It Really is Very Hard to Make Shared EHRs Work.

Sobering news for all the proponents of Shared EHRs came in overnight.

The original article from E-Health Insider can be found at the following URL:

http://www.ehiprimarycare.com/news/item.cfm?ID=2635

iHealthBeat (http://www.ihealthbeat.org/) summarises the key findings well.

“Majority of British Physicians Oppose IT Project, Survey Finds

Sixty-six percent of British general practitioners said they will not allow their own health records to be shared through the National Health Service's Summary Care Record program, according to a survey of general practitioners by Pulse magazine, E-Health Insider reports. Only one-third of respondents said they plan to advise their patients on sharing their health information.
The survey also found that:

• About one-third of physicians said they will allow full sharing of their patient records;
• Four out of 10 physicians say they will opt out completely from the program and allow none of their records to be shared;
• 80% of physicians surveyed still think that sharing electronic health records can threaten patients' confidentiality, despite a government marketing campaign to promote the IT program; and
• 67% of general practitioners oppose the implied consent "opt out" model, which has formed the basis for the program to be rolled out, E-Health Insider reports.

Lord Warner, the former head of the NHS IT program, said that physicians have become "over-protective" of their existing health record system, according to E-Health Insider (E-Health Insider, 4/24).”

The lessons here are clear. The first lesson is that the implementation of a Shared EHR is a project which must be undertaken with continuing and ongoing consultations with clinicians and patients to ensure the directions being adopted are acceptable and will foster adoption and use.

The second lesson it seems to me is that in 2007 the Shared EHR is not a technical problem but a cultural change problem where is the trust of the users of the system is not developed and maintained the risk of failure of the overall project failure is greatly increased.

The third important lesson is that if the approach adopted minimises compulsion, maximises patient control of their information and maximises voluntary choice as to whether to use the technology or not, assuming good technical design, while slower to reach, genuine adoption and use is much more likely.

Separate from this report, the interested reader is referred to my article of March 15, 2007 which is found at the following URL:

http://aushealthit.blogspot.com/2007/03/shared-ehr-can-it-be-done-simply-and.html

Without going over old ground it seems to me a simple Shared EHR can be very useful, but only if it is developed in the context of using the information from advanced clinical systems to provide information to and retrieve information from the shared record. Clearly the shared record also needs to be properly standardised and securely transmitted, received and stored.

All this is easily done, using standard and well tried technology. Making use of the record voluntary for both doctor and patient is the way to go. With a voluntary record, I am sure what will happen is that those for who having their record available is important the service will be used, and those who are unsure or uninterested simply won’t. It should really be as simple as that.

I suspect that among those with chronic and complex disease, in the scenario I suggest above, there would soon emerge pressure on clinicians from their patient’s to upload records as “information insurance” for the chronically ill as well as assisting in the overall co-ordination and delivery of their care.

We must make sure any Australian initiative to develop and deploy a Shared EHR has these lessons from the UK firmly in mind and approaches the project in a genuinely voluntary way!

David.

It’s the Season for Silly Health IT Benefits Claims!

No sooner have we had NEHTA tell us how much we can save from e-Health but now we have a second entrant to tell us something different and even more incredible.

The Australian Centre for Health Research has just published (April 2007) a 19 page document entitled “E-Health and the Transformation of Healthcare”.

For those interested in reading the full document it can currently be found at the following URL:

http://www.achr.com.au/pdfs/ehealth%20and%20the%20transofrmation%20of%20healthcare.pdf


The headline claims from the executive summary are as follows:

“The impact on the individual can be imagined; the cost to the nation is immense. In Australia, it’s estimated that improved knowledge sharing and care plan management for patients with chronic disease would generate direct savings to the health care system of more than $1.5 billion per annum. Savings to the community from associated non-health care costs are of the same order. And increased workforce participation and productivity could add a further $4 billion per annum to the economy.

For the patients, home monitoring could reduce emergency room visits by up to 40%, hospital admissions by 30-60% and length of hospital stays by up to 60%.”

All I can say is “Here we go again!

”The argument made in the paper is:

• Disease Management (DM) and similar process improvement processes work
• Technology and ICT is an important enabler of DM
• If we approach Chronic Disease with technology there is a huge benefit possible.

This is all true as far as it goes. There is also no doubt – from a huge range of studies mentioned in other reports not cited here - that Health IT can make a difference. However the evidence as I read it does not support the proposed approach.

The paper does however get one point exactly right in the following:

“The Paper raises one final, important point - that of incentives. There is a cost to building this connectivity and information sharing but there is a mis-alignment between those who pay and those who receive the benefit.”

And rightly suggests who should pay

“Another important component is for the major beneficiaries of more efficient and effective health care (that is, governments, private insurers, and employers) to provide incentives for the use of electronic services, broadband health networks, and best practice processes.”

Of course we have yet to see any offers from Government etc to really ante up what is needed!

In summary the suggested approach is:

“ We should focus on three important areas:

1. get healthcare providers connected to one another
2. track health events across the continuum of care
3. create a broadband network of health services

In business, most high priority and high volume communications are handled electronically. But in health care, high-importance communications – e.g. referrals and hospital discharge summaries – are created using paper and pen and delivered via fax, letter and even by hand.

This is the point where we should begin – simply, aim to get referrals and discharge summaries to be delivered electronically in a convenient and secure form.”

To be polite this is a spectacular over-simplification of what is needed to achieve substantial benefit. Sure, - I have always been very keen on aiding the flow of key clinical documents electronically – but for a lot of good reasons this should be done in a secure, standardised, managed fashion and not as seems to be suggested here by provision of simple connectivity.

Likewise the second and third focus areas are dramatically more complex than identified in the paper.

The document has a ready, fire, aim feel to it. It is of note that the only Health IT benefits study that seems to be cited is this one while there are many other much deeper and much more recent studies readily available:

DMR Consulting, “HealthConnect Indicative Benefits Report”, Final Version, February, 2004 (extrapolated to latest chronic disease data). This can be found here:

http://www.health.gov.au/internet/hconnect/publishing.nsf/Content/C50C3B807441ADBACA257128007B7EC4/$File/hcibrv1.pdf

This document was so unpersuasive as to the available benefits of HealthConnect that the Commonwealth commissioned a review by the Boston Consulting Group (April 2004) and this review resulted in the change of HealthConnect from a funded strategic program to nothing more than a “change management strategy”.

Let me be clear about the problem I have with all this. Realistic estimation of the value of benefits from Health IT requires a clear exposition of what technology is to be implemented and how it will then provide benefit. To not have a Strategy for what is to be done, an Implementation Plan that describes how it will be done and a realistic Business Case that identifies both costs and benefits no one is going to care to take notice of, or action, unsupported claims of benefits.

We have seen two claims for major benefits that can be derived from Health IT (This present one and the study mentioned in NEHTA’s recent presentations). It seems passing strange that the two studies identify largely different sources of benefits and seem to come up with wildly different estimates of what is achievable.

The flaw in both studies is that they don’t proceed from a deep understanding of the business of Health Services Delivery and are not informed by what is needed at the clinical coal face. Only once the requirements and problems of the sector are clearly identified can a strategy to deploy technology to assist be developed and have a chance of success. Implicit in the strategy will be the benefit opportunities that will need to be firmed up. This is what then needs to be refined through the development of the implementation plan and business case which will reveal where investment makes sense and can make a difference. The last step (not the first) is to estimate the quantum of benefits and develop the approach to be used to capture them as implementation proceeds.

As I have said before the work required to convince the hard heads in Treasury to invest is substantial and needs to be a comprehensive package (Strategy, Implementation Plan, Business Case and Benefits Realisation Plan).

Without this work being done to a high quality I predict just nothing will happen.

These half baked studies do more harm than good I believe.

David.

Useful and Interesting Health IT Links from the Last Week

Again, in the last week I have come across a few reports and news items which are worth passing on. These include first:

http://www.govhealthit.com/article98187-04-16-07-Print

Finding Foreman

George Foreman named his five sons George. Will the National Health Information Network be able to pinpoint his health records? Maybe. Maybe not.

BY Nancy Ferris

Published on April 16, 2007

George Foreman — boxer, clergyman and entrepreneur — named his five sons after himself. So when the Nationwide Health Information Network (NHIN) is up and running, how will a doctor find the records for the right George Foreman?

Accurately matching patients with their electronic records is at the heart of the proposed network. But what if doctors search NHIN and find no records for anyone named George Foreman? If few matches are found, users will soon pronounce the network a waste of time and money, and they’ll abandon it.

However, if too many George Foreman records are found, the network could seem equally useless. Just imagine the number of records created over the years for the boxer’s sons and others with the same name who are not related to the more famous Foremans.

In that case, a doctor might be unable to determine which of the many records relate to his or her patient. If the doctor guesses wrong, the patient could end up with treatment that’s ineffective or even harmful. What’s worse in the eyes of many people is that the doctor’s employees could see the records of someone else’s patients.

Alternatively, someone from the doctor’s office could call the patient and ask questions such as, Did you ever live on Maple Street? Did you seek treatment for a broken leg in Grand Rapids? What was your maiden name? But that approach is labor-intensive and hardly seems to fit with the notion of a 21st-century information network. It also isn’t likely to provide enough value in return for the billions of dollars it will cost to create the network.

…..

As always see the sites for the full article. This is a useful listing of the problems you can face without really robust unique identifier approaches and is an especially large problem for Shared EHRs which do not have such technology at their core.

http://www.e-health-insider.com/news/item.cfm?ID=2618

IT and e-health is 'every nurse's business'

17 Apr 2007

IT and e-health is every nurse’s business because it has to be integrated into practice, nursing leader, June Clark, said on the eve of a major discussion at the Royal College of Nursing’s annual congress this week.

The discussion on the theme “Computerised records – what can they offer?” will be available online at the College website. Professor Clark, a former president of the college and chair of the RCN Information in Nursing Forum, told E-Health Insider she hoped as many people as possible in the e-health community would get involved.

She hopes the session will raise awareness on several fronts: “The first is awareness among nurses that e-health and IT and the introduction of IT into the NHS is every nurses’ business because it has to be integrated into nursing practice,” she said.
“The other awareness that I want to get across to this audience and more generally that electronic patient records must have appropriate nursing content, not just medical content.”

…..

Another useful point is being made here – the reason we prefer the term “Health Informatics” rather than “Medical Informatics” - it the Health IT needs to be used by all health professionals if the full benefit is to be achieved.

http://news.zdnet.co.uk/itmanagement/0,1000000308,39286714,00.htm

Parliamentary report urges action on NPfIT

17 Apr 2007 09:26

Public Accounts Committee has published a report that calls for urgent action to reduce the risks of the NHS National Programme for IT.

The success of the NHS National Programme for IT is precarious, with key projects running late and suppliers struggling to deliver, according to a long-awaited report from Parliament's influential Public Accounts Committee.

"There is a question mark hanging over the National Programme for IT (NPfIT), the most far-reaching and expensive health information technology project in history," said committee chair Edward Leigh on 17 April.
…..

The full report can be found here:

http://www.publications.parliament.uk/pa/cm200607/cmselect/cmpubacc/390/390.pdf

There seems little doubt that the huge UK programme has a large number of both good and bad bits. Despite the differences in Health Systems there is always a lot to learn from such reports. Careful reading recommended for those involved in major Health IT projects.

Further perspective can be found in a recent editorial in the MJA entitles "Lessons from the NHS National Programme for IT" written by Professor Enrico Coiera of UNSW. See the following URL:

http://www.mja.com.au/public/issues/186_01_010107/coi11007_fm.html

http://www.smh.com.au/news/National/Report-backs-electronic-health-records/2007/04/19/1176696992965.html

Report backs electronic health records

April 19, 2007 - 5:39PM

Up to $7 billion could be saved each year if Australia's health providers shared patient data electronically, says a new report.

Commissioned by the Australian Centre for Health Research, the report argues a broadband network of health services should be created to allow patients to be tracked no matter where they go for medical services.

Monash University e-health research unit director Michael Georgeff said about one-quarter of all Australians suffered from a chronic illness and many had complex health needs.

"Chronic illness requires close monitoring and, often, intensive management by a team of health professionals," Professor Georgeff said.

"But because of the way our health system currently operates, one doctor will often not know what tests or medications have been prescribed by another doctor even when they are members of the same team."

…..

The full report can be found at the following URL:

http://www.achr.com.au

I have deep concerns about this report and it claims which will be the subject of a future article. Download it and consider the claims it makes for yourself. (It’s only 19 pages)

David.

Policy Relating to Comments on the Blog.

The purpose of this blog is to provide a forum for discussion of the issues surrounding Health IT in Australia.

In that purpose there is the desire, from me, for accuracy, honesty and openness from all contributors.

Lately there have been a number of anonymous / whistle-blower comments on specific topics.

My view is that I will publish these – as long as they are free of direct personal attack and other objectionable comment on the basis that sunlight is a very good thing in the public policy arena – which is where this blog engages.

I am also more than prepared to publish any contrary views – both anonymously and as named contributions. Such contributions are both welcome and encouraged. Objectivity and truth is what is sought here!

I am also not planning to censor discussion – but I will protect any party from gratuitous personal abuse where possible - , including deleting posts I am informed or see are defamatory, obscene or deeply personally offensive. I will, of course, be the arbiter of that.

I believe in an open and transparent society and that the organs of government that support society should be equally open and transparent.

Would it were so!

David.

ps - I know that this is obvious - but it needed to be said. D.

A Few Other Things Regarding the AFR Article on E- Health.

The Australian Financial Review Article of the 13^th April, 2007 entitled “National e-health would save $30bn” by Julian Bajkowski makes a few comments I really don’t think should go through to the keeper.

The article states:

“The study has increased pressure on the federal government to abandon a number of failing federal electronic initiatives, including the $128 million HealthConnect project, which has yet to deliver tangible results.”

I would suggest this is wishful thinking as we see the grossly overfunded non-strategic trials which are being still being conducted by HealthConnect SA and HealthConnect Tasmania. It would be good however if this was an outcome and they were canned.

The article states:

“ Doctors, clinicians and hospitals have long sought electronic health and medical records that could be used across Australia's different state health systems.”

This really misses the mark. Most care (95%+) is delivered within a patient’s local area and virtually all care is delivered in the state of a patient’s residence. Doctors would be very keen to see records for their patients able to be used between the local practice, the local hospital and the local investigatory providers. The rest would be a cherry on the icing on the cake I would contend.

The article states:

“But developing the standards has been a battle because of a series of bitter quarrels between technology suppliers and standards bodies.”

This is largely just wrong. Between NEHTA and Standards Australia’s (SA) Health IT working parties there have been tensions and a lack of quality two way communication – but the Health IT industry has, for the most part, very good relations with SA. Relations between the Health IT industry and NEHTA are dodgy, at best, despite anything NEHTA may say.

The article states:

“NeHTA recently recruited the former head of Queensland-based Cooperative Research Centre for the Distributed Systems Technology Centre, Mark Gibson, as its chief technology officer.

The hiring represents a coup as it will ease NeHTA's access to a vast repository of e-health-related intellectual property held in trust by the shareholders of DSTC after the group's funding was terminated by the federal government in 2005.”

While not commenting on this particular appointment directly, I seriously doubt there is much useful intellectual property held in trust by DSTC given the failed and never properly reported HealthConnect trials it was involved in.

I hope these comments assist in understanding where things currently sit.

David.

A Headline To Die For - National e-health would save $30bn – Pity it’s a Wild Unsupported Bit of Speculation.

Friday 13 April, 2007 will go down in history as a very black day for e-Health in Australia. On that day, based on an apparent back door leak, Julian Bajkowski of the Australian Financial Review published an article entitled “National e-health would save $30bn”. This assertion is based on work undertaken by the National E-Health Transition Authority (NEHTA) under its Benefits Realisation work program and is based on a Systems Dynamic Model developed by modelling consultants. Before discussing the details it is important to keep in mind a very important fact about all such models. That is that ‘no models are correct, but some are useful’ (Robert Box)

Regular readers of the blog will wonder why I should be concerned by this claim of such huge net benefits. The reason is very simple. While I firmly believe there are major benefits to be harvested from the deployment and use of e-health – and I believe the literature makes it reasonably clear where they are to be found – such claims are simply unsupportable without very substantial additional evidence.

NEHTA talks of the model they have developed in the following terms:

Modelling approach used for the study
• System Dynamics Model:
- Increasingly preferred (e.g. NHS)
- 900+ variables, 300+ calculation nodes, 25 sectors
• National and international expertise engaged:
- Jurisdiction, consumer and clinician input
• Focuses on major e-health benefits, costs and relationship to demand, quality and safety as e-health initiatives are rolled out over a 10 year period

Additionally they cite a range of published evidence from CITL, RAND etc and claim that from 3400 papers published since 1980 that Adverse Drug Events can be reduced by 50% (or more) by using Computerised Physician Order Entry (CPOE) with effective interactive decision support – among a range of other benefits that have been identified for e-Health.

They also suggest that there are 500,000 years of life to be saved in the Australian Population over 10 years with the implementation of e-Health.

What is conspicuously absent from all the presentations is the ‘how’? We are not told any of the basics that are required to make this credible. Obvious questions are:

What is the strategy, transition and implementation plan to move from where we are now to this 10 year future nirvana? If you don’t have that properly understood, documented and agreed with stakeholders how can you make any sensible comments about possible benefits? This is serious cart before the horse material I believe!

What are the assumptions for the capabilities of the systems to be used in hospitals and ambulatory practice to achieve these benefits? (It should be noted CPOE is notoriously difficult and complex to implement in hospitals – to the extent that – when last I looked – no more than 5% of hospitals globally have such systems in place. They are also not cheap to buy and implement.)

How much will such systems cost and who is going to pay for them?

What is a realistic time frame for replacement of present systems with the new more capable systems assuming they are readily available?

Given the vast majority of patient care is delivered in the private sector just what incentives (from Government) will be required to get the private sector on board?

Do we have the doctors, nurses and pharmacists who are sufficiently well trained and skilled in IT to make the transition to the e-health way of doing things?

Who is going to capably manage and co-ordinate such a huge change management and technology implementation program?

Are the assumptions in the model regarding a Shared EHR strategy correct? Is that ultimately the right approach for Australia? There is certainly a case for a careful review of the options being deployed around the world.

So what do we have here? Essentially what we have is a model without a strategy for architecture, implementation, funding and subsequent benefits management. There is no point putting out a generic claim about a possible scale of benefits without laser like clarity on just what is being proposed – or the economic hard heads in Treasury will shoot you down before you get started. This is where my concern lies. We have a once in a generation chance to propose a major re-investment in e-health for Australia and for it to succeed we need a model of an implementable and stakeholder approved strategy and implementation approach. Without clear and totally credible answers to all the questions I pose above, this initiative will turn out to be an expensive waste of time and effort.

It is vital in all this that those managing this proposed implementation ‘under promise’ and ‘over deliver’. I see no evidence of that approach in all this.

It is all very well for the Financial Review to publish an exciting headline and it is always important not to let the facts get in the way of a good story but I really think a little more digging regarding the reliability of NEHTA’s numbers, the assumptions and risks involved, the underlying strategic assumptions and recognition that things are usually much more complicated than they appear in a proposed, and largely yet to be defined, project of this scale would have been useful.

I look forward to NEHTA’s release of the Strategy and Implementation Plan that the model assesses along with the model and its assumptions. I will not be surprised to find I am once again disappointed and that sadly it all turns out to be largely ‘smoke and mirrors’ which will get us nowhere.

A final point that should be made is that the NEHTA Benefits Case relies on the deployment of clinical decision support (CDS). That, CDS, is sadly not actually part of NEHTA’s work plan as currently published. If it is actually worth so much, focus is needed and fast! Whoops!

We will wait and see!

David.

Useful and Interesting Health IT Links from the Last Week

Again, in the last week, I have come across a few reports and news items which are worth passing on. These include first:

http://www.reuters.com/article/healthNews/idUSN1236605720070412

Wal-Mart sees medical clinic boom in retail stores

Thu Apr 12, 2007 4:40PM EDT

ORLANDO, Florida (Reuters) - Wal-Mart Stores Inc. is forecasting more than 6,600 in-store medical clinics will open their doors in the next five years in retailers nationwide, a company official said on Thursday.

"I think it's an indication of how bullish individuals (chief executives of clinics and retailers) are," Alicia Ledlie, senior director for Wal-Mart's health business development, said at a health care retailers convention in Orlando.

With 75 clinics in Wal-Mart stores in 12 states, the company has ended its pilot program and plans a faster roll-out of additional clinics nationwide.

Ledlie said Wal-Mart is considering providing its in-store clinics with a common electronic medical records system so patient care can be tracked from store to store.
She said the system could ultimately be part of a universal electronic medical record system for the country

…...

See the rest of the article at the URL above. This is a really interesting development where the world’s largest retailer is developing both a huge number of medical clinics and, presumably for good commercial reasons, to utilise a sophisticated EHR system to provide seamless care to their customers no matter which store the seek care from. 6,600 clinics is an amazing number of clinics!

Second I noted this report from Europe. The value is in the second and third URLs that permit access to a wide range of information on e-health plans in all 27 member countries of the EU.

http://www.euractiv.com/en/health/report-shows-good-progress-health/article-163098

“Report shows good progress on e-Health

Published: Thursday 12 April 2007

Member states have made good progress in implementing the EU's e-Health strategy but have failed to address education and socio-economic issues falling under their responsibility, a new progress report shows.

An EU report confirmed that good progress has been made across the continent following EU member states' commitment, in the European e-Health action plan to develop a national or regional roadmap for e-Health.

http://ec.europa.eu/information_society/activities/health/docs/policy/200703ehealthera-countries.pdf

"e-Health is increasingly becoming an integral element of national health system objectives. It is seen as a key enabler in wider contexts like improving the quality and efficiency of public services, or speeding up the development towards knowledge driven societies," states the report, drafted by a project entitled Towards the Establishment of a European eHealth Research Area (eHealth ERA).”
…..

A useful listing of European Approaches to E-Health

http://www.ehealth-era.org/database/database.html

The third is a short piece of Australian news.

http://www.computerworld.com.au/index.php?id=523856106&eid=-180

“E-health authority appoints new chair

Sandra Rossi 10/04/2007 10:31:43

Director-general of the Queensland department of health, Uschi Schreiber, has been appointed chair of the National E-Health Transition Authority (NEHTA).
Schreiber will replace the outgoing secretary of the Victorian department of human services, Patricia Faulkner.”

There is but one comment to be made on this appointment. Ms Schreiber needs to be a hands on Chairperson of NEHTA and ask the hard questions about the appropriateness of the current NEHTA strategic directions. This is the core function of the NEHTA Board and especially its chairperson. If she does not do this – and listen to a broad range of voices who are not largely beholden to NEHTA for their income - she runs the risk she will be seen my many in the e-health domain as a dog who is being wagged by an organisational tail!

A good place to research for some had questions might be this very blog.

David.

Why The Government will Never Fund a Shared EHR – And Probably Shouldn’t.

As regular readers of the blog will know development of a National Shared Electronic Health Record (SEHR) has been some form of Holy Grail for the e-Health bureaucracy and for many government e-health strategists and planners. Indeed it is no secret that NEHTA is developing such a project. From their web site we read:

“Shared Electronic Health Record

NEHTA is working to develop specifications and requirements for a national approach to shared electronic health records. These records will enable authorised healthcare professionals to access an individual's healthcare history, directly sourced from clinical information such as test results, prescriptions and clinician notes. The shared electronic health record will also be able to be accessed by individuals who have received healthcare services.

Specifically, NEHTA will focus on developing:

• Operating concepts for a national approach to establishing and maintaining shared electronic health records;

• Policies, requirements, architecture and standards for a national approach to shared electronic health records; and

• A business case to substantiate and validate the proposed approach.

For the health system within Australia to reap the full benefits from the IT, governments and healthcare providers need to make the case for undertaking further investment including the development of a national system of shared electronic health records. The case for the required level of investment depends on the credible quantification of the costs and benefits of providing such.”

I understand that NEHTA plans to have developed the SEHR business case ready for submission to the Council of Australian Government (COAG) sometime in 2008. I would be prepared to wager a whole days wages they will not get approval to proceed to implementation, but will concede there may be some funding provided to have NEHTA (or someone else) go ahead to develop some more detailed plans and costings.
Before considering the possibility of SEHR Project success and funding we need to identify what is being proposed. From the most recent NEHTA presentations we see the following:



So from when funding is approved to proceed with the total project – probably in 2008 / 9 at the earliest - we will have the following happening. First two years of set up, certification, planning and procurement of a SEHR provider – to 2011 – and then over the next five years a rollout of an interoperable healthcare provider desktop. Starting in 2013 it is also planned that remote e-consultation will begin.

Can I say that the whole plan has a total air of un-reality and fantastic (in the real sense) wishful thinking about it. Among the realities that need to be faced are the following:

Firstly the present Federal Government has had over a decade to consider a major investment of this sort on Health IT and has not done so – what has suddenly changed that a 2008 proposal would suddenly meet acceptance? The answer is not much. If Government changes at the end of the year then all bets would clearly be off ( and planning would start again most likely ) and if it does not I suspect the 2011 election would see change – and a long and detailed review would be inevitable. Timing thus seems less than optimal at best.

Secondly large scale top down complex IT projects – in mixed health sector funding environments – are likely to be very problematic. The only examples of success in such a strategy are Kaiser Permanente (and a couple of similar managed care entities in the US) and the UK NHS. Both of these projects have proved to be both quite expensive and very difficult to manage. The other successes at a national scale have been in countries like Denmark and the Netherland where a messaging based bottom up relatively simple, standards based and incremental strategy has been successful. The co-operative disseminated model adopted by Infoway in Canada also seems to be progressing reasonably well and is possibly the closest match to the Australian situation.

Thirdly no Government in their right mind would invest in a SEHR project of the type presently proposed without some very substantial pilot and trial implementations at considerable scale. At the very least an implementation of the scale of a smaller state (say South or Western Australia) would be required to provide a credible ‘proof of concept’. This pilot / trial would take at least two years to be planned, implemented and evaluated. Given the abysmal failure of the various HealthConnect pilots – and the consistent withholding from public review of any detailed evaluation reports – success in this pilot endeavour could hardly be guaranteed. To not conduct a rigorous pilot / trial would, of course, be the height of folly and exceptionally high risk. It is not clear where this is planned to be undertaken on the NEHTA timetable shown above.

Fourthly there is a major project risk which is in-escapable in projects of this type. That is the inevitable political interference that is seen with large public projects and the difficulty of preserving direction and focus over many years required to deliver satisfactory outcomes. It is hard to think of any major Federal Government computer systems which have met both financial and planed time-lines. An additional risk, which should not be minimised, is the technical and system integration risk. As anyone with experience of the Health IT field will confirm very often interoperable simply isn’t (despite the use of recognised Standards) and much work is needed to make it so!

Fifthly at present the scale of costs of such a project – extending over at least four to five years – is essentially unknowable until the pilot implementations are complete. Any business case prepared before such information is available is likely to be more wishful thinking than fact. Associated with this issue is the lack of clarity as to what would be invested in and who would be investing in what and who would be paying for what. It seems improbable that such a major infrastructural upgrade will be willingly paid for by the users – i.e. GPs, Specialists, Hospitals and Diagnostic Providers – without some major cost recovery mechanisms being in place that obviates their financial risk.

Sixthly there will be a problems with having Hospitals and GPs / Specialists / Diagnostics in the private sector (they have most of the information that is to be shared.) being co-ordinated and managed in terms of information flows, implementation timetables and investment levels by NEHTA / Government.

Seven, any Shared EHR will inevitably face the privacy, confidentiality and consent issues associated with projects of this type, where the is always lingering public doubt as to just who can access the shared records and what control the patient has over such sharing. A program to convince a sceptical public of the benefits of a project of this sort will be neither brief or cheap.

Eight, right now there is a total lack of a credible business case that actually explains what will be paid for and who will pay. It is all very well to assert that there will be vast benefits from clinical decision support and e-consultation but until all the assumptions regarding the technology(ies) and capabilities to be deployed, what information is shared and what remains on local systems, who will be the users of these new systems, how the transition will be funded and managed and how the required knowledge bases are acquired and maintained credibility is severely stained at best.

Nine, while a simple PowerPoint slide can illustrate the concept of a SEHR the length of time and the level of work required to have even the smallest amount of health information sharable across a national entity (e.g. the UK) shows this is an undertaking of very considerable complexity, which is underestimated at considerable peril. Remember the basic idea has been around in Australia since 2000 / 1 and real progress towards a working outcome has not been impressive to date.
Last it needs to be appreciated that the development of a transition plan to take Australia from a wide variety of partially linked disparate client systems to a reasonable number of certified high quality client systems with rich functionality all supplying appropriate standardised, reliable information to some central SEHR securely and privately will of itself be major and as yet unaddressed and unfunded task.

What should be done instead?

With adjustments to suit our local Commonwealth / State divide it seems to me a national strategy based on locally based health information sharing initiatives on a background of proven Standards and compliance certification has the highest probability of success – especially when combined with an appropriate benefits re-distribution strategy to ensure those who are meeting the costs are rewarded for their efforts.

We could learn from ONCHIT in the US and let three or four contracts to build demonstration systems based on established standards and take the best features of each to develop a scalable bottom up approach that could then be rolled out at relatively low risk. These would be project managed commercially and their outcomes fully evaluated in public.

I am also strongly persuaded of the truth of the argument that real benefits are predominantly derived from advanced (Level IV) system and that the key to real benefits lie in standardised basic information sharing between advanced client systems. Secondary data sharing also needs to be part of the mix to ensure public health and post marketing surveillance of medication side effects (as well as bioterrorism) are effectively addressed. A top down strategy is almost certain to fail in the Australian environment and we would be better to go down a path that involves the determination of client functionality required, development of appropriate certification processes and standards and have the private sector develop and support appropriate systems. There could also possibly with an initially government funded Open Source alternative that could be developed, supported and provided at low (but reasonable) cost and maintained as an exemplar of what is required. This strategy could provide an incentive for commercial system developers to ‘out develop’ the basic system to demonstrate the additional value provided by their offering.

The total funding of any national SEHR at the COAG meeting in 2008, based on the current plans, seems to me to be ‘courageous’ in the extreme. Cooler heads need to prevail and a strategy suitable for Australia in 2008 to 2018 and beyond needs to be developed free from the unsuitable large scale SEHR proposal that seems to currently be dominating NEHTA thinking.

David.