NEHTA – How Far Has it Come?

The Medical Software Industry Association (MSIA) is convening a MSIA Round Table Conference on Tuesday – 22nd May, 2007 in Sydney at the Stamford Plaza Sydney Airport Hotel. Tomorrow, if you are reading this on the day it is being posted!

According to the Pre-Meeting Publicity:

“This is a key opportunity for Federal and State Health agencies, clinicians, academics, standards bodies, and health information professionals to exchange views with the nation’s leading providers of clinical software and health communications systems solutions.

With the increase in government Health Information Management initiatives such as Health On-line, The Medical Software Industry Association (MSIA) has become increasingly active in representing the interests of all healthcare software providers and has negotiated a range of important changes.

This MSIA led Round Table Conference will reflect the MSIA's current standing on these relationships and develop strategies to move towards formalising these relationships with industry organisations and government groups. This is a major opportunity for various bodies to express their concerns and aspirations to a wide audience to create a better understanding of major issues affecting the health sector and the impact upon the industry.

Presentation and discussion forums will include:

1. Communicating with the Software Industry – what has worked?

• Commonwealth e-health Agencies and Initiative,
• PBS on-line,
• Pharmbiz,
• DoHA,
• MBF
• nehta Communication Strategies

2. Interoperability and Messaging – Why is it so Hard?

• What Standards should be used?
• Accreditation
• Making e-Communication more like the Telephone Network

3. nehta – what has been achieved?

• SNOMED CT – Update & Licensing
• Medications Terminology
• Building Blocks and Communication

4. E-Claiming

• HIC on-line – What next?
• Is x400 dead?
• Who is making money?
• The banks and e-Claiming

5. The Health IT ‘Action Agenda’

• What is it and what is the potential?
• What I need to know about it?
• How will it help me and my business?
• Current state of play and progress – DoHA presentation

6. The Way Forward and Conclusion”

This sounds like a very useful meeting and it seemed a good opportunity to prepare some thoughts on the question of NEHTA – what has been achieved and to try and form a view as to whether we are headed in the right direction. It is a pity that NEHTA – for their own reasons as I am informed – has chosen not to attend.

I think the answer to the question of what NEHTA has achieved is that "It is too early to tell yet” as the probably apocryphal story suggests was said by the great Chinese revolutionary Chou En-lai when asked for his for his evaluation of the French Revolution.

This said there are two things that can also be said. First , what NEHTA is attempting is no doubt a major complex challenge and second that so far, from the point of view of an external observer, they seem to be going about their brief very incompetently. From where I sit the risk of overall failure looks worryingly high.

What have they and are they doing wrong?

The key things I see as mistakes are:

1. The failure to develop an operational Strategic Plan, Business Case and Implementation Plan to facilitated the delivery of the outcomes sought by Health Ministers in August 2004 when NEHTA was authorized (Based on the Boston Consulting Group work of the same year).

2. The decision to corporatise the NEHTA entity which has removed NEHTA from effective public scrutiny and review and has disengaged the body from many of its public sector clients.

3. The ongoing lack of quality in many of the NEHTA documentary deliverables. Other than the document relating to the adoption of HL7 there have – in the last year – been a series of either useless or incomplete or excessively impractical documents produced with have added minimum value to the Australian E-Health domain. ( A secondary problem is the ‘ex cathedra’ approach to document release).

4. The continuing lack of transparency regarding NEHTA internal decision making with commercial-in-confidence and secrecy being made an art form quite unnecessarily. Given the public policy and standards role NEHTA is meant to play there should be totally open policy development processes and all strategic advice received by NEHTA should be made public for comment and feedback. Equally the NEHTA Board should publish relevant and adequately detailed minutes of the policy aspects of their meetings.

5. The failure to seek proper engagement with the Medical Software Industry.

6. The failure to ensure the boundaries between the roles of DoHA, the Australian Health Information Council, the States and Standards Australia’s IT-14 Committee were well defined and able to be understood so roles and responsibilities were clear.

7. The tokenistic way much of the stakeholder consultation has been undertaken and the almost Joh like “don’t you worry about that” style of management. The privacy consultations undertaken so far are examples of listening at its worst.

8. The obvious “tail wagging the dog” mode of operation seen in the way the NEHTA Executive and the NEHTA Board interact. Given the public sector backgrounds of the Board members if they actually understood what was at stake and enough of what was happening internally within NEHTA to manage it actively I am sure it would be a different, more open, more consultative and much more useful organisation.

9. The failure of the NEHTA Board and Management to recognise there are urgent issues which need to be addressed at both State and Commonwealth levels. The time frames NEHTA is working to are excessively relaxed – especially given the level of resourcing and staff available.

10. The sectional focus – on Public State Hospital Issues and Commonwealth Issues with minimal focus on either the private hospital or private practitioner needs. The lack of a holistic Health System Wide vision and approach is a key failing.

11. The delays that are now becoming obvious in a range of the work program components. The worst apparent examples are in the Benefits Realization , Shared EHR and Medicine Terminology areas.

To date the only successes I can see are the acquisition of the national license for SNOMED CT and the decision to adopt HL7 as a messaging and possibly EHR content Standard. Not much really for the $20+ million NEHTA has cost to date – excluding the money being spent on the UHI projects. Progress on the needed extensions to SNOMED CT before it is useful has been slow and seemingly badly managed if the delays in delivery are anything to go by.

The bottom line is that what NEHTA is trying to do is very badly needed, but the way they are going about it is deeply flawed in my view and the direction needs serious modification.

One can only hope the planned review will get them back on a sensible path.

David.

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).

---------

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.

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Comments are welcome!

David.