Useful and Interesting Health IT Links from the Last Week – 20/05/2007

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.informatics-review.com/

“Improving Information Technology Adoption and Implementation Through the Identification of Appropriate Benefits: Creating IMPROVE-IT

This paper describes the objectives of a collaborative initiative, IMPROVE-IT, that attempts to provide the evidence that increased information technology (IT) capabilities, availability, and use lead directly to improved clinical quality, safety, and effectiveness within the inpatient hospital setting. This collaborative network has defined specific measurement indicators in an attempt to examine the existence, timing, and level of improvements in health outcomes that can be derived from IT investment. These indicators are in three areas: (1) IT costs (which includes both initial and ongoing investment), (2) IT infusion (ie, system availability, adoption, and deployment), and (3) health performance (eg, clinical efficacy, efficiency, quality, and effectiveness).”

The full paper can be found at:

http://www.jmir.org/2007/2/e9

This is a useful contribution which aims to foster careful research on the value contributed by Health IT towards healthcare system quality, safety and efficiency and effectiveness. The lack of a totally compelling integrated evidence set on this matter is a significant blocker of further investment in the area and the initiative is to be encouraged.

It should not be underestimated just how hard this task is and how complex gathering credible data can be in this area.

It would be good of some health service organisations in Australia could contribute to the research.

Second we have:

http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=45023

Recent Releases | Issue Brief Examines How Personal Health Record Products Meet Needs of Underserved Minorities

[May 18, 2007]

"Personal Health Records: What Do Underserved Consumers Want?" Mathematica Policy Research: The issue brief describes features of personal health records -- paper- or electronic-based systems to record an individuals health information -- and looks at how those features meet the needs and wants of underserved minorities. According to the brief, based on focus groups conducted with underserved minorities from New Brunswick, N.J., people want PHRs that are portable, secure, private, simple and affordable. Minorities also would pay modest fees to set up and update the PHRs, but they would be reluctant to pay maintenance fees. The brief suggests that PHR developers might need to increase their efforts to assess their products' usability among low-income minorities who might have limited access to computers and low health literacy (MPR release, 5/17).”

The full issue brief can be found here:

http://www.mathematica-mpr.com/publications/pdfs/phrissuebr.pdf

It was interesting that the focus group participants, questioned by the study found that:

• All favoured a smart card, or other device as large as a credit card, that can be scanned by health providers to obtain their records;
• All wanted to choose who can access their PHRs, with restricted access to certain individuals and an audit trail to show who accessed the records and why;
• Most want basic personal health information in their PHRs, including demographic and health insurance information and lists of conditions, medications and allergies; and
• Many would pay setup fees of up to $30 and update fees of up to $5.

It is worth noting that even in a disadvantaged group there was considerable clarity about the need for the individual to control what happened to their information and that keeping it simple is probably the best way to start.

Third we have:

http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=482678

“Mirror, Mirror on the Wall: An International Update on the Comparative Performance of American Health Care

Overview

Despite having the most costly health system in the world, the United States consistently underperforms on most dimensions of performance, relative to other countries. This report—an update to two earlier editions—includes data from surveys of patients, as well as information from primary care physicians about their medical practices and views of their countries' health systems. Compared with five other nations—Australia, Canada, Germany, New Zealand, the United Kingdom—the U.S. health care system ranks last or next-to-last on five dimensions of a high performance health system: quality, access, efficiency, equity, and healthy lives. The U.S. is the only country in the study without universal health insurance coverage, partly accounting for its poor performance on access, equity, and health outcomes. The inclusion of physician survey data also shows the U.S. lagging in adoption of information technology and use of nurses to improve care coordination for the chronically ill.

Executive Summary

The U.S. health system is the most expensive in the world, but comparative analyses consistently show the United States underperforms relative to other countries on most dimensions of performance. This report, which includes information from primary care physicians about their medical practices and views of their countries' health systems, confirms the patient survey findings discussed in previous editions of Mirror, Mirror. It also includes information on health care outcomes that were featured in the U.S. health system scorecard issued by the Commonwealth Fund Commission on a High Performance Health System.

Among the six nations studied—Australia, Canada, Germany, New Zealand, the United Kingdom, and the United States—the U.S. ranks last, as it did in the 2006 and 2004 editions of Mirror, Mirror. Most troubling, the U.S. fails to achieve better health outcomes than the other countries, and as shown in the earlier editions, the U.S. is last on dimensions of access, patient safety, efficiency, and equity. The 2007 edition includes data from the six countries and incorporates patients' and physicians' survey results on care experiences and ratings on various dimensions of care.

The most notable way the U.S. differs from other countries is the absence of universal health insurance coverage. Other nations ensure the accessibility of care through universal health insurance systems and through better ties between patients and the physician practices that serve as their long-term "medical home." It is not surprising, therefore, that the U.S. substantially underperforms other countries on measures of access to care and equity in health care between populations with above-average and below average incomes.

With the inclusion of physician survey data in the analysis, it is also apparent that the U.S. is lagging in adoption of information technology and national policies that promote quality improvement. The U.S. can learn from what physicians and patients have to say about practices that can lead to better management of chronic conditions and better coordination of care. Information systems in countries like Germany, New Zealand, and the U.K. enhance the ability of physicians to monitor chronic conditions and medication use. These countries also routinely employ non-physician clinicians such as nurses to assist with managing patients with chronic diseases.

The area where the U.S. health care system performs best is preventive care, an area that has been monitored closely for over a decade by managed care plans. Nonetheless, the U.S. scores particularly poorly on its ability to promote healthy lives, and on the provision of care that is safe and coordinated, as well as accessible, efficient, and equitable.

For all countries, responses indicate room for improvement. Yet, the other five countries spend considerably less on health care per person and as a percent of gross domestic product than does the United States. These findings indicate that, from the perspectives of both physicians and patients, the U.S. health care system could do much better in achieving better value for the nation's substantial investment in health.”

This report is available to download from the web-site referenced above.

The slide pack of 130 or so comparative slides which is also available for download from the same site is an invaluable and carefully researched resource.

The report provides useful coverage of the adoption and use of Health IT in the countries analysed and is well work a download and review.

Fourth we have:

http://www.healthcareitnews.com/story.cms?id=7130

Home telemonitoring works, study claims

By Richard Pizzi, Associate Editor

05/10/07

MONTREAL – Home telemonitoring of chronic diseases appears to be a promising approach to patient management, says a team of Canadian scholars who reviewed more than 65 telemonitoring studies in the United States and Europe.

The study, entitled “Systematic Review of Home Telemonitoring for Chronic Diseases: The Evidence Base,” appeared in the May/June 2007 issue of the Journal of the American Medical Informatics Association.

Researchers at the University of Montreal in Quebec, Canada, searched the Medline and Cochrane Library databases for research studies on telemonitoring published between 1990 and 2006. The 65 papers they examined included studies on the home-based management of chronic pulmonary conditions, cardiac diseases, diabetes, and hypertension. Each of the studies employed various information technologies that were used to monitor patients at a distance.

The Canadian scholars, led by Guy Paré of the University of Montreal’s Health Administration department, concluded that home telemonitoring produces accurate and reliable data, empowers patients and influences their attitudes and behaviors, and may improve their medical conditions.

Paré and his colleagues claimed that the magnitude and significance of the effects that telemonitoring has on patients’ conditions still remains inconclusive. Nevertheless, the study’s results suggest that patients will comply with telemonitoring programs and appear to embrace the IT involved. This seemed to be true regardless of a patient’s nationality, socioeconomic status, or age.

…..

The complete article can be read at the URL above.

This is a very interesting systemic review that show the well planned telemonitoring initiatives can make a difference to the outcomes of patient care. Another brick in the wall showing the value of ICT in the health sector.

Lastly we have

http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20070514/FREE/70514003/1029/FREE

Peel brings privacy issues 'front and center': profile

By: Joseph Conn / HITS staff writer

Story posted: May 14, 2007 - 8:55 am EDT

Part one of a two-part series:

The telephone rang as Deborah Peel was driving to the airport outside Austin, Texas, a few weeks ago.

It was one of several long-distance calls she'd had that day with someone, though not a patient, who nonetheless was seeking Peel's help and support. For Peel, a physician trained in psychoanalytic psychiatry, her end of the conversation was a blend of delicate probing, empathic listening and full-bore affirmation.

When the phone call ended, Peel smiled, knowing that even though the problem was not yet fully resolved, her caller was in a better place.

"Everybody needs to be listened to," she explained. It's a phrase that isn't on Peel's business cards, but perhaps it should be.

According to Peel, 55, who is winding down her solo psychiatric practice of 30 years, today she's listening to far more patients than have ever been through her Austin office, with its Oriental rug, cloth upholstered couch and four glass-fronted bookcases stuffed with texts, including 23 light-blue volumes of the writings of Sigmund Freud.

…..

This is a useful pair of articles that describe the views of Dr Peel on the requirements for Health Information Privacy that are sought by the American public. The issue of the use of health information in data-mining is currently flying ‘under the radar’ in Australia but I would suggest this is likely to change as awareness of such practices on behalf of Medicare Australia and the Private Health Funds becomes more common.

More next week.

David.

Now Hold on Just A Moment! - Privacy Report Part 2

In the previous article I mentioned that NEHTA had just released a new document entitled “Privacy Blueprint on Unique Healthcare Identifiers - Report on Feedback - Version 1.0 - 14/05/2007”.

A friend of the blog has managed (through considerable diligence) to locate three of the 14 written submissions mentioned in the report and provided detailed comment in the same blog as the first comment. These submissions come from the Office of the Commonwealth Privacy Commissioner (31 Pages), the Australian Privacy Foundation (4 Pages) and the Consumer Health Forum (11 Pages).

These are available on-line and the links to those submissions are as follows:

APF:

http://www.privacy.org.au/Papers/NeHTA_UHI_Blue070313.pdf

OPC:

http://www.privacy.gov.au/publications/subnehtauhi200703_print.html

CHF:

http://www.chf.org.au/Docs/Downloads/430_NeHTA_Privacy_Blueprint_Submission.pdf

Having had a chance to review what these three submissions say, I would suggest it is even more important that all the submissions are made public as it is clear the summary of what was submitted to NEHTA vastly understates the subtlety, number, importance and complexity of what NEHTA has been told.

Readers are asked to download and read for themselves and I am sure they will realise, and agree, just how severely NEHTA’s summary sells the issue very much short.

Given the terrible experience overseas of e-health projects when privacy is not properly addressed NEHTA seems to me to be "burying its head in the sand" over the complexity and difficulty of all this - despite its new found keenness to employ a Privacy Officer.

David.

PS – To answer the question posed in the earlier comment, no, I did not provide a written submission.

D.

NEHTA Goes Back to Its Old and Less Desirable Ways.

NEHTA has just released a new document entitled “Privacy Blueprint on Unique Healthcare Identifiers - Report on Feedback - Version 1.0 - 14/05/2007”

The eight page document provides a summary of the fourteen written submissions received during the two-month public consultation period (which began in December 2006) with several bodies requiring an extension until mid-March 2007.

The first and most obvious question is where are the actual submissions? It seems we are not allowed to read them and form our own view as to what are the respondents views. We have to be given a 'pre-digested' and simplified summary. This is of course totally different to the operation of the Access Card Privacy Task Force where all the submissions – even the anonymous ones – are made available on the Department of Human Services web-site. I wonder what NEHTA has to hide?

As for the document itself the following caught my attention:

1. “ It is clear from submissions that the discrete concept of unique healthcare identification is difficult to understand in isolation from other e-health activities (such as the application of identifiers in clinical systems).”

Well clearly I am with the stupid! It seems pretty clear you only have healthcare identification (i.e. the allocation of a unique number or code to an individual person of healthcare provider) so you can apply, look up or use it in some application or system – so precisely how can it be understood in isolation? Blowed if I know.

2. “NEHTA will identify additional avenues and means of communication throughout 2007-08 to ensure wide coverage of key stakeholders for future consultation activities”

I see from this we are going to be consulted and communicated with for the next eighteen months. Seems to me a bit of focus and effort could do what is required in about a quarter of that time!

3. “Many submissions specifically commended and endorsed NEHTA's proactive approach to privacy management and consultation.”

I read this as saying those consulted appreciated being asked – not that they actually agreed with what was proposed.

4. “The connection to the Australian Government's Health and Social Services Access Card was queried by many submissions, some revealing the mistaken belief that there was or should be a formal relationship between the two initiatives.”

This statement comes from Section 3.2 “Overlap of UHI with other initiatives”. It is a great pity this section does not explain its position. All we get, in five short paragraphs, is that many respondents who thought there was or should be a ‘link’ were mistaken. But why were they mistaken? Where is the explanation?

It is clear that both projects are identity management initiatives being undertaken by government, that a key use of the Access Card is to provide access to health services, and that the Access Card will be a more trustworthy identifier than the IHI from NEHTA. So we need to have it explained to our simple minds just why the two ought not be linked – especially now we know the same department – Human Services – will be operating both databases almost certainly. The denial around this is just bizarre. They are clearly parallel projects that aim to do similar things. So why not explain why separate initiatives are needed. Blowed if I know – especially since we also now know that the IHI will almost certainly need its own enabling legislation – just like the Access Card.

5. “NEHTA's view remains that legislative support for the UHI Service will provide the greatest level of legal certainty around meeting consent requirements, and therefore promote trust and confidence.”

Section 3.3 on Consent gives us four paragraphs that say we will need to legislate but it does not say what the terms of the legislation will be. This is about as useful as the legendary 'barnacle on a battleship' and reflects the arrogance of the initial blueprint with its Joh like 'don't you worry about that' type of approach.

As I argue in another article it you don't get consent right in e-health projects you can doom yourself. It is not clear from this document NEHTA understands that.

6. “NEHTA's planned secondary uses consultancy for 2007 will identify principles for assessing secondary uses in both the UHI and Shared EHR and develop a secondary uses framework. NEHTA will examine national and international approaches to secondary uses, which will also inform recommendations on the degree to which secondary uses should be supported by and managed within NEHTA initiatives.”

In section 3.4 we get three paragraphs to cover what was learned from the fourteen submissions.

Essentially the document says we need to do more work.

I would make two points. First it is important to distinguish between the IHI and the associated data. I can conceive of no reason for the actual data record to be the subject of secondary use and second it would seem to me that the UHI itself would be recorded on any record that was to be the subject of secondary processing so it is all that is needed for secondary record linkage. That being the case I struggle to understand just why the IHI record would ever be disclosed external to the IHI service.

The use of the actual UHI identifier for secondary record linkage would of course need to be controlled as other such identifiers presently are under legislation and to required specific authorisation from ethics bodies and the like.

7. “NEHTA was aware of these overarching privacy risks as a result of internal privacy analysis combined with the results of the early-2006 preliminary Privacy Impact Assessment. Knowledge of these particular privacy risks for the UHI Service has informed the development and design of the UHI Service and will continued to be managed through work examining:

· Data security;

· User authentication;

· Audit and access requirements; and

· Governance.”

What this is really talking about is the 'honey pot effect'. Create a database with the demographics of all 16 million citizens and you create a resource every debt collector, thug and violent husband will look forward to be able to access, for a small fee. Access will be provided by the greedy and unprincipled in the healthcare provider community of which we all know there are some. Not many, but enough, to make any privacy assurances largely moot.

NEHTA just hopes no one will notice although it is of concern as they write:

“The remaining principle (informing consumers fully about any privacy breaches) is consistent with NEHTA's position on the need for openness and accountability, however was not specifically considered in the Privacy Blueprint.”

Pity it was not made clear NEHTA will make sure this is implemented – along with compensation for those who are forced to re-locate to escape the violent ex-spouse.

8. “Key issues noted in submissions included:

· The extent of administrator access and healthcare provider organisational access to healthcare individual's unique identifier and associated record;

· The requirement for strict guidelines for access to UHI Service to prevent abuse and the chance of errors in the system;

· The range of data fields on individuals proposed to be collected; and

· The need for a flexible framework dealing with authorised representatives so that the provision of healthcare is not adversely affected by administrative requirements.”

These are all important issues and again we get no answers.

In summary this document is a less than useful re-statement of the problems associated with the introduction of the UHI service which offers no significant answers, insights or progress.

Worse the material on which it is based is not disclosed despite “NEHTA's position on the need for openness and accountability”.

Yet another hastily pushed out useless and obfuscatory document. The imminent review of NEHTA’s usefulness must really have NEHTA worried. And rightly so in my view.

David.

And now some very late news!

Finally NEHTA is hiring a dedicated privacy officer!

“The National E-Health Transition Authority Limited (NEHTA) is advertising for a Privacy Officer. Advertisement is below.

Be part of Healthcare Reform

An exciting opportunity exists for an experienced Privacy Officer to join the Unique Healthcare Identification (UHI) Program - one of the cornerstones of a new e-health framework

• Sydney CBD

• Great development opportunity

The National E-Health Transition Authority Limited (NEHTA) is a not-for-profit company established by the Australian Commonwealth, State and Territory governments to develop better ways of electronically collecting and securely exchanging health information.

NEHTA’s mission is to set the standards, specification and national infrastructure requirements for secure, interoperable electronic health information systems. The Australian State and Territory governments will then adopt these requirements nationally, with the aim of creating a common national approach that will set the foundations for widespread and rapid adoption of e- health across the national health sector.

NEHTA and privacy

From the outset, NEHTA has recognised that privacy is an issue of great concern to Australians – particularly in the health sector. Protection of privacy is fundamental to maintaining consumer confidence and encouraging individuals to participate in e-health initiatives. At the same time, the frameworks must facilitate the best possible outcomes for the improved provision of healthcare and safety in Australia, including better sharing and availability of health information.

NEHTA’s privacy management strategy for the UHI Service is primarily set out in its Privacy Blueprint publication (available on the NEHTA website under Publications). The Privacy Blueprint for the UHI Service provides a framework for identifying and Discussing privacy issues and sets out an action plan for managing privacy risks. Using this approach has ensured that NEHTA has proactively considered its privacy compliance position and promoted a coordinated approach to privacy management.

An exciting opportunity exists....for an experienced Privacy Officer who will be responsible for further developing the UHI Program’s privacy framework and supporting documentation, including policies, procedures and privacy notices, and assisting with the management of key privacy activities, such as the Privacy Impact Assessment (PIA).

For further details about this position, please go to the NEHTA website at www.nehta.gov.au and navigate to the Employment page.

For enquiries please email careers-at-nehta.gov.au.”

Only three years too late and hardly making it clear they know what is public wants is key!

D.

SA HealthConnect Opens an Appalling e-Health Tender.

SA HealthConnect are at it again – working hard to squander public money as quickly as possible.

On May 8 the HealthConnect SA Released a Tender Seeking a South Australian Care Planning System (SACPS).

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Apology: I am sorry to be posting a lot of detail – but to follow just how bad this tender is it is important to read closely and with the background that can be found at the HealthConnect SA website.

http://www.healthconnectsa.org.au/ - was temporarily unavailable Mon 14 May at 4:47 pm EST. Fixed at time of posting.

For those who want the message without pain the next two or three and last 10 paragraphs will do it!

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Essentially the tender says – as I read it – we are seeking to procure a South Australian Care Planning System (SACPS). We are not sure what it should look like and what functionality it will be able to deliver but it has to be implemented and ready to be evaluated by March 2008. It also has to provide a shared care planning record that is web accessible and that can be used by GPs, Specialists and Hospitals (at least). Oh! – and yes - the money runs out on June 30, 2008 and ongoing operation beyond that time is not guaranteed. As an additional complication for you, our humble responder, we want the system to utilise NEHTA services which are not planned to exist until 2009/10 at the earliest.

What the tender goes on to say is – because we are so vague as to what we want and what is likely to be available, either off the shelf or needing to be developed – we want a fixed price bid that we can negotiate around to come up with something we think is suitable. Also, again because of our vagueness, can tender respondents please come up with a range of implementation and delivery options we can choose from.

Clarity around the decision making to decide how many respondents to negotiate and discuss with – and possibly collect intellectual property from for free – is also not provided as best I can tell!

And to make potential tender respondents really comfortable we then read:

“Because of this, the HealthConnect SA Program is seeking partnership with a preferred vendor that:

Demonstrates an innovative approach to this RFP;

Is able to articulate the vision for the goal-state SACPS;

Is committed to delivering or migrating to standards-based solutions;

Shares the financial burden associated with developing standards-based solutions; and

Recognises the commercial value of partnering with HealthConnect SA.

In responding to this RFP, respondents are requested to identify how such a partnership might work, the benefits envisaged by such a partnership and what would be expected of HealthConnect SA in entering into such an arrangement.”

This is code for “we want you to bear a good part of the cost of getting this thing up”!

Even more fun is an earlier part of Section 3.26 as follows:

“The HealthConnect SA Program expects the goal-state SACPS to be at the forefront of a new generation of ICT systems in the Australia health system. The goal-state SACPS will lead on three fronts:

The extent to which enhanced care planning functions will be available to support health care providers across disparate healthcare settings;

The high levels of interoperability that will exist between the SACPS and other key State and National initiatives; and

The adoption and use of standards and migration of the SACPS in line with developments in the NEHTA work program.”

To help the SA HealthConnect workout what they are asking for the responding vendor to provide a “Gap Analysis” identifying the differences between the possible and the fantasy they have in mind but have not clearly articulated.

Forgive me but this is really just nonsense. But it gets worse. Mandatory requirements are provided in Section 32.9.1

Mandatory Requirements

· Financial viability of the Respondent;

· Health Industry Experience of the Respondent;

· Evidence of proven integration experience with HL7;

· A clear vision for their system architecture;

· Evidence of a history of embracing standards;

· Evidence that a satisfactory governance structure is in place between all participants in the response; and

· Demonstrated project management experience.

That's it! – All the rest seems to be optional and to be responded to on a “here is what we can do” basis.

Also of note is that

“The scope of the initial care planning function set will be determined by:

1) The care planning functionality already available in the respondent's proposed products;

2) Any functionality that can be developed within the timeframes for Phase 1; and

3) Affordability.”

This is saying we want as much as you can provide – but if it is going to cost a lot we might want a bit less.

The timetable provided in section 32.5 is also a stunner:

“As such, the following timeframes for the SACPS are envisaged:

Issue of the RFP – Tuesday 8^th May 2007;

Deadline for RFP responses Tuesday 12^th June 2007;

Evaluation of responses and identification of preferred respondent by Friday 6^th July 2007;

Detailed negotiation phase including an agreed scope of work and award of contract by the 17^th August 2007 or earlier where possible;

Phase 1 implementation must commence as early as possible in the period between 17^th August 2007 through to 31st March 2008 - based on implementing an agreed set of care planning functions. This timeframe is to allow for as much operational use of the SACPS by participating providers and consumers prior to a project evaluation occurring;

A project evaluation some time between March and June 2008;

Formal support mechanisms commencing July 1st 2008 under the business model agreed during the negotiation phase; and

Phase 2 – Further functionality scoped and rolled-out post July 1st 2008, subject to securing ongoing funding.”

This says you have from August 2007 until March 2008 to have something going (7-8 Months) before it will be evaluated and a decision made as to whether funding will continue from elsewhere.

What is more amazing is that nowhere is it stated how many practices, specialists, hospitals and so on are to be connected, using the system etc for the evaluation to take place.

Lastly we have the costing. The responder is asked to provide the following cost breakdown:

Implementation

Base Package Licence Costs

Gap Analysis Costs

Software Customisation / Modification Costs

Third Party Software Costs

Base Software Package Maintenance Costs

Training Costs

(identify training courses and their number)

Other Costs / Alternative Costs

(provide a breakdown of costs)

Project Management Costs

Implementation Costs

Interface Development Costs

(including testing and commissioning)

Data Conversion / Migration Costs

(including acceptance testing costs and conversion process)

Documentation Costs

Travel Expenses

Total Implementation Costs

Ongoing Recurrent Costs

Hosted Service Costs

Software Maintenance / Support

Interface Maintenance / Support

Third Party Maintenance / Support

Other Costs / Alternative Costs

(Provide a breakdown of costs)

Total Ongoing Recurrent Costs

Total Project Costs

These costs are not required for just the initial first year but for the next seven years!

So any provider who tenders is meant to provide an unknown scope of solution, reaching an unknown number of users, in a strategic vacuum with undefined functionality, but provide fixed costings for the next seven years.

There is also another and more subtle issue with all this. The tender makes a great fuss about all the NEHTA directions and standards but fails to really recognise the need to use HL7 in the list of Standards to be complied with and does not mention CDA R2 as a record format – rather than the older and virtually unusable, in my view, CIP standards. It would seem vital that at the moment of issue any tender issued by SA Health would be totally up-to-date on NEHTA directions given it is a core member. One really wonders just how much input NEHTA has had in shaping all this?

Also of interest are the following:

1. Just what approach is being taken to manage patient expectations regarding the privacy of patients – a key factor in the success of all Shared EHR initiatives. While the tender says those involved in the procurement will conform to the Health Department's Code of Fair Information Practice, just what will happen to patient information is not stated.

Regular readers will recall we have yet to hear just how privacy compliant OACIS is in South Australia. I have asked twice and the silence has been deafening!

2. Just how a design of the SACPS will ultimately be made conformant to final NEHTA Shared EHR requirements given they are presently not at all well defined. The amount of re-work required must be impossible to estimate and cost at this time

3. The prospective providers are not asked to address a Migration Strategy from the current OzDocOnline Trial to their solution. Is it assumed all that data will be lost or is the outcome of the tender less uncertain than it may appear?

4. This tender is weeks late in its release – originally promised for March 2007 – that is part of the reason the timelines are so silly. The writers can’t project manage and now the providers have to suffer and evaluation has to be truncated..what a joke!

This really is the most laughable public Health IT tender I have ever seen and I have seen some bad ones. Anyone who spends any time to respond to this rubbish is out of their mind I believe and deserve all the pain they get..and it will be a great deal.

What should be done is easy:

1. This tender should be withdrawn before anyone spends money responding to it.

2. The review of the Care Planning Trial needs to be completed and the lessons learnt.

3. Working with clinicians and users a real set of functional and requirements needs to be developed.

4. A new tender with all the appropriate attributes, reasonable timelines and clarity of purpose should then be released after review by NEHTA and DoHA.

As always it seems we have plenty of money to waste getting it wrong, but are not prepared to spend a little more money and take a little more time to get it right!

Someone needs to put a stop to this – and soon! (NEHTA maybe)?

David.

Guest Contribution – Patrick Gallagher – e-Health Veteran and Consultant.

Our guest today is Mr Patrick Gallagher. Pat has been involved in all sorts of activities which have focussed on trying to actually have e-health deliver on its promise. He is presently the principal of his own consulting company that has clients both here and overseas. He is also the chair of Standards Australia’s IT14-10 Committee on Health Industry Supply Chain.

Contact:

Casprel Pty Ltd
e.commerce, e.health, e.change
Process, Practice and Technology solutions and advice

He can be reached at casprel-at-attglobal.net.

Take it away Pat!

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A prescription for many ills:

Take 3 chains with confidence

For a long time I have been informally debating my admirable friend David More on e.health matters. Not that we disagree on the big picture, just the pathway to the end of the rainbow. He is intellectually rigorous in all things, based on clear planning and detail, while I am impatiently, a step at a time, just do it, guy.

David contributed an enormous amount to the issues I feel strongly about, when way back in 1996 he led the team that produced the pivotal study and report on the emerging application that has become known as electronic prescriptions. The report, commissioned by the then Health Department became commonly known as the IBM Report. I have always thought of it as the David More Report.

So when David asked me to contribute to the Blog and have a good old rant, where to start, and where to end, wasn’t hard to decide.

Hereyago David – my serve

The average dictionary has a half page of very different meanings of the word ‘chain’. Mostly to do with metal, jewellery, groups of retail stores and so forth; the meaning referred to here though is that of ‘continuity and coherence’ of activity to a common end, or working together ‘in a set series of steps towards a shared goal’.

And the foundational chain this article will discuss is the health sectors very sick supply chain. Noting that a supply chain is not a freestanding function, but a service to some other function.

In the health sector an efficient supply chain needs to be a fully linked activity to the clinical chain that in turn comes together in the recording and financial chain and all linked in the interest of patient care.

Our health system today still has by and large, three separate systems. As such, the focus on health records of some sort remains firmly focused on the top down approach. That is a medical history linking back to clinical activity by recording some standard of terminology with little regard to how the consumed or used product will be linked-in to the end process. The most typical is the discharge summary in a hospital, or the prescription in any and all pharmacy situations.

In computer-speak this is the seamless exchange of common data between interoperable systems. Or, moving data from one machine to another machine without a human re-working and re-keying the data.

A simple series of data processing steps that retailers do, oh so well, while the health sector does it all oh so badly.

Direct comparisons of information management in the supply chain practice and other business processes between say a ‘Colesworth’ and a hospital are stark indeed.

A similar eye opener is to compare the performance of a hotel organisation to an average hospital, where the difference in information management outcomes is night and day. Yet the underlying start and end point of accommodating a guest and a patient are very similar.

Pundits are quick to say health, and hospitals in particular, is a complex beast. Certainly the events in a hospital are far more important and sensitive than what one does while relaxing in some hotel on holiday or when on business. But is the information gathering and sharing more complex? No it isn’t.

What is complex in a hospital is the tribal-like disparate relationships and Chinese-walls that prevents all of the common data being captured and used universally. By means of seamless electronic reticulation. Big words that any hotel would call routine information sharing of core data.

Mountains of anecdotal evidence aside, my own experience some years ago was to be asked eleven times for my basic details of age and address in a six-day stay. Simply archaic.

For something that is relatively simple the machinery of supply chain management is a deep, if not totally boring, mystery to many health sector administrators.

Perhaps it is a situation where clinicians are perhaps too intelligent to be bothered by the simple art of supply management. Something they feel is better left to the guys in cardigans to do perhaps.

Yet, having the right product available for clinical use is a fundamental part of patient care and is therefore something that should be done efficiently and in an interoperable manner.

Leading to the question of - ‘when is the supply chain a clinical chain matter’? In every sense and certainly in terms of patient safety the answer is - all the time.

When it comes to money the picture gets quite grubby. There is any number of global studies over the past ten years that constantly tell the story of wasted funds related to poor supply practices. The largest examples are in the USA where it is estimated that up to 15% of product purchased for a patient is never used by or for a patient.

If that is true then the proportional '‘waste'’ in the Australian system would be around $2 billion per annum.

Moreover the USA reports estimate that 90 000 American are victims of lethal episodes of medical misadventure a year. Incorrect product usage or error in product selection comes second only to misdiagnosis in accounting for most events.

Wrong product usage is clearly a supply chain factor, or more correctly a unique product identifier factor. Management requires a ruthlessly efficient cataloguing maintenance service to underpin the supply chain data exchange, of the many steps between source of supply and point of consumption or use.

Why is this so bad still in 2007?

The usual explanation is the conga line of experts who always say that health is ‘complex’ and that’s that. All too hard.

Emphasising that patient care, privacy of data and security of information exchange is paramount and is different to any other sector. But these are parameters that many sectors of the economy manage daily; the ATO, Defence Department, the banking industry and insurance sectors to name a few. And do it for a far larger audience than just those of us that are sick

Electronic Information exchange is a practiced and reliable art outside health. Why not inside health? Management of information isn’t complex; the problem lies with people. Hospitals are indeed complex, consisting as they do of complex communities of interest with everyone’s individual discipline or interest at the forefront of the common interest.

Again an overly simple analogy is the hotel comparison. When a guest is processed anywhere in a hotel the staff practice is to see the guest as ‘our guest’.

In a hospital the more common view is – ‘this is my patient’; and my patient’s information is mine to use and protect.

Of course what has made this situation worse, over the past decade or so, has been the silly implementation of closed-off proprietary computer systems. Systems that, again in jargon-speak, are non-interoperable.

Yet, still, the focus of our interoperability saviours is on the technology. Usually explained with such gobblygock that it all ends up as useless pap. But with a lot of well remunerated advisers happily waiting for the next ‘study’ tender to be announced.

Meanwhile it isn’t technology that is non-interoperable; rather it is people and their behaviour that needs to change. And in changing things for them, it must be made better, more convenient and not less so as is often the case.

So in 2007 in the average hospital the computer links between supply, pharmacy, wards, theatres, pathology, radiology, administration and accounts are all too often a set of separate chains of babble.

It is scandalous that is 2007 we still have a mismatch in information structures that can only be made interoperable by a human re-writing (just awful) or re-keying (plain silly) common data between systems and in so doing make mistakes. That in turn makes the situation more farcical than it ever needs to be in this day and age

Anecdotal tales, tall and maybe true, of patients getting bills months after they are discharged are infamous. But in reality this is more or less to be expected because while a Hilton chain can do ‘it’ instantly the hospital takes months to reconcile the product-related ‘minibar’ bills from many sources with different systems essentially recording the same things in a different manner

So let us take a quick benchmark of your world:

· is the supply chain system integrated into the daily clinical care system

· to patient records, and

· to accounting procedures?

Answer yes and there is not much point in reading further.

Answer no and the pressure on how to fix the problem will only intensify in how to meet the challenges of seamless information exchange as the demand for e.health applications grows.

That is to do ‘it’ once, and electronically share the information, without unnecessary re-keying and re-working of common data. In our health information chains it needs to be an everyday, commonplace happening as it is elsewhere.

The one underlining-driving factor is the ‘Internet’ word. It is the Internet that is, and will continue to drive change more than any politician, or bureaucrat, consultant or computer sales person ever will.

The business use of the Internet requires standards to exchange common content data, in a common template for a common purpose with a common set of rules. As opposed to say using the Internet by an individual buying a book or booking a seat on an aeroplane, online.

The frustrating fact remain that Australia is a leader in worldwide health informatics standards setting, while we remain hopelessly delinquent in the critical mass use of the standards we develop.

Take electronic prescriptions. A medical application that links a product from a prescriber to a dispenser to a patient, to a record and onto a payer.

A classic case of the supply chain meeting the clinical chain and ending in the reporting and accounting chain for the good of a patient.

The prescription as an application touches more Australians than any other procedure, yet the public have not been made aware of the benefits to be had by electronic processing of this most basic service of the health care system.

Consider this. Ten years ago Australia was the leading developer of ISO facilitated e.script standards. Meanwhile in 2003 Standards Australia published the complete set of e.commerce document standards for the health supply chain. Moreover eight years ago an eminent committee of thirty experts agreed a template for standardising product databases and catalogues in Australia. Where is all this collateral in actual use? Well, almost no where.

Meanwhile in Denmark, in Holland and in the UK, 90%, 70% and 50% respectively of prescriptions are now routinely exchanged electronically over the Internet. And Scandinavian hospitals can reconcile a medical mini-bar bill at time of discharge

Are we crazy, lazy, dumb or just blissfully unaware?

Or is it disunity? It is shameful to say that this country still spends time and money squabbling between government jurisdictions and clinical branches, only to ensure that nothing happens in improving (supply-related) patient care outcomes.

And this is not to mention the impact on patient care by being unable to share patient data between practioners, their service partners and their payers.

However the worse crime is the huge sums of money unavailable every day due to ‘shrinkage’.

‘Shrinkage’ is a corporate word used to describe the nasty and the useless outcomes of bad supply chain and inventory management.

Retailers know their shrinkage to a decimal point and is held ideally at a touch over 2%. That is 1% staff theft and 1% shop lifting and a bit of supply error.

Not that many hospitals know their shrinkage, but it is between a ‘good’ of 5% to 8% and a ‘bad’ of 12% to 15% and sometimes an outrageous 20% plus.

Most of this loss is not theft; it is poor management of funds invested in the procurement cycle. There is almost no visibility of inventory. If the problems aren’t known every day how can the problems be fixed? In fact there are twenty-two reasons for shrinkage and only 4 of them are theft related

So the mention of $2 billion above being awash in black holes is not an exaggeration. Not when you consider that the national spend on product procurement is $20 billion PA. Just do the maths.

The short answer? Let us stop talking, meeting, reporting, PowerPointing and pontificating and just do it. Start the e.health evolution at the bottom and work up, a step at a time.

It is worth mentioning the workplace in all of this. Shrinkage in all its forms causes knock on problems.

First there is the hassle and inconvenience for nurses who have to do another person’s job to make sure that patients have constant product availability.

Secondly in the blame game it is always the powerless who cop it. A scandal hits the media and the brown stuff spins out of some Elite’s fan straight at the nameless scapegoats. Yet these poor sods are stuck with technology that is in tune with a 1950s mindset.

One bright spot that policy makers and experts all ignore is the Australian Defence Force, Surgeon General’s PILS system (Pharmaceutical Integrated Logistics System). For which I am unashamed to give the ADF a commercial plug.

PILS has over 40,000 pharmaceutical, medical device and OTC products in one shared catalogue online to sixty sites. The catalogue is to a global standard template, using global standard unique product identifiers.

Product can be tracked and traced (by batch number and date) from a manufacturer right onto a serving member, giving a full medical record at the end. The prescription process is fully linked from prescribing, to dispensing and to recording, by the unique product identifier.

Reporting can be done instantly by dozens of categories and sub-categories - by product, person, place, procedure, practice, performance and payment.

This is Commonwealth IP, at worlds best practice in health supply/clinical linkage, and is freely available for benchmarking. Yet nobody is interested to learn what has been learnt and what can be done, step by step. Humph.

If the ADF can manage this routinely why isn't it routine elsewhere?

Humph indeed.

Are our policy makers and administrators blind as well as dense? Of course not. Perhaps just too busy looking down, from the top, which is the wrong way to make things happen. Looking up is the way to go.

This is all about patients. Patients are at the coalface. Seems obvious that the focus should be in harmonising the integrity of data captured, data use and data sharing, from that point of service and consumption - in, out and then up. Not the other way around

It is more than enough to make one sick and thereby one needs to keep taking the tablets until someone else comes along and fixes it all.

Seriously though, so much for continuity and coherence in linking information chains, let alone working together in a set series of steps towards a shared goal to share the common data for the common good, in a common sense manner.

Double humph to it all.

--------------------

Comments are welcome!

David.

Useful and Interesting Health IT Links from the Last Week – 13/05/2007

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.latimes.com/news/nationworld/nation/la-na-fda10may10,0,7729043,full.story?coll=la-home-nation

Senate passes sweeping drug-safety bill

The FDA's powers and staff would be enlarged to more quickly scan the marketplace for risky medications.

By Ricardo Alonso-Zaldivar
Times Staff Writer

May 10, 2007

WASHINGTON — The Senate overwhelmingly approved a landmark drug safety bill Wednesday, doubling the number of government scientists assigned to ferret out risky side effects in medicines already on the market.

The measure also would create a computerized network to scan medical insurance and pharmacy records for signs of trouble with new drugs, and significantly expand the Food and Drug Administration's power to require drug makers to reduce risks.

"This is unquestionably the biggest change in the FDA's regulatory authority in a very long time," former agency Commissioner Mark B. McClellan said. "It is really a new era for the FDA that will start after this law is implemented."

The Senate bill was drafted in response to highly publicized safety lapses — including the belated withdrawals of the painkiller Vioxx and the diabetes drug Rezulin, as well as the FDA's tardy warning about the suicide risks of antidepressants.

Rezulin, which was found to cause liver failure, was pulled from the U.S. market after being cited in more than 500 deaths. Vioxx was found to increase the risk of heart attacks.

David Willman, a veteran reporter in The Times' Washington Bureau, won a Pulitzer Prize in 2001 for his investigation into FDA approval of seven drugs, including Rezulin. The Times investigation found that the FDA had given the drug fast-track approval despite concerns within the agency over its safety.
…..

Key Points of Legislation

Drug safety

Some highlights of the prescription drug safety bill passed by the Senate:

• Creates a computerized system to monitor potential problems with new drugs.

• Gives the Food and Drug Administration stronger legal powers to require follow-up safety studies and stronger warnings for medications already on the market.

• Provides significant increases in funding and staff for the FDA drug safety office.

• Expands public disclosure of clinical trials and their results.

• Requires the FDA to release dissenting opinions of agency scientists.

• Imposes stricter conflict-of-interest rules for the FDA's outside advisors.

This is really a major set of changes for the US Food and Drug Administration to try and improve drug safety and drug side effect monitoring. Of course it is only through more effective use of Health IT that such improved outcomes and safety can be achieved.

In Australia we will soon have a new regulator. The new regulator will be the Australia New Zealand Therapeutic Products Authority (ANZTPA), and will replace Australia's TGA and NZ's Medsafe in evaluating the risks and benefits of prescription and non-prescription medicines, blood products and medical devices. This planned new regulatory agency should look very hard at what is happening in the US in this area.

Second we have:

http://www.e-health-insider.com/comment_and_analysis/index.cfm?ID=212

Deal or no deal?

10 May 2007

With a full blown bid for iSoft by Australia's IBA Healthcare now appearing imminent, a number of pressing questions are raised by the potential deal.

Not least, is whether the acquisition of the principal clinical software supplier to the NHS IT programme by a smaller Australian rival would best serve the interests of the NHS?

First, it's worth remembering that iSoft is not spoilt for choice of suitors. IBA Health is the only potential bidder to yet identify itself publicly. Press reports suggest that the likes of health IT giant McKesson withdrew after taking an initial look.

After a suffering a litany of body blows in the past 18 months – most notably mounting delays in delivering the key Lorenzo product, ongoing regulatory and financial investigations and being forced to restate its accounts – iSoft has seen its stock market valuation plummet, together with City confidence.

Since taking over at the helm last summer executive chairman, John Weston, has managed to bring stability and cut costs sufficiently to ensure the company remains a going concern until November. But it must deliver the next generation Lorenzo product to its key LSP customer, Computer Sciences Corporation, and has a pressing requirement to secure long-term funding or find a buyer.

The key question for NHS customers remains whether IBA will be able to deliver Lorenzo any quicker or more effectively than iSoft or whether it would instead offer alternative products – potentially iSoft legacy products. The current stated delivery deadline for Lorenzo is early 2008; would an IBA acquisition make this more or less likely to happen?

…..

It will be fascinating to see how this plays out. It is well worth while to read the whole article for background. My views on this proposed takeover are to be found here:

http://aushealthit.blogspot.com/2007/02/some-gratuitous-advice-for-iba-health.html

To date I have had no reason to change my views.

Third we have:

http://www.healthleadersmedia.com/view_feature.cfm?content_id=89387

Avoiding the Iceberg: Technology's Affect on Operations

Cynthia Centerbar, for HealthLeaders News, May. 10, 2007

Over the past 20 years, healthcare information technology has improved dramatically (remember when a 14K speed modem was considered fast?). Likewise, healthcare managers have become more sophisticated technologically-speaking. There is no shortage of meticulous IT implementation plans replete with specific objectives, critical success factors and detailed timelines. However, more often than not these plans neglect a crucial element that can determine whether the entire project fails or succeeds: The effect of the technology on operations.

…..

This article is well worth a read and makes the vital point that the impact of technology on those at the workplace is a very important aspect of health IT technology implementation.

Fourth we have:

http://www.fcg.com/Research/FCGNewsletters-HealthcareIndustryNewsSummary.aspx

Healthcare Industry News Summary

April 2007

This News Summary contains synopses of, and commentary on, health-related articles that have been published in the industry and popular press. The Summary is posted by FCG to this website monthly to help you stay abreast of industry issues and trends. The Summary is not intended to be a comprehensive review of these publications, but it will highlight innovations, advances in the state of the art or practice, interesting facts, and "scuttlebutt" about the industry that will help you keep up with what is happening. The information has been sorted into categories to assist you in identifying information that is relevant to your interests.

…..

This monthly newsletter from the First Consulting Group in the USA – which is a major Health Consulting firm with a very significant interest in Health IT – typically extends to 30+ pages of very useful summaries on topic of interest to readers of this blog. I strongly recommend those interested sign up for the monthly alert.

Last we have:

http://www.smh.com.au/news/technology/privacy-concerns-over-government-net-plans/2007/05/07/1178390224540.html

Privacy concerns over Government net plans

• Saved
  

Adam Turner
May 8, 2007
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Privacy advocates fear the introduction of a single-user name and password for accessing all online government services has the potential to become a digital national ID card.

Today's Federal Budget allocates $42 million to create a single sign-on service as part of the Australian Government Online Service Point. To be built at australia.gov.au, the service will enable Australians to carry out transactions with multiple government agencies, and move between government websites, without the need to reconfirm their identity.

In addition, australia.gov.au will use "smart forms" to automatically draw a user's details from various government departments - such as inserting Medicare details into electronic tax forms. The site will also offer a National Government Service Directory and a change of address service to eliminate the need for users to notify multiple government departments when they move house.

Around 500,000 people currently visit the site every month and 20 government agencies use australia.gov.au to provide search services for their own websites. From next year, users will have the option to create a single sign-on account.

…..

This particular announcement may have not attracted your attention but, at first look, this seems to be yet another identity management system which has the potential to create yet another data-base of the Australian citizenry. The list of these demographic databases existing or planned in the federal public sector now seems to include the Access Card Database, the various Medicare Australia demographic databases, the Document Verification System database, the NEHTA IHI and now this current proposal.

One really wonders why we can’t develop a co-ordinated national approach to electronic individual identity management.

More next week.

David.

NEHTA Really Gets One Right!

On May 8, 2007 NEHTA released a report entitled “Standards for E-Health Interoperability, An E-Health Transition Strategy Version 1.0 – 08/05/2007”. As someone who has been involved in assisting NEHTA in developing reports in this area in the past, and so has considerable familiarity with the issues and difficulties that surround the area, I must say I am genuinely impressed.

It seems to me the key messages contained in this document are all very robust and sound and should be strongly supported by the e-health community. It would be of much benefit to everyone concerned with the future of e-health in Australia if the vendor community at large and anyone else took a little time to lodge their comments in that regard on this blog site - anonymous or otherwise. I repeat, I am genuinely impressed.

The key messages I draw from the report – in my words - are as follows:

1. Clarity and clear differentiation is required when thinking about and deciding how to approach health messaging and the internal structure of electronic patient records.

2. There is a recognition that e-Health in Australia is going to be largely delivered by commercial off-the-shelf software and that any approach to standardisation of interoperation needs to recognise this fact.

3. NEHTA’s customers (the Australian jurisdictions) are interested in deploying web services approaches and SNOMED CT in future systems, but right now they are wanting to implement and utilise what they already have and to consider such steps in parallel with future upgrades.

4. That Australia does not have sufficient critical mass (too small) to try to be a global standards trend setter given the investments in e-health standardisation that are now occurring in the rest of the developed world. We need to be a contributor and ‘quick learner’.

5. Just as the CEN / ISO EN13606 standard was unfinished and incomplete 18 months ago it remains so today, and with the progress being made by HL7, it is increasingly becoming practically irrelevant.

6. For the present the incumbency of HL7 V2.x messaging should be recognised and supported – and extended where appropriate – while planning commences for ultimate migration to HL7 V3.x when that is assessed as appropriate. There are still some concerns about the technical viability and implementation complexity of V3.x, but with the evolved NHS approach to its use it is highly probable useful results will be obtained in the medium term.

7. The Healthcare Services Specification Project (HSSP) seems to be an initiative with a lot of intellectual and practical fire-power behind it and looks likely to deliver highly useful outcomes over time.

8. Efforts to persuade Health Information System Vendors to change key underpinnings, internal structures and design approaches in their software are likely to be resisted unless a very compelling business case is provided.

9. The report sees no substantive place for openEHR type approaches in Australia’s e-Health future.

10. To have actual full scale implementations before standards are agreed is essentially a sensible approach wherever possible

On the basis of these insights and findings – the following conclusion and recommendation seems both rational and sound:

“On the basis of this assessment, migrating to a Document/Services-Centric HL7 v3 approach was selected as the preferred longer-term direction, complemented by support for continued use of HL7 v2.x and development some limited extensions in the short-to-medium term.”

This clearly defines the long term future as being based on migrating to a document/services-centric approach using HL7v3 CDA R2 and HSSP. (and I presume successors). This is certainly a choice I endorse.

Implicit in all this is a new sense or practicality, pragmatism and a recognition of the reality that actual achievement of goals such as ‘semantic interoperability’ are very much more difficult and complex than may appear even at a third close look – let alone at first glance. This change is to be welcomed heartily.

If I have one problem with the report it is that in deciding not to utilise openEHR it failed to make clear the complexity of openEHR deployment at any substantial scale which I remain convinced is a major problem.

Overall it seems to me this is an excellent review and heads in the right direction.

It seems on this basis we can now adopt some of my other pragmatic suggestions from previous blogs given the place we now, at long last, find ourselves.

Steps might include:

1. A major pragmatic review of the current further standardisation priorities (in conjunction with industry and Standards Australia).

2. A review of how best to get short term improvements into the field ASAP – again in conjunction with industry.

3. Re-shaping of the NEHTA work plan to be more aware of outcomes and clinical needs.

4. A new work program to ensure appropriate information flows between the major actors (GPs, Specialists, Hospitals and Service Providers).

5. Suppression of initiatives which do not conform to the directions defined above (e.g. the money wasting activities in South Australia and Tasmania under the dead HealthConnect banner).

6. A careful review of just what Information Infrastructure is required with this direction now so determined. (Where does the Commonwealth Government single-sign-on initiative fit, and also where do the Access Card project and the Medicare e-Prescribing work now fit, etc.)

7. A re-assessment of just what may be a practical and useful SEHR that offers utility and value for money and is politically and financially acceptable. A study of the quality of the present document on that topic would be invaluable for all concerned.

8. Utilise the same, or even wider QA processes, to ensure deliverable quality is at the level seen in this document.

I see this report as a watershed – I wonder whether it can be successfully built on?

David.

One small nit:

“Each of the approaches and the strengths and weaknesses of each are discussed in Section 0.” Page 12. This needs to be Section 4.1 I think.