With the political turmoil happening in the Australian Labor Party – and an election for leadership positions happening on Monday 4 December, 2006 – it seemed important to bring to the attention of my readers the views on e-Health of one of the key protagonists.
On the basis of these remarks I would be keen to see her succeed I must say – all other issues laid to one side.
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AUSTRALIA'S E-HEALTH REVOLUTION: PROMISE UNFULFILLED
Remarks to the ACT Chapter of the Australian College of Health Service Executives
Date: 18 June 2006
Remarks by
Julia Gillard, MP
Shadow Minister for Health
Introduction
Thank you very much for inviting me here this evening. It’s a pleasure to be able to join you for dinner once again, to celebrate the ACT Chapter’s 30th birthday, and to hear more about the work of the Australian College of Health Service Executives.
Health issues are never out of the news. Some days we hear of health care miracles, other days we hear stories of those for whom the system failed.
But whether today’s news story is a good one or a bad one, the fact remains that our health care system is in need of reform and we need strong national leadership to make that happen.
That’s why Labor has insisted that we must be bold enough to undertake long-term reform to address the gaps, holes and duplications in the system caused by the separate Commonwealth and State funding streams and to end the bickering, cost shifting and blame game that currently passes for the national management of our health system.
As individual health executives and as members of a key professional organization, you will be players in determining what reforms are needed, and in implementing them.
Which is why I thought that tonight I would address the issues around the information and communications technologies which must underpin these reforms.
Everyone agrees that new IT systems and capabilities can transform our health care system by revolutionising the way services are delivered, health care professionals work together, resources are managed and deployed, and research and its outcomes are communicated.
There is the expectation that the use of IT to integrate patients’ health records could help prevent over-referrals and over-prescribing and help minimise medical mistakes.
There is the hope that it can ensure that patients are more involved in their own health status and health care.
And without improved and consistent national data collection, we can’t assess the full impact of changes made, we can’t know the full costs and attribute them to the right funding source, and there can’t be full accountability.
Revelations from Senate Estimates
Let’s look at where we are today.
Recent developments suggest that our national e-health strategy has stalled. To be honest, I’m tempted to say it has been an expensive failure.
Following what the Department of Health and Ageing and Medicare Australia are doing in this regard is not easy. Responsibilities have shifted, programs have changed names, and the plethora of committees and advisory groups continues to grow.
One of the advantages of the Senate Estimates process is that you can, with a little effort, find out some of the things that the Government haven’t told us.
No Smart Card to enable patient access to e-health records
In Senate Estimates this time we around we discovered that Minister Hockey made the decision in May – unannounced – to scrap the Medicare Smart Card. At the same time, in his speech to the AMA Annual General Meeting, he let drop that the proposed Access Card will not have the ability to provide access to electronic health records.
In a speech to the National Press Club back in April 2004, I outlined how a second generation Medicare Card could link together the information that currently sits scattered across the health system and enable the management of a seamless health system for patients.
I spoke about a Medicare Card that could contain basic health information, the kind which would be useful in an emergency. I talked about how this Medicare Smart Card, when used with a unique patient identifying number, could give access to a patient’s full electronic health records. And I emphasised how important it was that the patient would control who was given access to their health data.
When Tony Abbott rolled out his Medicare Smart Card, with much fanfare in July 2004, I supported it.
But Tony Abbott’s Medicare Smart Card is dead, and there is nothing on the horizon to replace it, as Joe Hockey has made clear.
The whole-of-government Access Card now being developed under Joe Hockey’s oversight will replace your current Medicare Card and you won’t be able to access Medicare rebates without it.
But Joe Hockey’s whole-of-government Access Card isn’t about access to electronic health records.
We know that of funds committed through COAG to the National e-Health Transition Authority, $45 million will be spent on a unique patient number for every Australian, but there is no information as to how this system relates to anything else the Howard Government is doing.
We don’t know how it relates to Joe Hockey’s Access Card. We don’t even know how it relates to the fact that Medicare Australia will be spending even larger sums on developing a different unique identifier for each Australian.
What we do know is that Joe Hockey’s whole-of-government Access Card won’t do the job a Medicare Smart Card was supposed to do and his plans are fraught with uncertainty and privacy concerns.
HealthConnect has disappeared
From Senate Estimates we also learned that HealthConnect no longer exists as a program, leaving only three small HealthConnect initiatives currently running in South Australia, the Northern Territory and Tasmania.
Indeed, HealthConnect has disappeared from the lexicon of the Department of Health and Ageing and there is some revisionist history at work.
HealthConnect used to be described as a “the proposed national health information network to facilitate the safe collection, storage and exchange of consumer health information between authorised health care providers.” (2003-05 Health Connect Project Plan)
Now the Secretary of the Department of Health and Ageing says: “[HealthConnect] is not actually a program. We should be clear about that: HealthConnect is not a program. There were a series of projects that were funded historically. We have moved now from the trial stage. I think I said yesterday that we have continued with a couple of projects, but we are now moving into an environment where we are looking to a national approach to e-health.”
I think we can say that, in terms of a coordinated national initiative, we are not much further advanced in this area than we were back in April 1999, when the Australian Health Ministers agreed to set up the National Health Information Management Advisory Council (NHIMAC) to “oversee new strategies for more effective health sector information management”.
This Advisory Council then commissioned a National Electronic Health Records Taskforce to report on technology and health records which was done in July 2000.
As a result of the Taskforce report, the Health Ministers agreed to support the development and implementation of HealthConnect and the Better Medication Management System. The cost of the scheme was then cited at around $440 million over 10 years.
The Better Medication Management system morphed into MediConnect and then died after two small trials in Launceston and Ballarat.
HealthConnect trials began in 2002 and as I have noted, some of these continue today, but the reality is something considerably less than we might hope for after 4 years and an investment of more than $200 million.
To date the only real legacy we have is a document released in April 2005 entitled “Lessons learned from the MediConnect and HealthConnect Trials”.
It’s not what I would call bedtime reading. The report is pretty bland and the lessons learned are not obviously stated, but I guess this paragraph sums it up:
“An electronic health record system is technically feasible, but the underlying infrastructure and connectivity ….limited the success of most trails and will be critical to the successful implementation of HealthConnect.”
What went wrong?
Hindsight is always twenty-twenty and I’m certainly willing to acknowledge that introducing new approaches to the management and delivery of health care is not an easy task.
It’s as much about changing the culture and individual behaviour as it is about the sequences of putting the infrastructure and software in place, testing it, and spending resources wisely.
But I think there are some fairly obvious mistakes and some very real missed opportunities.
1. There was no real public statement of what a major investment in e-health would achieve.
The need for a major investment in e-health has been pretty well articulated at the macro level, with some very grand promises made. But at the grass roots level – the level where acceptance and adoption of new systems and approaches is required – individuals have found it hard to see the benefits and easy to see the disadvantages.
People in Tasmania saw no value in spending the time and money to get a full birth certificate and 100 identification points to get a Medicare smart card, with the only apparent difference from the current Medicare Card being the photo on it.
Busy GPs saw no value in spending more time in writing up electronic health records when many of their colleagues did not use the same IT system or in some cases, did not use an IT system at all.
Surely the single biggest objective should have been ensuring all hospitals could communicate with each other and with GPs electronically using the same medical terminology. To achieve this big objective would have required a true partnership with the States and Territories.
But rather than a single-minded pursuit of a big objective – an objective that would potentially save lives and dollars – what we have seen over the past five years is the Howard Government spraying funds on consultancies and individual projects.
Unfortunately, it seems the Howard Government is still on that same merry-go-round with Minister Hockey’s whole of government Access Card. Privacy issues in particular have not been addressed and already there are legitimate concerns about cost management.
Unless and until these issues are addressed and there is a clear statement of intent about the Access Card, the public are entitled to remain sceptical.
I am not the first person to criticise the Howard Government’s approach to e-health as unfocussed and uncoordinated. Back in 2004, the Boston Consulting Group released a report that made the following observations about a flurry of activity in e- health:
* The average project size was small with funding spread across many priorities;
* There were many areas of overlap, due in large part to a lack of national leadership;
* Decision-making was frustratingly slow and lines of responsibility were unclear; and
* There was a real need for the adoption of common standards.
Unfortunately these messages went unheeded.
2. People need to see the advantages of e-health systems for them personally.
There are some wonderful examples out there of how e-health can make a real difference in the effective delivery of health care services, with a positive impact on peoples’ health.
The use of IT to link specialists into the diagnosis and care of cancer patients in rural areas is a great example.
At Geelong Hospital Dr Stephen Bolsin has pioneered an individual performance monitoring system that uses small hand-held computers to continuously check doctors’ clinical performance against recognised standards, leading to better medical training, fewer adverse incidents and improved safety for patients.
But at the same time, grandiose talk about smart cards and shared electronic health records from the Howard Government has left many Australians concerned that
current systems to protect privacy and ensure secure transmissions are inadequate.
3. We must create a real partnership between the Commonwealth and the States.
As a consequence of the problems outlined in the Boston Consulting Report, the States and Territories felt they had to proceed with their own efforts in e-health, and several States have made some very significant investments.
This has led to the very real fear that we will end up with a national e-health system as fragmented and disconnected as the railway system once was. That means a lot of money and resources going to waste.
There was a real opportunity to address this issue in the context of the 2003-08 Australian Health Care Agreements. Unfortunately, that opportunity was lost.
4. Basic IT systems are not there in many parts of Australia
Finally, I think we must also acknowledge that until we have a situation in Australia where everyone can have ready access to super fast and affordable broadband access, there is no possibility of driving even the simplest proposals forward nationally. That’s why Kim Beazley has committed that a Beazley Labor Government would invest in a national broadband network.
Conclusion
I think we have to face the fact that a national e-health system is at least a decade off.
We have lots of good intentions and, finally, some important agreements in place between the governments. But we have very little of the needed infrastructure,
including the basics like broadband, only the first draft of a set of standard clinical terms, no current means of accurately identifying health care providers or patients, and no systems to ensure the privacy of shared e-health records.
A lot of money has been spent and I’m concerned that goodwill and opportunities have also been wasted.
I know you wouldn’t manage your health services in this manner, but the Howard Government’s management of e-health does matter to you and does impact on your work.
To fix the problem we will need a national, collaborative approach and strong national leadership. We will also need all your skills, insights and abilities. Only then can we begin to reap the benefits of the e-health revolution.
Thank you."
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It is hard to take much exception to much of what is said here. Perhaps it would be good to see a recognition of the need to develop a consensus driven National E-Health Plan and some real commitment to actual investment in the plan to operationalize it once developed.
This statement is as sound as could be hoped for and reflects a degree of understanding of the issues I have yet to see from any other National politician.
More power to her e-health arm!
David.
Sunday, December 03, 2006
Saturday, December 02, 2006
Health IT – What is in the Way of Progress?
In the last few weeks I have been ruminating on what is in the way, and what are the roadblocks, to improved Health IT deployment and use in Australia.
There is no doubt that this is a multi-factorial issue that involves human, technical and financial aspects. If we consider the current situation there are some clear facts.
1. It is possible to build, deploy and have used computer systems that can assist with the operations, efficiency, safety and quality of hospitals. Suitable systems both from here and overseas are available to suit most of the patient management, clinical and administrative operations of both small, medium and large hospitals. The same can also be said systems to operate diagnostic laboratory and imaging services.
2. The same is true in the provision of support for General Practice and Specialist Office Practice with the market beginning to mature and evidence of significant contestability of system selection emerging. (Medical Director’s market share is no longer more than 2/3 of the market with IBA, Genie and Best Practice making some headway). Recent changes in the Commonwealth Practice Incentive Program is also ensuring more of the available functionality is actually being used.
3. Messaging of pathology and radiology results is being widely deployed via a number of providers (Argus, Medical Objects, HealthLink, Promedicus etc). Referrals to specialists are also gradually beginning to happen electronically – albeit as yet in pretty un-standardised form by and large. At present there is a great deal of prescription printing but very little, if any, in the way of prescription transmission electronically.
4. There has been considerable investment on development of a range of Standards which have facilitated the communication of pathology results at the individual test level using HL7 V2 which has made these results more usable. At present, however, a majority of results are still transmitted using the PIT format.
All this is very positive and if there could be near to complete penetration of these technologies where ever they are needed it would be a major public good.
Consideration of what has been achieved and what is known to work today leads to a recognition of there being a range of gaps.
First messaging of useful clinical content in computable, as opposed to “blob” forms is yet to be developed and needs to be as a priority.
Second the information held in many systems (both Ambulatory and Hospital) is held in forms which are not easily transferred between competing systems (leading to a level of ‘vendor lock in’) Indeed some vendors even encrypt information and them refuse to provide access keys without payment of maintenance fees – a most cynical exercise indeed.
Third the data, information and terminological standards to enable more that be most basic system inter-operation are still under development or unproven.
Fourth there is a very complex and highly contested debate about how information should be stored, versioned and structured within the EHR. Both the openEHR Foundation and HL7 have spent a very long time working in this area – especially trying to work out how to preserve the clinical meaning of patient information as it is moved from one computer system to another – and it is by no means clear if either have a practical and workable solution to the problem. This issue is in turn causing some difficulties as far as the finalisation of CEN/ISO 13606 (EHRCom) standard for the transmission and receipt of extracts of patient clinical records.
Fifth Australia’s full deployment of SNOMED CT is still years off given the need for localised subsets and other necessary enabling add-ons.
Australia at present has also not decided on the approaches it will use for clinical documents sharing in more general messages and in the shared EHR environment (CDA RII, plain XML and the CCR are all possible candidates among others I understand).
What is common in all the areas that are outstanding as not yet being easily soluble?
I would like to suggest that moving to the next level of information sharing and interoperation is an order of magnitude more complex than what has so far been achieved and that the standardisation and ontological issues that need resolution for confident forward investment to be made are not easily resolvable and may take many years of further effort for resolution and clarity to be achieved. If it were easy it would have been done by now!
My discussions with those close to and my readings of a range of sources from the key camps involved in these efforts (and in the harmonisation efforts) admit to very considerable levels of difficulty in defining a way forward – especially if consensus is to be reached. There are many strong opinions and a lot of conviction around forward paths which may not be easily harmonised.
It seems to me that this situation argues strongly for focus and investment on those things that are proven and known to work while there is continued (but lesser) investment in attempts to solve the five and ten year problems.
There is plenty to do to get the basics in place, develop the privacy and other necessary policy infrastructures and get some simple generalised messaging in place (covering referral, discharges and prescriptions) while waiting for the much more complex issues to be sorted by those capable of really ‘deep thought’.
I would suggest NEHTA would be better of sponsoring a set of proven basics as a major part of its forward work plan rather than the current laudable, but risky, push towards a form of health informatics nirvana which may prove essentially unreachable. If neither HL7 or openEHR have fully implemented scalable demonstration systems after a decade or more of development how much longer are we to wait on trust?
David.
There is no doubt that this is a multi-factorial issue that involves human, technical and financial aspects. If we consider the current situation there are some clear facts.
1. It is possible to build, deploy and have used computer systems that can assist with the operations, efficiency, safety and quality of hospitals. Suitable systems both from here and overseas are available to suit most of the patient management, clinical and administrative operations of both small, medium and large hospitals. The same can also be said systems to operate diagnostic laboratory and imaging services.
2. The same is true in the provision of support for General Practice and Specialist Office Practice with the market beginning to mature and evidence of significant contestability of system selection emerging. (Medical Director’s market share is no longer more than 2/3 of the market with IBA, Genie and Best Practice making some headway). Recent changes in the Commonwealth Practice Incentive Program is also ensuring more of the available functionality is actually being used.
3. Messaging of pathology and radiology results is being widely deployed via a number of providers (Argus, Medical Objects, HealthLink, Promedicus etc). Referrals to specialists are also gradually beginning to happen electronically – albeit as yet in pretty un-standardised form by and large. At present there is a great deal of prescription printing but very little, if any, in the way of prescription transmission electronically.
4. There has been considerable investment on development of a range of Standards which have facilitated the communication of pathology results at the individual test level using HL7 V2 which has made these results more usable. At present, however, a majority of results are still transmitted using the PIT format.
All this is very positive and if there could be near to complete penetration of these technologies where ever they are needed it would be a major public good.
Consideration of what has been achieved and what is known to work today leads to a recognition of there being a range of gaps.
First messaging of useful clinical content in computable, as opposed to “blob” forms is yet to be developed and needs to be as a priority.
Second the information held in many systems (both Ambulatory and Hospital) is held in forms which are not easily transferred between competing systems (leading to a level of ‘vendor lock in’) Indeed some vendors even encrypt information and them refuse to provide access keys without payment of maintenance fees – a most cynical exercise indeed.
Third the data, information and terminological standards to enable more that be most basic system inter-operation are still under development or unproven.
Fourth there is a very complex and highly contested debate about how information should be stored, versioned and structured within the EHR. Both the openEHR Foundation and HL7 have spent a very long time working in this area – especially trying to work out how to preserve the clinical meaning of patient information as it is moved from one computer system to another – and it is by no means clear if either have a practical and workable solution to the problem. This issue is in turn causing some difficulties as far as the finalisation of CEN/ISO 13606 (EHRCom) standard for the transmission and receipt of extracts of patient clinical records.
Fifth Australia’s full deployment of SNOMED CT is still years off given the need for localised subsets and other necessary enabling add-ons.
Australia at present has also not decided on the approaches it will use for clinical documents sharing in more general messages and in the shared EHR environment (CDA RII, plain XML and the CCR are all possible candidates among others I understand).
What is common in all the areas that are outstanding as not yet being easily soluble?
I would like to suggest that moving to the next level of information sharing and interoperation is an order of magnitude more complex than what has so far been achieved and that the standardisation and ontological issues that need resolution for confident forward investment to be made are not easily resolvable and may take many years of further effort for resolution and clarity to be achieved. If it were easy it would have been done by now!
My discussions with those close to and my readings of a range of sources from the key camps involved in these efforts (and in the harmonisation efforts) admit to very considerable levels of difficulty in defining a way forward – especially if consensus is to be reached. There are many strong opinions and a lot of conviction around forward paths which may not be easily harmonised.
It seems to me that this situation argues strongly for focus and investment on those things that are proven and known to work while there is continued (but lesser) investment in attempts to solve the five and ten year problems.
There is plenty to do to get the basics in place, develop the privacy and other necessary policy infrastructures and get some simple generalised messaging in place (covering referral, discharges and prescriptions) while waiting for the much more complex issues to be sorted by those capable of really ‘deep thought’.
I would suggest NEHTA would be better of sponsoring a set of proven basics as a major part of its forward work plan rather than the current laudable, but risky, push towards a form of health informatics nirvana which may prove essentially unreachable. If neither HL7 or openEHR have fully implemented scalable demonstration systems after a decade or more of development how much longer are we to wait on trust?
David.
Thursday, November 30, 2006
What are the Trends in Australian Hospital Information System Market?
The international research firm has recently released a report entitled Australian Hospital Information Systems Markets (Frost & Sullivan, March 2006).
The summary of the report makes some interesting points.
The first is that they see the key driver of increasing investments in Health IT as being driven by a growing demand for safer and improved healthcare noting there are ambitious plans underway in a number of states and at the Commonwealth level.
The second point they make is that there is a strategic shift in healthcare IT requirement that is expected to boost market growth. They go on to say:
“Hospitals in Australia are replacing legacy systems with sophisticated and integrated ones. Similarly, there is a strategic shift from the adoption of administrative systems to clinical systems and healthcare providers of various states and territories are looking at integrating their IT systems under programs such as the nation-wide electronic health records. Australia is slowly moving toward an integrated healthcare delivery structure, where healthcare agencies will be linked with each other, notes the analyst of this research service. Information systems are expected to play a vital role in this structure and there is likely to be an increased uptake of hospital information systems to allow seamless integration between the legacy and contemporary healthcare information systems.”
I must say that while the shift to more clinically based computing is certainly evident in most States I am less sure there could really be said to be a move towards “an integrated healthcare delivery structure” really underway as yet. As of 2006 the State / Commonwealth divides are as real and as damaging as ever in my view.
Integration between the legacy and contemporary healthcare information systems is also very much a work in progress I would suggest and is certainly not seamless.
The following would seem to be an important paragraph and I would read this as suggesting care is needed before making major investments by vendors of hospital systems in Australia.
“Nevertheless, despite these positive developments, participants must remember that there has been chronic under-investment in healthcare IT in Australia, leading to the adoption of fragmented and inefficient information systems by the healthcare providers. Further, there is also a huge level of penetration of legacy systems in Australian hospitals and migration to packaged software could pose considerable challenges.”
In the last section they say the market for clinical systems holds high growth potential. To quote:
“With hospitals replacing low-quality patient administration and financial systems with standardized and integrated solutions, the administrative HIS segment currently accounts for a majority of the market revenues. However, public and private hospitals are now showing considerable interest in clinical solutions and health departments are expected to allocate more funds for the adoption of clinical systems.
Consequently, there is growing interest in clinical systems such as radiology information systems (RIS), picture archiving and communications systems (PACS) and electronic medical records (EMR), which is expected to accelerate the growth of the overall Australian HIS markets.”
This is all true, however the next paragraph is more problematic.
“Considering the shift toward integrating the IT systems, huge contracts are expected to be awarded in the Australian HIS markets in the coming years. With the health departments of various states and territories planning numerous IT initiatives during the next few years, vendors need to enhance client relationships through better customer service and scheduled project completion, says the analyst. Also, with the increasing demand for clinical solutions, developing solutions tailored to local needs is likely to evolve as a market necessity.”
In recent times we have seen major decisions taken for clinical hospital software in the public sector in NSW, Victoria, Tasmania and South Australia. This really leaves only Qld and Western Australia to declare their hands. Qld is likely to be very conservative after the problems of the recent past (i.e. will probably follow NSW / Victorian approach if they are seen to be successful) and WA has developed its Health IT Strategy (HealthTec founded in January 2006) ) but as far as I know is probably a good way off making procurement decisions. WA does, however, need a refresh of all hospital systems sooner rather than later according to my WA correspondents.
Overall I see this report as being rather too optimistic as far as new prospects are concerned while having correctly identified the general trend to raised investments in the clinical sector. The major spending over the next few years I envisage as being focussed on implementation and integration services rather than software purchases.
Work on implementation will run for the next five to ten years so – other than Qld and WA - I suspect a quiet time will be had in the public sector for the next decade.
The private hospital sector, on the other hand, will gradually come under more pressure to provide clinical hospital systems, and I would expect this is where the major hospital market will be over the next five years in terms of new system sales.
David.
The summary of the report makes some interesting points.
The first is that they see the key driver of increasing investments in Health IT as being driven by a growing demand for safer and improved healthcare noting there are ambitious plans underway in a number of states and at the Commonwealth level.
The second point they make is that there is a strategic shift in healthcare IT requirement that is expected to boost market growth. They go on to say:
“Hospitals in Australia are replacing legacy systems with sophisticated and integrated ones. Similarly, there is a strategic shift from the adoption of administrative systems to clinical systems and healthcare providers of various states and territories are looking at integrating their IT systems under programs such as the nation-wide electronic health records. Australia is slowly moving toward an integrated healthcare delivery structure, where healthcare agencies will be linked with each other, notes the analyst of this research service. Information systems are expected to play a vital role in this structure and there is likely to be an increased uptake of hospital information systems to allow seamless integration between the legacy and contemporary healthcare information systems.”
I must say that while the shift to more clinically based computing is certainly evident in most States I am less sure there could really be said to be a move towards “an integrated healthcare delivery structure” really underway as yet. As of 2006 the State / Commonwealth divides are as real and as damaging as ever in my view.
Integration between the legacy and contemporary healthcare information systems is also very much a work in progress I would suggest and is certainly not seamless.
The following would seem to be an important paragraph and I would read this as suggesting care is needed before making major investments by vendors of hospital systems in Australia.
“Nevertheless, despite these positive developments, participants must remember that there has been chronic under-investment in healthcare IT in Australia, leading to the adoption of fragmented and inefficient information systems by the healthcare providers. Further, there is also a huge level of penetration of legacy systems in Australian hospitals and migration to packaged software could pose considerable challenges.”
In the last section they say the market for clinical systems holds high growth potential. To quote:
“With hospitals replacing low-quality patient administration and financial systems with standardized and integrated solutions, the administrative HIS segment currently accounts for a majority of the market revenues. However, public and private hospitals are now showing considerable interest in clinical solutions and health departments are expected to allocate more funds for the adoption of clinical systems.
Consequently, there is growing interest in clinical systems such as radiology information systems (RIS), picture archiving and communications systems (PACS) and electronic medical records (EMR), which is expected to accelerate the growth of the overall Australian HIS markets.”
This is all true, however the next paragraph is more problematic.
“Considering the shift toward integrating the IT systems, huge contracts are expected to be awarded in the Australian HIS markets in the coming years. With the health departments of various states and territories planning numerous IT initiatives during the next few years, vendors need to enhance client relationships through better customer service and scheduled project completion, says the analyst. Also, with the increasing demand for clinical solutions, developing solutions tailored to local needs is likely to evolve as a market necessity.”
In recent times we have seen major decisions taken for clinical hospital software in the public sector in NSW, Victoria, Tasmania and South Australia. This really leaves only Qld and Western Australia to declare their hands. Qld is likely to be very conservative after the problems of the recent past (i.e. will probably follow NSW / Victorian approach if they are seen to be successful) and WA has developed its Health IT Strategy (HealthTec founded in January 2006) ) but as far as I know is probably a good way off making procurement decisions. WA does, however, need a refresh of all hospital systems sooner rather than later according to my WA correspondents.
Overall I see this report as being rather too optimistic as far as new prospects are concerned while having correctly identified the general trend to raised investments in the clinical sector. The major spending over the next few years I envisage as being focussed on implementation and integration services rather than software purchases.
Work on implementation will run for the next five to ten years so – other than Qld and WA - I suspect a quiet time will be had in the public sector for the next decade.
The private hospital sector, on the other hand, will gradually come under more pressure to provide clinical hospital systems, and I would expect this is where the major hospital market will be over the next five years in terms of new system sales.
David.
Tuesday, November 28, 2006
Questions for Minister Abbott to Ask – How to Decide whether to Continue NEHTA.
An article by Julian Bajkowski of The Australian Financial Review on the 28th Nov 2006 suggests that the AMA is seeking to have Health Minister Tony Abbott to create legally enforceable standards that govern the sale and use of electronic health systems.
Quoting an AMA position paper obtained by The Australian Financial Review we are told that medical practitioners remain deeply concerned about various state electronic health initiatives. We are also told the AMA fears the plans, if not properly governed, will recreate rail gauge incompatibilities - various state health systems will be unable to share critical patient data at a clinical level.
This will come as no shock to any reader of this blog who will be aware that for the last eight months I have been suggesting there is a critical pressing need for the development of a consensus based National E-Health Plan, Business Case and Implementation Plan. The AMA is dead right that nationally E-Health is in one serious hole and urgent action is required to correct the situation.
As my manifesto of last Friday made clear I hope we can lift from the present rather messy base. To quote
“My view is that right now there is a lot of unfocussed, uncoordinated activity going on (some good and some bad) and that it is the time to take a step back, work out, at a national level, what is needed and how best to get there. As a nation in 2000/1 we had some good ideas with HealthConnect but we then lost the plot and momentum by early 2005. We can’t afford another wasted four years.
In the blog I hope to alert and warn where I see mistakes being made and lessons we should already have learnt being repeated. Hopefully the assumptions above will point to those things which need to be assured before investments are made.
Overall I am hoping to foster the change from a heard of cats to a sleek shoal of fish all swimming towards real, practical and achievable goals.”
The article also goes on to say – as its second main point – that the continuing funding of NEHTA beyond 2008/09 is now under review by the Health Minister. This review is timely as NEHTA has now been operational for a decent period. As I stated previously “My view is that unless there are some really useful and practical outcomes within the next six months (i.e. NEHTA 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.”
Before continuing funding there are a number of questions I suggest Mr Abbot should ask:
1. Has NEHTA developed and articulated the consensus based National E-Health Plan, Business Case and Implementation Plan which is needed to frame all other E-Health activity and investment? If not, why not?
2. With the effective gutting of both the E-Health Implementation Branch of DoHA and the Australian Health Information Council (AHIC) should NEHTA have been more aware of the strategic gap at the core of Australian E-Health an moved promptly to address this gap?
3. Have NEHTA’s interventions and work products contributed positively to the development of the E-Health industry in Australia through the provision of clear, usable advice and technical frameworks?
4. Have clinical users of E-Health system seen a perceptible improvement in the quality and availability of satisfactory systems which interoperate and also allow for the smooth and reliable communication of clinical information?
5. Has the agenda of improving Clinical Decision Support within E-Health Systems to assist with the quality and safety of patient care seen a significant advance since NEHTA’s inception?
6. Has access to critical clinical information in life-saving and emergent situations been improved in the last 2-3 years under NEHTA’s guidance?
7. Is the present governance of NEHTA with a CEO level board and advisory committees whose membership is not made public the right way to manage a critical national effort such as the National E-Health Agenda?
8. Has NEHTA’s cross jurisdictional nature lead to a much improved alignment of the E-Health initiatives in each of the States and Territories?
9. Are the stakeholders who are involved in the delivery of E-Health products and services finding it easier or harder to make progress with NEHTA’s presence in the arena?
10. Is the value obtained for the investment in NEHTA becoming clear to the extent that funding should be continued or is a major strategic re-assessment required?
11. Should Australia have both NEHTA and Standards Australia involved in E-Health Standards setting or should this role be clearly placed in one place of the other?
12. Is it realistic for NEHTA to continue to work on a National Shared EHR when the financial, technical and human aspects of such a project remain so uncertain and problematic?
13. Why is it that NEHTA has not addressed the issues around clinical software quality and certification despite significant clinical and industry concern that guidance is important and needs careful consideration?
14. Does NEHTA have adequate clinical input given its technical importance to the health system?
It seems to me that unless most of these questions can be confidently answered in the affirmative by the Minister then a serious strategic review is virtually mandatory.
The more astute reader may notice that the emphasis in the list above is on strategic rather than technical issues. This actually offers the Minister another approach. He could formally re-constitute AHIC and provide it with a strategically trained and aware E-Health secretariat and have NEHTA then change its role to a technical delivery arm for the AHIC strategy. This would be a very, smart choice. To leave things the way they are would not be.
David.
Quoting an AMA position paper obtained by The Australian Financial Review we are told that medical practitioners remain deeply concerned about various state electronic health initiatives. We are also told the AMA fears the plans, if not properly governed, will recreate rail gauge incompatibilities - various state health systems will be unable to share critical patient data at a clinical level.
This will come as no shock to any reader of this blog who will be aware that for the last eight months I have been suggesting there is a critical pressing need for the development of a consensus based National E-Health Plan, Business Case and Implementation Plan. The AMA is dead right that nationally E-Health is in one serious hole and urgent action is required to correct the situation.
As my manifesto of last Friday made clear I hope we can lift from the present rather messy base. To quote
“My view is that right now there is a lot of unfocussed, uncoordinated activity going on (some good and some bad) and that it is the time to take a step back, work out, at a national level, what is needed and how best to get there. As a nation in 2000/1 we had some good ideas with HealthConnect but we then lost the plot and momentum by early 2005. We can’t afford another wasted four years.
In the blog I hope to alert and warn where I see mistakes being made and lessons we should already have learnt being repeated. Hopefully the assumptions above will point to those things which need to be assured before investments are made.
Overall I am hoping to foster the change from a heard of cats to a sleek shoal of fish all swimming towards real, practical and achievable goals.”
The article also goes on to say – as its second main point – that the continuing funding of NEHTA beyond 2008/09 is now under review by the Health Minister. This review is timely as NEHTA has now been operational for a decent period. As I stated previously “My view is that unless there are some really useful and practical outcomes within the next six months (i.e. NEHTA 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.”
Before continuing funding there are a number of questions I suggest Mr Abbot should ask:
1. Has NEHTA developed and articulated the consensus based National E-Health Plan, Business Case and Implementation Plan which is needed to frame all other E-Health activity and investment? If not, why not?
2. With the effective gutting of both the E-Health Implementation Branch of DoHA and the Australian Health Information Council (AHIC) should NEHTA have been more aware of the strategic gap at the core of Australian E-Health an moved promptly to address this gap?
3. Have NEHTA’s interventions and work products contributed positively to the development of the E-Health industry in Australia through the provision of clear, usable advice and technical frameworks?
4. Have clinical users of E-Health system seen a perceptible improvement in the quality and availability of satisfactory systems which interoperate and also allow for the smooth and reliable communication of clinical information?
5. Has the agenda of improving Clinical Decision Support within E-Health Systems to assist with the quality and safety of patient care seen a significant advance since NEHTA’s inception?
6. Has access to critical clinical information in life-saving and emergent situations been improved in the last 2-3 years under NEHTA’s guidance?
7. Is the present governance of NEHTA with a CEO level board and advisory committees whose membership is not made public the right way to manage a critical national effort such as the National E-Health Agenda?
8. Has NEHTA’s cross jurisdictional nature lead to a much improved alignment of the E-Health initiatives in each of the States and Territories?
9. Are the stakeholders who are involved in the delivery of E-Health products and services finding it easier or harder to make progress with NEHTA’s presence in the arena?
10. Is the value obtained for the investment in NEHTA becoming clear to the extent that funding should be continued or is a major strategic re-assessment required?
11. Should Australia have both NEHTA and Standards Australia involved in E-Health Standards setting or should this role be clearly placed in one place of the other?
12. Is it realistic for NEHTA to continue to work on a National Shared EHR when the financial, technical and human aspects of such a project remain so uncertain and problematic?
13. Why is it that NEHTA has not addressed the issues around clinical software quality and certification despite significant clinical and industry concern that guidance is important and needs careful consideration?
14. Does NEHTA have adequate clinical input given its technical importance to the health system?
It seems to me that unless most of these questions can be confidently answered in the affirmative by the Minister then a serious strategic review is virtually mandatory.
The more astute reader may notice that the emphasis in the list above is on strategic rather than technical issues. This actually offers the Minister another approach. He could formally re-constitute AHIC and provide it with a strategically trained and aware E-Health secretariat and have NEHTA then change its role to a technical delivery arm for the AHIC strategy. This would be a very, smart choice. To leave things the way they are would not be.
David.
Monday, November 27, 2006
Personal Health Records – What a Good Idea Mr Hockey!
In this post I want to make a simple suggestion. That is that Mr Hockey should reward those people who register for their Access Card with the capability – rather than store health information on the card itself – for citizens to enter information on their health in a standardised form on a national Personal Health Record server access to which is provided by provision of the card.
The standard format to be used can be a matter of discussion but the basic elements of the contents could be as follows. Note: All content would be optional for each individual patient as would be use of the record as a whole be totally optional.
1. Very basic demographics (derived from the card record) – Name, Age, Sex, Current Address and a Date Last Reviewed by Patient, Pharmacist or GP.
2. Ordinary Regular GP with phone number etc
3. Allergies (simple record of what substance, what reaction and had a doctor confirmed the validity of the allergy (Y/N).
4. Important Family Medical History if individual wants to record it (e.g. heart attacks run in family etc).
5. Known Chronic Illnesses (e.g. diabetes, epilepsy, arthritis etc) and important past surgery.
6. Listing of Current Medications and Dosage and Frequency.
7. Results of Tests and Investigations – these would be sourced from the GP or specialist and placed on the record for the patient – and marked with the contact details of the source of the information
8. A recurrent simple record where the individual could record a date, time and measurement (e.g. a blood pressure reading, spirometry or patient measured blood sugar levels)
9. A place for notes of information such as appointments, immunisations etc as free text.
10. The capacity to store important health related documents in any of the standard formats as an attachment if needed for any specific reason.
The record would be only accessible if the card owner placed the card in a reader in the presence of an appropriate health professional – for initial creation or updating – or via the use of a secure one-time validated web site log-on. (e.g. you enter your ID, your e-mail or SMS phone number is already stored on the Access Card database – and that is used to send you back a one time usable password that expires in say one hour.).
Anyone trying to wrongly access your account needs to know your ID Number, your phone number or e-mail (not on the card) and to be expecting the password to arrive. This would be more secure than current internet banking which millions of people use daily.
I would envisage Medicare would provide an annual payment in the form of a standard Medicare benefit for your GP to review and update your record on an annual basis. A small fee could also be provided to pharmacists to update the medication record.
The advantages of this proposal are:
1. The user owns and is responsible for the record – but the record can be flagged as having been medically reviewed on a particular date.
2. Slightly more technical information is provided by the GP for the patient and again this process provides more review.
3. The system is totally voluntary and indeed other providers may be able to set up similar services (e.g. health funds, banks) (it would be important the format be standardised properly – perhaps NEHTA could own that problem).
4. A lot of the benefits potential of HealthConnect like proposals could be realised quite cheaply.
5. The proposal, intrinsically, ensures those with complex health issues are those who would set up such a record and it is those who we need the most information available for in emergent and multi health provider (team) situations.
6. The record is totally voluntary and avoids any privacy concerns – with a Government or other provider guarantee of strict security enforcement.
7. The system could make a real contribution to continuity of care of patients within the community.
8. It would be very easy to design the record to be downloadable to GP computing systems to provide very useful background information when a patient changes practice or location. Also has the benefit of providing an off-line backup of possibly important records.
It should be noted that this proposal would provide a very useful testbed for shared EHR possibilities, infrastructure and utility and, if sensibly designed, permit migration to a more clinically orientated system over time. There is also the possibility that an interested consortium could undertake the entire project with funding from a range of sources possible (Health Insurers, Users, Government or a mix of some or all.).
I wonder will the policy gurus give the idea a careful review. I hope so.
David.
The standard format to be used can be a matter of discussion but the basic elements of the contents could be as follows. Note: All content would be optional for each individual patient as would be use of the record as a whole be totally optional.
1. Very basic demographics (derived from the card record) – Name, Age, Sex, Current Address and a Date Last Reviewed by Patient, Pharmacist or GP.
2. Ordinary Regular GP with phone number etc
3. Allergies (simple record of what substance, what reaction and had a doctor confirmed the validity of the allergy (Y/N).
4. Important Family Medical History if individual wants to record it (e.g. heart attacks run in family etc).
5. Known Chronic Illnesses (e.g. diabetes, epilepsy, arthritis etc) and important past surgery.
6. Listing of Current Medications and Dosage and Frequency.
7. Results of Tests and Investigations – these would be sourced from the GP or specialist and placed on the record for the patient – and marked with the contact details of the source of the information
8. A recurrent simple record where the individual could record a date, time and measurement (e.g. a blood pressure reading, spirometry or patient measured blood sugar levels)
9. A place for notes of information such as appointments, immunisations etc as free text.
10. The capacity to store important health related documents in any of the standard formats as an attachment if needed for any specific reason.
The record would be only accessible if the card owner placed the card in a reader in the presence of an appropriate health professional – for initial creation or updating – or via the use of a secure one-time validated web site log-on. (e.g. you enter your ID, your e-mail or SMS phone number is already stored on the Access Card database – and that is used to send you back a one time usable password that expires in say one hour.).
Anyone trying to wrongly access your account needs to know your ID Number, your phone number or e-mail (not on the card) and to be expecting the password to arrive. This would be more secure than current internet banking which millions of people use daily.
I would envisage Medicare would provide an annual payment in the form of a standard Medicare benefit for your GP to review and update your record on an annual basis. A small fee could also be provided to pharmacists to update the medication record.
The advantages of this proposal are:
1. The user owns and is responsible for the record – but the record can be flagged as having been medically reviewed on a particular date.
2. Slightly more technical information is provided by the GP for the patient and again this process provides more review.
3. The system is totally voluntary and indeed other providers may be able to set up similar services (e.g. health funds, banks) (it would be important the format be standardised properly – perhaps NEHTA could own that problem).
4. A lot of the benefits potential of HealthConnect like proposals could be realised quite cheaply.
5. The proposal, intrinsically, ensures those with complex health issues are those who would set up such a record and it is those who we need the most information available for in emergent and multi health provider (team) situations.
6. The record is totally voluntary and avoids any privacy concerns – with a Government or other provider guarantee of strict security enforcement.
7. The system could make a real contribution to continuity of care of patients within the community.
8. It would be very easy to design the record to be downloadable to GP computing systems to provide very useful background information when a patient changes practice or location. Also has the benefit of providing an off-line backup of possibly important records.
It should be noted that this proposal would provide a very useful testbed for shared EHR possibilities, infrastructure and utility and, if sensibly designed, permit migration to a more clinically orientated system over time. There is also the possibility that an interested consortium could undertake the entire project with funding from a range of sources possible (Health Insurers, Users, Government or a mix of some or all.).
I wonder will the policy gurus give the idea a careful review. I hope so.
David.
Sunday, November 26, 2006
Healthelink – Trundling Towards Failure?
Its now been about eight months (March, 2006) since the NSW Health Minister announced the commencement of the Healthelink trials in the Hunter and at Westmead so it seems about time to consider what has been reported or leaked out about progress.
The concept of the trial is as follows:
Healthcare providers (hospitals, GPs, diagnostic providers and community services etc) in two specific areas treating two specific categories of patients (the 65 + in the Hunter and the young children in Westmead) have an encounter record created each time they attend a participating facility.
The idea is that over time a longitudinal health record on each individual will be built up.’
On each encounter both demographic and clinical information will be captured.
The encounter from the GP, for example, will capture the following information automatically at the end of a consultation. Quoting directly from an Healthelink information sheet.
“The following fields will be extracted from GP electronic health record systems following completion of each consultation:
a Patient demographic data
b Consultation data
GPs will be encouraged to enter the data into the coded fields (e.g. reason for visit, medications) in their practice clinical systems as only these data will be sent to Healthelink. Free text information entered into the clinical notes for example will not be sent to Healthelink. The coded field only approach means that GPs can be confident that a sensitive free text comment entered into the clinical notes will not be sent to Healthelink and will not be available for other providers or the patient to view.”
With this background a few comments and discoveries made while researching the progress of the project are worth sharing.
First, the exclusion of the text notes and the expectation of using the coded information in the diagnostic fields is quite problematic. Experience from HealthConnect trials in the NT showed coded data was often not provided and this often led to the situation where it was impossible to understand just what a particular encounter was about. Healthelink looks likely to have similar data-quality issues.
Second, a review of the patient searching capabilities provided to users of the system confirm the worst fears of those concerned with privacy protection. A search on a partial name and approximate age (+/- 5 years) generates a weighted (for match) listing which contains a pretty full demographic record with full name, address etc. Just the sort of thing abused wives etc want to keep to themselves! The system should insist on a much higher level of initial knowledge – not that even this would help in the case of an abusive spouse.
Third, the system has no apparent concept of location etc – so if you are on the data-base and have not opted out you are findable. Extension of such a system state wide is clearly very problematic.
The record displayed by the system once the patient is located is also not segmented into more or less confidential information which means the patient has to make a choice to opt totally in or out on the basis of the most sensitive piece of information in the record as far as they are concerned.
All these issues are in addition to the lack of initial consent to having information stored as would be the case had ‘opt in’ been selected. For reasons best known to itself the NSW Department has decided to ignore not only its own earlier reports on the matter but also its own explicit Health Privacy Principle.
“HPP15 Linkage of Health Records
“Personal health information must not be included in a system that links health records in one service with health records in another health service unless the individual it relates to has expressly consented”.
A specific regulatory exemption from HPP15 has been provided for the Healthelink pilot. Whether this exemption should be retained after the end of the pilot will form part of the pilot evaluation.
The regulation provides for the use of an “opt out” consent model. This ensures health consumers will continue to be able to exercise the choice as to whether or not they participate in Healthelink and to exercise this choice at any time.”
I am aware that at least some physicians are by no means convinced this NSW regulation does not violate the Commonwealth Privacy Act.
Leaving the whole privacy issue aside there are a few other points to be made and question to be asked.
1. Just why has all this taken so long?
Taken from the March 2006 Project Outline:
"In March 2000, the NSW Health Council set an objective for the NSW health system to implement the Electronic Health Record (to be known as Healthelink) by 2010. Health Ministers also endorsed the proposal for a National Health Information Network, known as HealthConnect. The NSW Healthelink pilots were endorsed as one of the trials for the National HealthConnect program.
In May 2004 the Health Minister announced that the Care Junction Consortium consisting of LogicaCMG, Orion International and Healthlink had been selected to work with NSW Health to implement NSW electronic health record pilots – expected to commence operation in the first quarter of 2006.”
We now know what was then EHR*NET was the original proposal and the rename came a good deal later. We also must wonder why the whole thing should take six years from concept to pilot. At this pace 2010 does not look all that good for a total state roll out. (Note the 2002 implementation plan of EHR*NET indicated the project would be complete by June 2007 – time to really pick up pace!)
2. In a very recent (25/09/2006) GP information document we find the following:
“How would the Practice apply for the GP Testing Grant?
The Healthelink system is complex and although the components of the system will be thoroughly tested centrally, assistance will be required with testing the system once installed at practices and as used by GPs. Healthelink is therefore requesting that practices offer to assist the testing process and become early adopters.
A grant of $10,000 will be available to these practices subject to signing up to participate, meeting the eligibility criteria and being in a position to install the Healthelink software by 30 November 2006 or a date otherwise agreed with Healthelink. More details are available in the GP Testing Grant Agreement. “
I wonder how the announcement of this largesse was missed by the press and when the decision was made to be so generous!?
It seems to me this is a sign of desperation on the part of the project to have practitioners concerned about liability and indemnity to get moving.
3. It seems to me there will some real issues involved in the scalability of this system in a technical and user sense. Having a search operate across million people data-bases may turn out to be a real challenge.
4. There is also a real issue about just what impact the system as presently conceived will have on practice work flow and what value the practitioner will receive. The lack of proper integration between Healthelink and the practice management system may prove to be very difficult to use in practice - switching between one system and another. To have the system used properly it needs to be quick to access and consistently provide useful and relatively complete information.
5. The project's approach of making records unavailable for 30 days clearly makes very little sense and needs to be reviewed in the context of an overall privacy approach review.
I am afraid this project has all the signs of a project that is on the ropes. I hope not since it has taken so long to get this far. In many ways I am not surprised. As those who have read this blog for a while will know I have always been convinced that the complexities and difficulties associated with shared summary electronic health records have been very underestimated.
Maybe a strategic re-think and revision of the privacy approach can grab victory from the jaws of defeat. I hope so.
David.
The concept of the trial is as follows:
Healthcare providers (hospitals, GPs, diagnostic providers and community services etc) in two specific areas treating two specific categories of patients (the 65 + in the Hunter and the young children in Westmead) have an encounter record created each time they attend a participating facility.
The idea is that over time a longitudinal health record on each individual will be built up.’
On each encounter both demographic and clinical information will be captured.
The encounter from the GP, for example, will capture the following information automatically at the end of a consultation. Quoting directly from an Healthelink information sheet.
“The following fields will be extracted from GP electronic health record systems following completion of each consultation:
a Patient demographic data
- Surname, Given Names
- Date of Birth
- Medicare Number
- Gender/Sex
- Contact details (e.g. address, phone numbers)
b Consultation data
- Provider/clinician – name, role and location
- Diagnosis/reason for visit
- Allergies
- Pathology/radiology test results (when a GP associates a report with a patient record)
- Medications - Prescription Order Information (Script number, GP name and ID), Prescribed Medication (Name, Route and Instructions) and Medication Administration Information
GPs will be encouraged to enter the data into the coded fields (e.g. reason for visit, medications) in their practice clinical systems as only these data will be sent to Healthelink. Free text information entered into the clinical notes for example will not be sent to Healthelink. The coded field only approach means that GPs can be confident that a sensitive free text comment entered into the clinical notes will not be sent to Healthelink and will not be available for other providers or the patient to view.”
With this background a few comments and discoveries made while researching the progress of the project are worth sharing.
First, the exclusion of the text notes and the expectation of using the coded information in the diagnostic fields is quite problematic. Experience from HealthConnect trials in the NT showed coded data was often not provided and this often led to the situation where it was impossible to understand just what a particular encounter was about. Healthelink looks likely to have similar data-quality issues.
Second, a review of the patient searching capabilities provided to users of the system confirm the worst fears of those concerned with privacy protection. A search on a partial name and approximate age (+/- 5 years) generates a weighted (for match) listing which contains a pretty full demographic record with full name, address etc. Just the sort of thing abused wives etc want to keep to themselves! The system should insist on a much higher level of initial knowledge – not that even this would help in the case of an abusive spouse.
Third, the system has no apparent concept of location etc – so if you are on the data-base and have not opted out you are findable. Extension of such a system state wide is clearly very problematic.
The record displayed by the system once the patient is located is also not segmented into more or less confidential information which means the patient has to make a choice to opt totally in or out on the basis of the most sensitive piece of information in the record as far as they are concerned.
All these issues are in addition to the lack of initial consent to having information stored as would be the case had ‘opt in’ been selected. For reasons best known to itself the NSW Department has decided to ignore not only its own earlier reports on the matter but also its own explicit Health Privacy Principle.
“HPP15 Linkage of Health Records
“Personal health information must not be included in a system that links health records in one service with health records in another health service unless the individual it relates to has expressly consented”.
A specific regulatory exemption from HPP15 has been provided for the Healthelink pilot. Whether this exemption should be retained after the end of the pilot will form part of the pilot evaluation.
The regulation provides for the use of an “opt out” consent model. This ensures health consumers will continue to be able to exercise the choice as to whether or not they participate in Healthelink and to exercise this choice at any time.”
I am aware that at least some physicians are by no means convinced this NSW regulation does not violate the Commonwealth Privacy Act.
Leaving the whole privacy issue aside there are a few other points to be made and question to be asked.
1. Just why has all this taken so long?
Taken from the March 2006 Project Outline:
"In March 2000, the NSW Health Council set an objective for the NSW health system to implement the Electronic Health Record (to be known as Healthelink) by 2010. Health Ministers also endorsed the proposal for a National Health Information Network, known as HealthConnect. The NSW Healthelink pilots were endorsed as one of the trials for the National HealthConnect program.
In May 2004 the Health Minister announced that the Care Junction Consortium consisting of LogicaCMG, Orion International and Healthlink had been selected to work with NSW Health to implement NSW electronic health record pilots – expected to commence operation in the first quarter of 2006.”
We now know what was then EHR*NET was the original proposal and the rename came a good deal later. We also must wonder why the whole thing should take six years from concept to pilot. At this pace 2010 does not look all that good for a total state roll out. (Note the 2002 implementation plan of EHR*NET indicated the project would be complete by June 2007 – time to really pick up pace!)
2. In a very recent (25/09/2006) GP information document we find the following:
“How would the Practice apply for the GP Testing Grant?
The Healthelink system is complex and although the components of the system will be thoroughly tested centrally, assistance will be required with testing the system once installed at practices and as used by GPs. Healthelink is therefore requesting that practices offer to assist the testing process and become early adopters.
A grant of $10,000 will be available to these practices subject to signing up to participate, meeting the eligibility criteria and being in a position to install the Healthelink software by 30 November 2006 or a date otherwise agreed with Healthelink. More details are available in the GP Testing Grant Agreement. “
I wonder how the announcement of this largesse was missed by the press and when the decision was made to be so generous!?
It seems to me this is a sign of desperation on the part of the project to have practitioners concerned about liability and indemnity to get moving.
3. It seems to me there will some real issues involved in the scalability of this system in a technical and user sense. Having a search operate across million people data-bases may turn out to be a real challenge.
4. There is also a real issue about just what impact the system as presently conceived will have on practice work flow and what value the practitioner will receive. The lack of proper integration between Healthelink and the practice management system may prove to be very difficult to use in practice - switching between one system and another. To have the system used properly it needs to be quick to access and consistently provide useful and relatively complete information.
5. The project's approach of making records unavailable for 30 days clearly makes very little sense and needs to be reviewed in the context of an overall privacy approach review.
I am afraid this project has all the signs of a project that is on the ropes. I hope not since it has taken so long to get this far. In many ways I am not surprised. As those who have read this blog for a while will know I have always been convinced that the complexities and difficulties associated with shared summary electronic health records have been very underestimated.
Maybe a strategic re-think and revision of the privacy approach can grab victory from the jaws of defeat. I hope so.
David.
Friday, November 24, 2006
The AusHealthIT Manifesto – What is the Blog On About?
Since starting the blog in March I have written getting on for a hundred posts and have seen interest in the blog and comments slowly increase over that time. It has seemed to me that, with the research and thinking that has required, I now need to crystallise what I am trying to say and make sure I am achieving clarity in the objectives I have for all this. In doing this I want that the reader be under no illusion as to my background, perspectives and views.
As to background, its pretty simple. I am (was) a specialist in anaesthesia, intensive care and emergency medicine who has been working one way or another for the last 23 years to improve the use of information technology in the health sector.
As to perspective I am operating from the following assumptions which I am convinced are true.
First, Health IT is a potential major enabler of quality and safety in the delivery of health services, but is not the whole answer to safer, higher quality health service.
Second, the possible added value in increased deployment of advanced Health IT throughout the Health Sector is very large and delay is resulting in a very large opportunity costs in terms of both lives and dollars.
Third, while health service delivery is an information intensive activity which is able to be successfully assisted with Health IT, failure to involve and work with all types of health professionals and other stakeholder in the planning for and implementation of new Health IT is a catastrophic mistake.
Fourth, the deployment and use of Information Technology in the health sector in Australia is presently largely inadequate, underspent and ineffective.
Fifth it is clear that personal identified health information is seen by the public as something they want to have control over and any plans or implementation approaches that do not recognise this fact are for all practical purposes ultimately doomed.
Sixth, and somewhat paradoxically, what is needed is a carefully developed consensus based National E-Health Plan, Business Case and Implementation Plan which is then delivered in local contexts which respond to local needs but which conform to a national overall Framework (this is especially important regarding the selection and implementation of systems).
Seventh, there is pretty common agreement that most Government initiatives at both Federal and State level have not delivered as well as might be hoped. Most would also agree that at present there is little in the way of Federal Government leadership or direction being provided for the E-Health sector.
Eighth, there is a very large skills gap at both user and Health IT levels which needs to be addressed nationally with some urgency.
Ninth the lack of openness and transparency regarding both HealthConnect and other major Health IT project outcomes and failures has limited the learning that has been possible from the mistakes made so far. NEHTA appears to be replicating this mistake at the time of writing (November 2006). It is vital all lessons are learned – especially from the projects that have not worked out as desired
Tenth, it is important to recognise that commercial providers of Health IT have expertise and skills which should be exploited but equally health organisations need to bring comprehensive project management and change management skills as well as business understanding to any Health IT implementation.
Eleventh, in the words of the late Milton Friedman as far as Health IT is concerned there is “no such thing as a free lunch” (i.e. you have to pay for value received).
Twelfth, it is clear, largely because of the way benefits from Health IT are not recouped by the users of the technology, that there be mechanisms to have those return the benefits they receive to those who do the work.
Thirteenth, it seems highly likely that the major payoff from Health IT is to be found only in very advanced systems which improve clinical decision making and minimise errors both of omission and commission.
Last, there are proven and deployable Health IT solutions which can be successfully deployed today with the right project and change management. It is important to get on with it.
My view is that right now there is a lot of unfocussed, uncoordinated activity going on (some good and some bad) and that it is the time to take a step back, work out, at a national level, what is needed and how best to get there. As a nation in 2000/1 we had some good ideas with HealthConnect but we then lost the plot and momentum by early 2005. We can’t afford another wasted four years.
In the blog I hope to alert and warn where I see mistakes being made and lessons we should already have learnt being repeated. Hopefully the assumptions above will point to those things which need to be assured before investments are made.
Overall I am hoping to foster the change from a heard of cats to a sleek shoal of fish all swimming towards real, practical and achievable goals.
David.
As to background, its pretty simple. I am (was) a specialist in anaesthesia, intensive care and emergency medicine who has been working one way or another for the last 23 years to improve the use of information technology in the health sector.
As to perspective I am operating from the following assumptions which I am convinced are true.
First, Health IT is a potential major enabler of quality and safety in the delivery of health services, but is not the whole answer to safer, higher quality health service.
Second, the possible added value in increased deployment of advanced Health IT throughout the Health Sector is very large and delay is resulting in a very large opportunity costs in terms of both lives and dollars.
Third, while health service delivery is an information intensive activity which is able to be successfully assisted with Health IT, failure to involve and work with all types of health professionals and other stakeholder in the planning for and implementation of new Health IT is a catastrophic mistake.
Fourth, the deployment and use of Information Technology in the health sector in Australia is presently largely inadequate, underspent and ineffective.
Fifth it is clear that personal identified health information is seen by the public as something they want to have control over and any plans or implementation approaches that do not recognise this fact are for all practical purposes ultimately doomed.
Sixth, and somewhat paradoxically, what is needed is a carefully developed consensus based National E-Health Plan, Business Case and Implementation Plan which is then delivered in local contexts which respond to local needs but which conform to a national overall Framework (this is especially important regarding the selection and implementation of systems).
Seventh, there is pretty common agreement that most Government initiatives at both Federal and State level have not delivered as well as might be hoped. Most would also agree that at present there is little in the way of Federal Government leadership or direction being provided for the E-Health sector.
Eighth, there is a very large skills gap at both user and Health IT levels which needs to be addressed nationally with some urgency.
Ninth the lack of openness and transparency regarding both HealthConnect and other major Health IT project outcomes and failures has limited the learning that has been possible from the mistakes made so far. NEHTA appears to be replicating this mistake at the time of writing (November 2006). It is vital all lessons are learned – especially from the projects that have not worked out as desired
Tenth, it is important to recognise that commercial providers of Health IT have expertise and skills which should be exploited but equally health organisations need to bring comprehensive project management and change management skills as well as business understanding to any Health IT implementation.
Eleventh, in the words of the late Milton Friedman as far as Health IT is concerned there is “no such thing as a free lunch” (i.e. you have to pay for value received).
Twelfth, it is clear, largely because of the way benefits from Health IT are not recouped by the users of the technology, that there be mechanisms to have those return the benefits they receive to those who do the work.
Thirteenth, it seems highly likely that the major payoff from Health IT is to be found only in very advanced systems which improve clinical decision making and minimise errors both of omission and commission.
Last, there are proven and deployable Health IT solutions which can be successfully deployed today with the right project and change management. It is important to get on with it.
My view is that right now there is a lot of unfocussed, uncoordinated activity going on (some good and some bad) and that it is the time to take a step back, work out, at a national level, what is needed and how best to get there. As a nation in 2000/1 we had some good ideas with HealthConnect but we then lost the plot and momentum by early 2005. We can’t afford another wasted four years.
In the blog I hope to alert and warn where I see mistakes being made and lessons we should already have learnt being repeated. Hopefully the assumptions above will point to those things which need to be assured before investments are made.
Overall I am hoping to foster the change from a heard of cats to a sleek shoal of fish all swimming towards real, practical and achievable goals.
David.
Thursday, November 23, 2006
Correction to Comments on South Australian Oacis System Security.
It seems I have been misinformed regarding the level of security offered by the Oacis.
John Mleczko, Director Projects Branch ICT Services, Department of Health, South Australia has informed me of true security status today. I quote from his note.
“In response to statements made in your article "Personal Health Information Privacy - The Elephant in the Room" posted 28 Oct 2006 10:04PM CDT you ask for correction in regards to access to the Oacis system implemented in South Australia's major metropolitan public hospitals.
You suggest “a clinical user at one hospital, once logged on, could access any record of essentially any type for any South Australian”. The security model is facility based hence this is incorrect which means a user at a hospital can access the records of their patients at that hospital. You also suggest that access is “non-individualised and non role based”. Access to Oacis has always been individualised and role based.”
He then goes on to explain, in detail, the various steps taken to ensure the logged on users stay within the correct bounds – including warnings, audit trails etc.
This is good news.
In response I have asked the following questions by e-mail.
“Hi John,
Thanks for that...Just so I am clear this means that the access privileges for a medical registrar who is in charge of a hospital over night has his/her privileges changed according to the time of day (own service versus whole hospital) and that the intern in Emergency only sees results undertaken at that hospital - even if there are results at IMVS etc for the same patient done recently?
When I last chatted to people involved (a year or two back I admit) it was suggested to me that once you had medical or other high level access to the database it was essentially "open slather" - or is that only for those providing information into Oacis who clearly would seem to need to be able to access the whole results data base - for historical comparisons if for no other reason.
As you know audit trails and warnings have hardly been 100% effective at the Tax Office and CentreLink
If it has always been true that there were no group log-ons to Oacis I am happy about that!
I will happily place an edit noting your comments once I am clear.
On a related issue, given Oacis is a shared database just what control does the individual patient have about the recording of data on that database and who can see the data. This becomes an obvious issue as soon as any information is made available in a shared way. Does a patient admitted to an Oacis using facility have the choice of what is shared from say previous admissions (e.g. they may want to suppress a pathology report mentioning products of conception etc)?
Cheers
David.”
One of the Oacis brochures from 2004 has an intern saying how useful it is to be able to access information from previous admissions so clarity is important I believe.
I will keep everyone informed as information becomes available.
David.
John Mleczko, Director Projects Branch ICT Services, Department of Health, South Australia has informed me of true security status today. I quote from his note.
“In response to statements made in your article "Personal Health Information Privacy - The Elephant in the Room" posted 28 Oct 2006 10:04PM CDT you ask for correction in regards to access to the Oacis system implemented in South Australia's major metropolitan public hospitals.
You suggest “a clinical user at one hospital, once logged on, could access any record of essentially any type for any South Australian”. The security model is facility based hence this is incorrect which means a user at a hospital can access the records of their patients at that hospital. You also suggest that access is “non-individualised and non role based”. Access to Oacis has always been individualised and role based.”
He then goes on to explain, in detail, the various steps taken to ensure the logged on users stay within the correct bounds – including warnings, audit trails etc.
This is good news.
In response I have asked the following questions by e-mail.
“Hi John,
Thanks for that...Just so I am clear this means that the access privileges for a medical registrar who is in charge of a hospital over night has his/her privileges changed according to the time of day (own service versus whole hospital) and that the intern in Emergency only sees results undertaken at that hospital - even if there are results at IMVS etc for the same patient done recently?
When I last chatted to people involved (a year or two back I admit) it was suggested to me that once you had medical or other high level access to the database it was essentially "open slather" - or is that only for those providing information into Oacis who clearly would seem to need to be able to access the whole results data base - for historical comparisons if for no other reason.
As you know audit trails and warnings have hardly been 100% effective at the Tax Office and CentreLink
If it has always been true that there were no group log-ons to Oacis I am happy about that!
I will happily place an edit noting your comments once I am clear.
On a related issue, given Oacis is a shared database just what control does the individual patient have about the recording of data on that database and who can see the data. This becomes an obvious issue as soon as any information is made available in a shared way. Does a patient admitted to an Oacis using facility have the choice of what is shared from say previous admissions (e.g. they may want to suppress a pathology report mentioning products of conception etc)?
Cheers
David.”
One of the Oacis brochures from 2004 has an intern saying how useful it is to be able to access information from previous admissions so clarity is important I believe.
I will keep everyone informed as information becomes available.
David.
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