members of the community who may be unable to provide sufficient documentation to establish their identity should not be unnecessarily burdened by this process.”
It seems to me that while purely identifier based systems seem to have met with some success in places as diverse as Germany, Malaysia and Hong Kong we need to make sure the distinction between enabling access to services and an identity card is not blurred so severely as to become meaningless.
The general unease regarding the melange of identification systems being evolved is only heightened by the recent reports of the extent of individual surveillance happening in the UK and now moving to Australia at an apparently unstoppable speed.
One really begins to wonder whether it may be better overall to tolerate a little CentreLink and Medicare fraud and inefficiency rather than surrender so much control of our individual autonomy and freedom.
Comments, as always, welcome.
David.
The DOI Bookmark is: http://doi.ieeecomputersociety.org/10.1109/MIC.2006.127
The key insights and the reason why I think the article is important is contained in the following two paragraphs from the paper.
“Although no doubt exists about current identity mechanisms’ weaknesses, our efforts to design and successfully deploy network-based identity management systems have been so frustratingly unsuccessful that a new approach seems necessary. Elements of the new approach come into view when we compare Internet identity protocol designs with systems used in financial services.
Traditional computer security systems begin with a nearly metaphysical design goal of associating a single identifier with a single identity (whether a person’s name or pseudonym). Once the system verifies the identifier, all privileges associated with it become available to whoever possesses that identity. Rather than taking this unitary approach, however, credit-card authorization systems take a composite approach, in which the binding between an identifier (a credit-card number) and the associated privileges (access to credit) is established only after the system has completed statistically based antifraud checks. In other words, you aren’t actually recognized as the card holder simply for presenting the card or even after verification that the card token itself is genuine. You’re recognized as an authorized party only on the basis of traditional security checks combined with statistical verification that you’re likely to be who you say you are.”
What is being said here and in the rest of the paper is that the simple concepts of a unique identifier may not be appropriate or workable in the networked world in which we now find ourselves. Indeed the paper suggests we do not yet have “manageable identity systems” as yet.
The paper describes how, in real time we now have credit card providers, having been given an identifier (the card number and expiry date etc), running sophisticated analysis on the card’s transaction history to ensure the purchase looks to fit within the individuals known spending patterns as so on. Unexpected transactions (larger than normal, bigger than normal, from an unexpected location) are either flagged for later review or declined.
It is easy to see how such technology (were it to become widespread) could also be applied to verification of a health or social service identifier, of the sort now being proposed in the Access Card, before a benefit is paid or a clinical record is linked with others.
I wonder are such approaches part of the technology architecture being developed for the various Government identity initiatives?
In late 2005 the following announcement came from the Council of Australian Government.
http://www.coag.gov.au/meetings/270905/
“Identity Security
The preservation and protection of a person's identity is a key concern and right of all Australians. COAG agreed to the development and implementation of a National Identity Security Strategy better to protect the identities of Australians. The strategy will enhance identification and verification processes and develop other measures to combat identity crime. The strategy will be underpinned by an inter-governmental agreement.
COAG also agreed to:
• the development and implementation of a national document verification service to combat the misuse of false and stolen identities; and
• investigate the means by which reliable, consistent and nationally interoperable biometric security measures could be adopted by all jurisdictions.”
Further clarification came in May, 2006 in a press release from the Attorney General.
“The national strategy aims to strengthen identity security through rigorous enrolment and authentication processes while ensuring personal privacy. The national strategy is based on a cross-jurisdictional, whole-of-government approach to maximise its effectiveness and interoperability across all governments.
The key objectives of the strategy include:
• improved standards and procedures for enrolment and registration including identifying key Proof of Identity (POI) documents to be used by all appropriate organisations for the purposes of identifying and registering clients for services;
• enhancing the security features on these documents to reduce the risk of incidence of forgery;
• establishing mechanisms to enable organisations to verify the data on key POI documents provided by clients when registering for services;
• improving the accuracy of personal identity information held on organisations’ databases;
• enabling greater confidence in the authentication of individuals using online services; and
• providing appropriate legislative support.”
It is understood that this strategy relies on the concept of a “gold standard” proof of identity - via the so called Document Verification System – where Proof of Identity (POI) is established by confirmation of the validity (via checks of relevant sources such as Births Deaths and Marriage Registers etc) of the documents presented to confirm the POI.
Were this to be the case one is forced to wonder just how sophisticated the approaches being adopted are and whether there is the risk of the waste of a great deal of money in pursuit of a “gold standard” of identity proof which turns out to be chimera.
A number of things seem clear.
1. Even if an identifier is available and has been obtained with extreme levels of verification that may not be enough to provide certainty as compromise is always possible.
2. The level of certainty required for different transactions is different in different circumstances. (e.g. borrowing a video requires less certainty than linking clinical patient records).
3. Judgements as to the required level of certainty as to identity should be made on a pragmatic and reasonable ‘fit for purpose’ basis.
4. The approaches planned by the Access Card team, the NEHTA Identifier Team and those in the DVS team really need to be aligned, made consistent and fit for purpose and suitable to the application planned. It is hard to see how they are at present.
5. For at least some in the community POI will be very difficult to achieve and any systems implemented need to be sensitive to that fact.
Professor Fels makes relevant points in his November 8, 2006 press release entitled “Access Card Consumer and Privacy Taskforce Recommends Safeguards”
“The Taskforce notes statements by the Government that the card is only to be used for access to health and welfare services. The Taskforce notes that the Government is also in the process of considering the adoption of a National Identity Security Strategy which aims to require a very high (“Gold Standard”) proof of identity. However, the Taskforce does not believe that the ‘Gold Standard’ being considered for a National Identity Security Strategy is necessarily appropriate for use by to facilitate delivery of health and social services benefits. The most disadvantaged and marginalised members of the community who may be unable to provide sufficient documentation to establish their identity should not be unnecessarily burdened by this process.”
It seems to me that while purely identifier based systems seem to have met with some success in places as diverse as Germany, Malaysia and Hong Kong we need to make sure the distinction between enabling access to services and an identity card is not blurred so severely as to become meaningless.
The general unease regarding the melange of identification systems being evolved is only heightened by the recent reports of the extent of individual surveillance happening in the UK and now moving to Australia at an apparently unstoppable speed.
One really begins to wonder whether it may be better overall to tolerate a little CentreLink and Medicare fraud and inefficiency rather than surrender so much control of our individual autonomy and freedom.
Comments, as always, welcome.
David.
Saturday, November 11, 2006
AusHealthIT Blog – Where to From Here?
The blog has now been on-line for a little over eight months and it seems like a good time to take stock of where it has come to and where it should now go.
What I know is that for a topic as absurdly arcane and Health Information Technology in Australia there is more than a little interest. The blog has two counters of activity. One counts the page views and visitor numbers on the main site. The other counts the number of reads and visits generated by e-mail alerts and RSS feeds.
To my amazement – since setting up the feed - there have been 6,413 views of the 62 different items published. This excludes all the direct view from the actual blog site – which is also seeing about 100 page reads per day on average.
In summary it looks like each article is now being read by at least 100 different people with the more “interesting” articles being read over 200 times.
Interestingly the origin of readers is international with a very strong Australian bias. (Australia 70%, US 11%, UK 9% Ireland 2% Rest 8% (India, Macedonia etc!)
On the basis of the feed activity the following ten articles (in order, so far) have been the most popular.
• E-Mail Security and Clinical Practice
• E-Prescribing in Australia – Is there a New Plan
• Oh HealthConnect! – You Have Done it Again
• How to Really Fail at Health IT Strategy
• What is Happening in Electronic Decision Support?
• Just Who Do They Think They are Fooling?
• Electronic Prescribing – What is Needed?
• Clinical Decision Support - A Major Contribution
• An Australian e-Health Strategy - The Outline
• NEHTA's Approach to Privacy V 1.0
This leads me to believe the readers of the blog are most interested in the strategies to be adopted in developing and implementing e-Health and in reviewing possible solutions and approaches. It is also clear many of the readers are interested in what is going on under the NEHTA and HealthConnect banners as well as the progress with the Access Card.
What is now needed are two things.
1. Suggestions as to what other topics should be addressed in the future.
2. Information and feedback on what is going either well or badly in the E-Health space in the “wide brown land”. In this context I am particularly interested in success stories that can be cited or emerging problems that could maybe be rectified.
I already am getting e-mail from places as diverse and Hong Kong and Canberra and the more I receive the better I can tailor the blog to meet people’s interests and needs.
Contact me with tips, news, comments etc (anonymously is fine via a fake Hotmail or Yahoo account if needed) at davidgm – at – optusnet.com.au. (substitute the “– at –“ with “@”). No information on correspondents will be made public without explicit permission!
David.
What I know is that for a topic as absurdly arcane and Health Information Technology in Australia there is more than a little interest. The blog has two counters of activity. One counts the page views and visitor numbers on the main site. The other counts the number of reads and visits generated by e-mail alerts and RSS feeds.
To my amazement – since setting up the feed - there have been 6,413 views of the 62 different items published. This excludes all the direct view from the actual blog site – which is also seeing about 100 page reads per day on average.
In summary it looks like each article is now being read by at least 100 different people with the more “interesting” articles being read over 200 times.
Interestingly the origin of readers is international with a very strong Australian bias. (Australia 70%, US 11%, UK 9% Ireland 2% Rest 8% (India, Macedonia etc!)
On the basis of the feed activity the following ten articles (in order, so far) have been the most popular.
• E-Mail Security and Clinical Practice
• E-Prescribing in Australia – Is there a New Plan
• Oh HealthConnect! – You Have Done it Again
• How to Really Fail at Health IT Strategy
• What is Happening in Electronic Decision Support?
• Just Who Do They Think They are Fooling?
• Electronic Prescribing – What is Needed?
• Clinical Decision Support - A Major Contribution
• An Australian e-Health Strategy - The Outline
• NEHTA's Approach to Privacy V 1.0
This leads me to believe the readers of the blog are most interested in the strategies to be adopted in developing and implementing e-Health and in reviewing possible solutions and approaches. It is also clear many of the readers are interested in what is going on under the NEHTA and HealthConnect banners as well as the progress with the Access Card.
What is now needed are two things.
1. Suggestions as to what other topics should be addressed in the future.
2. Information and feedback on what is going either well or badly in the E-Health space in the “wide brown land”. In this context I am particularly interested in success stories that can be cited or emerging problems that could maybe be rectified.
I already am getting e-mail from places as diverse and Hong Kong and Canberra and the more I receive the better I can tailor the blog to meet people’s interests and needs.
Contact me with tips, news, comments etc (anonymously is fine via a fake Hotmail or Yahoo account if needed) at davidgm – at – optusnet.com.au. (substitute the “– at –“ with “@”). No information on correspondents will be made public without explicit permission!
David.
Sunday, November 05, 2006
HealthConnect Scottish Style – Cheap, Quick and Effective.
I can say I was more that a little pleased to see the following appear this week. It shows the canny Scots have not lost their touch and with decent planning and care good things in e-health can happen really quite quickly.
http://www.ehiprimarycare.com/news/item.cfm?ID=2238
Scottish emergency care records to be electronic by 2007
02 Nov 2006
The Scottish Emergency Care Summary is to become paperless by spring 2007, according to leading members of the Scottish Clinical Information Management in Practice.
Initially launched across Scotland last summer as a hybrid system, including paper and faxes, the Emergency Care Summary has already helped make out-of-hours communications more efficient effective.
Scottish health minister Andy Kerr said of ECS: “This new shared record means that NHS staff who need it to look after you can get important information about your health, even if they can't contact your GP. Health workers will also have a more complete picture of a patient's health and medical background.”
The minister added: "In the future, all health records will be stored and linked electronically and that will bring great benefits over the old paper files kept in different places and electronic records that are not linked up."
Libby Morris, chair of SCIMP told E-Health Insider Primary Care: “Following a public information campaign about the ECS, through leaflets delivered to all 2.5 million households in the country and a further 400,000 copies of the leaflet distributed to GP practices, primary and secondary care services, we were able to successfully go-live across all 14 NHS boards.”
The ECS contains important basic information such as name, date of birth, Community Health Index (patient ID number used in Scotland), medication prescribed by a GP and any adverse reactions to prescribed medicines.
The summary currently covers 2.5m patients, using a password protection system which is protected using the "highest standards of security". NHS staff will have to ask the patient's permission before they can look at the ECS, except in the event the patient is unconscious or unable to give consent.
Morris said of the early experience of the summary record: “ECS has made life so much easier for out of hours and accident and emergency staff. They can now have access to important information on the patients’ clinical history. Doctors, nurses and receptionists in out of hours medical centres; staff at NHS 24 involved in the patients care and staff in accident and emergency departments can all view records quickly and avoid risks to patients.”
NHS Scotland spent half a million pounds on publicising the new system, giving full details of how patients could opt-out of the scheme if necessary. To date, over 5 million records have been uploaded onto the system and only 174 patients in total have opted out of the scheme.
The system makes it possible to check who has looked at the patient's ECS. Patients can ask their GP to show them the information in their own summary.
…….
Plans are now in place to begin the switch over to electronic records and NHS Scotland is aiming to store and link full health records electronically by 2010 – beginning implementation in spring 2007.
A Gold Standards Framework Scotland (GSFS) IT development project has been established which aims to provide electronic patient records in one place helping those with cancer and palliative care needs in particular.
Staff will be able to fill in the patient record forms using the system, which can be saved electronically and then accessed by authorised staff. These will replace current paper-based tools and be integrated into existing practice IT systems.
Ian Kerr added: “GSFS will support clinicians to do the right thing at the right time, making it easy to have the best possible information available for forward planning, team review, consistent communication and sharing critical information.”
He also said that future work on the ECS will help to ensure that there is full integration with the NHS 24 advice centre and ambulance service databases. More data will be put onto the system over time, including lab results and statistics from nurse checks.
Morris told EHI Primary Care: “Patient-clinician interaction is important. Patients should know what is going on and who knows what about them. They must give explicit consent for information to be released, and trust the clinician not to abuse details which can be sensitive.”
The ECS has been piloted by various trusts, accident and emergency units and focus groups since its initial launch in October 2005. Kerr believes that the success of its national launch is thanks to the large amount of feedback received from patients, clinicians and administration staff. “
It would appear that virtually all the key issues that could block a successful implementation including proper public consultation and communication, a sensible approach to consent and privacy, having a clear implementation strategy and system wide technology approach and keeping it simple and quick have all be undertaken. The outcome seems to be great.
Well done to all those involved! Seems to me DoHA and NEHTA could learn a few things from this exercise.
David.
http://www.ehiprimarycare.com/news/item.cfm?ID=2238
Scottish emergency care records to be electronic by 2007
02 Nov 2006
The Scottish Emergency Care Summary is to become paperless by spring 2007, according to leading members of the Scottish Clinical Information Management in Practice.
Initially launched across Scotland last summer as a hybrid system, including paper and faxes, the Emergency Care Summary has already helped make out-of-hours communications more efficient effective.
Scottish health minister Andy Kerr said of ECS: “This new shared record means that NHS staff who need it to look after you can get important information about your health, even if they can't contact your GP. Health workers will also have a more complete picture of a patient's health and medical background.”
The minister added: "In the future, all health records will be stored and linked electronically and that will bring great benefits over the old paper files kept in different places and electronic records that are not linked up."
Libby Morris, chair of SCIMP told E-Health Insider Primary Care: “Following a public information campaign about the ECS, through leaflets delivered to all 2.5 million households in the country and a further 400,000 copies of the leaflet distributed to GP practices, primary and secondary care services, we were able to successfully go-live across all 14 NHS boards.”
The ECS contains important basic information such as name, date of birth, Community Health Index (patient ID number used in Scotland), medication prescribed by a GP and any adverse reactions to prescribed medicines.
The summary currently covers 2.5m patients, using a password protection system which is protected using the "highest standards of security". NHS staff will have to ask the patient's permission before they can look at the ECS, except in the event the patient is unconscious or unable to give consent.
Morris said of the early experience of the summary record: “ECS has made life so much easier for out of hours and accident and emergency staff. They can now have access to important information on the patients’ clinical history. Doctors, nurses and receptionists in out of hours medical centres; staff at NHS 24 involved in the patients care and staff in accident and emergency departments can all view records quickly and avoid risks to patients.”
NHS Scotland spent half a million pounds on publicising the new system, giving full details of how patients could opt-out of the scheme if necessary. To date, over 5 million records have been uploaded onto the system and only 174 patients in total have opted out of the scheme.
The system makes it possible to check who has looked at the patient's ECS. Patients can ask their GP to show them the information in their own summary.
…….
Plans are now in place to begin the switch over to electronic records and NHS Scotland is aiming to store and link full health records electronically by 2010 – beginning implementation in spring 2007.
A Gold Standards Framework Scotland (GSFS) IT development project has been established which aims to provide electronic patient records in one place helping those with cancer and palliative care needs in particular.
Staff will be able to fill in the patient record forms using the system, which can be saved electronically and then accessed by authorised staff. These will replace current paper-based tools and be integrated into existing practice IT systems.
Ian Kerr added: “GSFS will support clinicians to do the right thing at the right time, making it easy to have the best possible information available for forward planning, team review, consistent communication and sharing critical information.”
He also said that future work on the ECS will help to ensure that there is full integration with the NHS 24 advice centre and ambulance service databases. More data will be put onto the system over time, including lab results and statistics from nurse checks.
Morris told EHI Primary Care: “Patient-clinician interaction is important. Patients should know what is going on and who knows what about them. They must give explicit consent for information to be released, and trust the clinician not to abuse details which can be sensitive.”
The ECS has been piloted by various trusts, accident and emergency units and focus groups since its initial launch in October 2005. Kerr believes that the success of its national launch is thanks to the large amount of feedback received from patients, clinicians and administration staff. “
It would appear that virtually all the key issues that could block a successful implementation including proper public consultation and communication, a sensible approach to consent and privacy, having a clear implementation strategy and system wide technology approach and keeping it simple and quick have all be undertaken. The outcome seems to be great.
Well done to all those involved! Seems to me DoHA and NEHTA could learn a few things from this exercise.
David.
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