Minister Abbott Responds to Open Letter of March 11, 2007

Below I have provided a scan of the letter I received from Mr Richard Eccles who is First Assistant Secretary, Primary Care and Ambulatory Division of the Commonwealth Department of Health and Ageing. (click the image to read)

The really good news is provided in the second paragraph where we are told “The Australian Government agrees that better clinical outcomes and improved efficiencies can be achieved with better use of e-Health” while pointing out patient choice, privacy and confidentiality are matters that need to be carefully and fully addressed.

I will leave it for readers to form a judgement on just how much progress has actually been made for the funds expended and whether what has been done has been cost effective. On the basis of there being 36,300 GP(s) in 2005 it seems the Practice Incentive Program (at $40,000 per practitioner) has cost $1.432B or so over the last few years. When this is added to the other sums mentioned ($310M) to total expenditure (not including the $105 Million for NEHTA) is perilously close to $2.0Billion.

It seems to me, prime face, that spending $128 Million on providing an electronic health record for 10,000 people could hardly be seen as cost effective. Heavens, to expand to the population in general we would then be over $256 Billion (about a quarter of the national GDP). If even 5% of this sum could be found life would be just wonderful!

It should be pointed out that to date there have been no reports on the clinical impact of any of these initiatives that are seen as credible. It is a lot of money that might have been spent inappropriately!

Back to the good news. It is important to read work is actively underway on e-prescribing. It would be good if the plans for this were being developed more transparently with more discussion with all the relevant stakeholders.

In the second last paragraph we are told a combination of financial incentives, regulatory reform and Standards development are being supported to move the agenda on. All good as far as it goes – BUT – without a coherent e-Health Strategy that brings all these parts together will may well wind up wasting a good fraction of the next $2Billion if a second chance is ever offered.

Overall the lack of identification of the Australian Health Information Council’s (AHIC) importance to provide a workable strategy is worrying. NEHTA is not the answer for this problem. We can only hope AHIC is.

Many thanks for the good news Mr Eccles. Now can we have a plan please?

David.

The AHIC Survey – Will they Hear What they Need To?

Last week the President of the Australian College of Health Informatics (ACHI) was sent a survey which had been developed for the Australian Health Information Council out to ACHI members for comment. The survey – which was developed by the Nous Group (www.nousgroup.com.au) - had the following introduction and process description:

“The Australian Health Information Council (AHIC)

eHealth future directions

stakeholder survey

Purpose of survey:

In its role of providing advice to inform national policy direction for health information to the Australian Health Minister’s Advisory Committee (AHMAC), AHIC wishes to look strategically at the development of the national health information program out to 2013. Part of this process will be a summit on June 18 (evening) and 19, involving AHIC and the National Health Information Management Principle Committee (NHIMPC).

To ensure we cover as much ground as possible at the Summit, it will be useful to have a systematic analysis of:

· what’s worked and what hasn’t up until now

· where Summit participants and your constituencies (if relevant) stand on the health policy imperatives moving forward

· what should be in place by 2013 (or before) in terms of eHealth infrastructure and specific IT and communications tools to serve those health policy goals, and

· what might be the right model(s) moving forward.

The findings of this survey will be collated and presented in advance of the summit.

Process

The survey provides you with the opportunity to highlight the issues of most importance in your or your jurisdiction’s view. We will be conducting a phone interview with as many of the Summit participants as possible over the next two weeks, based on this survey.

If you are able to partially complete the survey before your phone interview it will help us to focus the discussion on the most important issues that you have identified.”

Those who feel they can add useful contributions over the next week or so can – by downloading the survey from here and providing a response to the Nouse Group or the AHIC Secretariat of DoHA.

I dutifully filled the questions in the 25 or so questions and sent it back to Professor Liaw for him to formulate a full response with the input of others or ACHI’s membership.

After mulling for a day or so I also decided to try and respond – in my own terms – as to what I thought AHIC should be considering at the June meeting. This resulted in the following e-mail to the consultants involved.

----------

Hi,

I was sent a copy of your AHIC survey being a Fellow of the Australian College of Health Informatics. I have filled it in and sent it back to Professor Liaw so he can integrate my comments with the others. I felt however it would be useful if I made a few higher level points.

My first point is that I feel that the survey, by talking about building blocks and the like has missed the essential fact that without a co-ordinating national Strategy the building blocks are not going to get anywhere on their own - they are not self organising.

There is a core need to develop a National e-Health Strategy, Business and Implementation Plan that is based on stakeholder consensus and is practical, needs orientated and implementable in a sensible time frame. Lives are being lost in droves as the strategic dithering continues. Solving this is actually urgent despite the relaxed approach being taken by DoHA and NEHTA to actually delivery of outcomes.

My second point is, that the background to possible approaches really does not fully address the nature of the strategic choices and options that are available in a satisfactory way. Not mentioning the almost certain need for a hybrid of what has been done overseas (and not even mentioning the very successful Danish and Dutch initiatives) leaves the reader poorly informed

My third point is that it is my view the Health / Medi Connect trials have been virtually uniformly dismal disasters which have been much too positively spun by DoHA. The secrecy around the lack of outcomes and the waste of money has been alarming and I know as I have seen many of the full reports - not just the obfuscatory summary.

My fourth point is that is it now virtually the Health IT Community consensus that NEHTA has been a severe constraint on progress of the e-health agenda.

My fifth point - having worked in this area since 1983 - is that this is a very complex problem - and that the complexity extends far beyond technical issues into areas of innovation diffusion, consumer trust and a range of other non-technical issues.

My sixth point is that without bringing the inherently conservative clinical community fully on board anything attempted is doomed.

My seventh point it that this is the fourth time we have seen attempts to set a direction and each attempt has been crucially flawed due to inadequate consultation, lack of holistic understanding of the health sector etc. I for one do not want to see yet another repeat.

My eighth and last point is that strategic execution in the public sector is very failure prone and this needs to be addressed carefully if any useful outcome is to be achieved.

A search of my Health IT blog will provide a lot of background on all these areas (address below)

I hope this helps - I am happy to chat if it would help

Cheers

David.

----------

Of course I missed a couple of points I wanted to make… (and so a second e-mail)

----------

Hi Michael,

Thanks for the response:

There is one more I overlooked that woke me in the middle of the night. That is that the benefit flow from the implementation of e-health accrues not to the technology users but rather to the those that pay for health services. This means there is a negative incentive to adopt the use of the technology despite the fact there is overwhelming evidence that Health IT deployment improves safety, quality and efficiency.

This is recognised all over the world and thus in the US the payers are now funding systems to get the benefits - witness the $6+Billion Kaiser Permanente is spending.

If incentives for adoption are not properly addressed any plan will fail.

Sorry for missing it out.

Cheers

David.

----------

Sadly there was another key point I mentioned in my survey response but also left out of my e-mail – the issue of addressing the dysfunctional Federal / State divide and the impact it is having on e-health.

Anyway I think I have now got the big 10 points I want to see made. If you have others please let me know and I will pass them on.

David.

Useful and Interesting Health IT Links from the Last Week – 03/06/2007

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

http://australianit.news.com.au/story/0,24897,21813343-16123,00.html

CSC blocks IBA's iSoft tilt

Ben Woodhead | May 29, 2007

update| GLOBAL outsourcer CSC has moved to block IBA Health's proposed 140 million pound ($339.2 million) takeover of UK medical software maker iSoft Group plc.

CSC announced its intention in a letter to iSoft's board, leading IBA to this morning request a halt to trading of its shares while it considered the development.

CSC is iSoft's largest customer and a change of ownership of the hospital software company is subject to approval by the outsourcer. CSC is rolling out iSoft's Lorenzo software as part of the UK National Health Service's £12.4 billion National Program for IT (NPfIT).

…..

For anyone in Health IT it is hard not to have become fascinated by the Jonah and the Whale like attempt of the Australian IBA to swallow the larger UK based iSoft. The latest as of the time of writing (June 3, 2007) according to the London Financial Times is that legal action is now planned. This looks like it might get messy and expensive. (Disclosure – being an IBA shareholder I hope not!)

Second we have:

http://www.informationweek.com/news/showArticle.jhtml?articleID=199702199

Why Progress Toward Electronic Health Records Is Worse Than You Think

Though use of E-records is growing, the hardest trick--data sharing--has barely begun. And in at least one high-profile case, it's lost ground.

By Marianne Kolbasuk McGee, InformationWeek
May 26, 2007

When people talked about the promise of electronic medical records, Santa Barbara County usually came up as a role model. In 1999, a nonprofit was created to connect hospitals and doctors' offices in the California region using interoperable e-records to share patient data across practices, with the goal of improving care and cutting costs.

The effort launched to national prominence Dr. David Brailer, a physician and former CEO of CareScience, a health care quality-measurement software provider that was the prime contractor of the project. Brailer went on in 2004 to spend two years as the first national health IT coordinator, leading the charge for electronic medical records, or EMRs. Hundreds of health care execs studied the exchange with an eye on adopting its approach.

In December, however, the Santa Barbara County Care Data Exchange quietly died. A $10 million grant ran out, and the health care community didn't see enough value to keep it going. There are still plenty of doctors using e-records in the area, but the dream of sharing data across practices, easily following patients where they're treated, has faded.

Santa Barbara serves as a reality check on the U.S. health care system's slow progress toward a real EMR network. The diagnosis: It's worse than you think.

…..

This series of three articles is a very useful summary of the issues in EHR adoption as seen from the USA. Much of what is said is very relevant to Australia and the articles are well worth a browse.

Third we have:

http://www.healthleadersmedia.com/technology/viewcontent/89882.html

TEPR Tantrums

Gary Baldwin, for HealthLeaders News, May 25, 2007

The presentation was called “Getting Physician Buy-in.” But TEPR Conference participant Tushar Shah, MD, a partner in a three-physician pediatric practice, wasn’t buying. Shah went to last week’s event in Dallas in search of an electronic medical record system for his small group, which is based in Abilene. He was one of one some 200-plus people who jammed into the session, which targeted small physician practices. So many participants crowded the presentation that event organizers halted it abruptly in mid-stream to move to a larger room.

They heard Paul Schadler, MD, describe how his 11-physician practice struggled through its EMR journey, which began five years ago. Unlike some EMR advocates, who are basically preaching to the IT choir, Schadler gave a warts-and-all account of his group’s experience. The EMR, he said, is a “dramatic work change” for physicians, one that creates “more work.” According to Schadler, much of the work in the paper-based practice shifts directly to the physician in the electronic world. “They billed, now you bill,” he said.

…..

Another article that points out the problem all who would like to see Health IT implementation face in ensuring that the users of Health IT share properly in the benefits that are obtained from implementation. This almost certainly means that to have implementations succeed there need to be incentives (probably financial) provided for those who actually have to implement and use the technology.

Fourth we have:

http://www.ehiprimarycare.com/comment_and_analysis/index.cfm?ID=180

System failure

07 Nov 2006

Fiona Barr

The use of paper-based systems for out-of-hours care and the financial pressures out of hours services face to fund IT upgrades have been highlighted following the case of a patient who died after speaking to eight different out of hours doctors over a bank holiday weekend.

Penny Campbell, a journalist, died after a series of doctors from the Camidoc out of hours service in north London failed to diagnose that she was developing septicaemia following an injection for haemorrhoids.

It became clear at the inquest that Campbell’s care had been based on a series of handwritten clinical notes rather than an electronic record system which, with the benefit of hindsight, could have alerted doctors to Campbell’s consultation history over a four day period.

…..

This article provides a nice case study of how paper clinical records can lead to significant patient harm.

See also

http://www.ehiprimarycare.com/news/item.cfm?ID=2721

Paper records a 'direct factor' in patient's death

Lastly we have

http://www.healthleadersmedia.com/view_feature.cfm?content_id=89918

Paper Kills

Newt Gingrich, for HealthLeaders News, May 30, 2007

The following article was adapted from the text of Speaker Newt Gingrich's introduction to Paper Kills: Transforming Health and Healthcare with Information Technology. Edited by Center for Health Transformation Project Director David Merritt, the new release from CHT Press features a collection of insights from many of the leading minds in the healthcare and health information technology fields, including providers, vendors, payers, government officials, and renowned scholars. The book includes discussion of such diverse issues as privacy in confidentiality, optimizing health IT in order to support early health, and the potential of health IT to advance clinical research and the adoption of best practices. (Release date: June 4, 2007; available at www.paperkills.net.)

When I wrote Saving Lives & Saving Money four years ago, I outlined a future in which all Americans will live active, longer, and healthier lives. This future can be achieved because the people will be at the center of a healthcare system that has been designed for them. From their doctors and hospitals to their pharmacies and insurers, every aspect of the system will be designed to maximize their health in an effective and efficient way.

In tomorrow's healthcare system, all Americans will have access to the care that they need--and everyone will have the ability to pay for it. All Americans will be empowered to make responsible and informed decisions about their own health and healthcare. Early health, prevention, and wellness will be at the core of delivery. Treatment decisions will be based on effectiveness, and reimbursement will be driven by outcomes. Consumers will own their personal data and have a right to know the cost and quality of the treatments they receive and the providers they visit. Innovation will be rapid, and the dissemination of knowledge will be secure and in real time.

All of these are fundamental changes from today's approach to healthcare. Embracing these values is absolutely necessary in order for us to build what we at the Center for Health Transformation call a 21^st Century Intelligent Health System. Health information technology is the key to getting there.

I often ask people: when was the last time you took out a pen, wrote a check for cash, and handed it to a bank teller? Most young people today have no idea what "writing a check for cash" means because online banking, debit cards, and a global ATM network is the only world they've ever known. Unfortunately, that kind of technology and that kind of reality has yet to reach healthcare. And we pay a very dear price for it.

To put it simply: paper kills.

…..

Newt Gingrich is a former Speaker of the United States of America’s House of Representatives. Since leaving office a few years ago he has been a passionate advocate for Health IT. The full paper and the book that is being discussed are both worth detailed review.

Other interesting URLs include:

http://www.phcris.org.au/elib/render.php?params=3700

Effect of computerisation on quality of general practice care—a comparison with quality indicators

Author(s)	Joan Henderson, Graeme Miller, Helena Britt, Ying Pan
Organisation	Family Medicine Research Centre, University of Sydney
Objectives	There is an assumption expressed in literature that computer use for clinical activity will improve quality of general practice care, but with little evidence to support or refute this assumption. This study compares GPs using a computer to prescribe, order tests, or keep patient records, with GPs who do not, using a set of validated quality indicators.

…..

This is an interesting paper but I have to say that without much more details on the actual functionality and level of use of the systems (which may indeed be provided in the full paper) it is hard to know just how valid the conclusion that “This study has found little evidence to support the claim that computerisation of general practice in Australia has changed the quality of care provided to patients” is. Worth keeping an eye out for the full paper I suggest.

http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20070531/FREE/70530008/1029/FREE

Guest commentary: Health IT integral for reform

By: Bruce McPherson

http://govhealthit.com/article102837-05-29-07-Web

Obama, like Clinton, proposes health IT investment

BY Nancy Ferris

http://healthdatamanagement.com/html/current/CurrentIssueStory.cfm?articleId=15242

CFOs Measure the Benefits of New Technology

Financial officers are playing a lead role in assessing the value of information technology investments and then measuring the impact.

By Howard J. Anderson, Executive Editor

http://healthdatamanagement.com/html/current/CurrentIssueStory.cfm?articleId=15250

Building a RHIO, Bit by Bit

Years in the making, a modest Texas networking effort is taking off.

By Zack Martin, Managing Editor

As a special treat for the reader we now have the membership of the Australian Health Information Council. Comments on the choices are welcome. I worry there is not a strong representation of individuals with proven Health IT Strategic Planning expertise and the leaders of either the Health Information Society of Australia or the Australian College of Health Informatics are not present.

More next week.

David.

Australian Health Information Council Members Contact List

Member	Organisation
Professor James Angus (Chair)	Dean Faculty of Medicine, Dentistry and Health Sciences University of Melbourne
Ms Yvonne Allinson	Executive Director Society of Hospital Pharmacists of Australia
Professor Enrico Coiera	Director, Centre for Health Informatics
Dr Moya Conrick	School of Nursing, Griffith University Royal College of Nursing Australia
Mr Rob Durie	Durie Consulting
Mr Richard Eccles	First Assistant Secretary Australian Department of Health and Ageing
Ms Fran Thorn	Chair of NHIMPC Secretary Victorian Department of Human Services
Dr Peter Garcia-Webb	Mayne Health, Western Diagnostic Laboratory Australian Medical Association
Professor Nicholas Glasgow	Director Australian Primary Health Research Institute
Ms Heather Grain	La Trobe School of Public Health
Ms Helen Hopkins	Executive Director Consumers’ Health Forum
Professor John Horvath	Chief Medical Officer Australian Department of Health and Ageing
Professor Michael Kidd	Head Discipline of General Practice The University of Sydney
Dr Ross Maxwell	Rural Doctors Association of Australia
Dr Louis Peachey	Medical Educator Mt Isa Centre for Rural and Remote Health
Dr Andrew Perrignon	Chief Executive Officer Northern Health
Ms Rosemary Sinclair	Managing Director Australian Telecommunications Users Group

Moving on Without NEHTA – Some Really Good News!

As is probably well known to readers of this blog by now the Medical Software Industry Association (MSIA) held a round table late last week to try and work out how best it could try to move the e-Health agenda forward.

The forum addressed a range of issues and, from all reports, there was quite lively discussion on a range of matters.

Those interested in press coverage of the event can visit the following two articles from the IT section of last Tuesday’s Australian.

http://australianit.news.com.au/story/0,24897,21810268-15306,00.html

Ill feeling over health forum snub

Karen Dearne | May 29, 2007

FOUR overturned chairs on the podium marked the absence of National E-Health Transition Authority representatives at a Medical Software Industry Association roundtable in Sydney last week.

Leading software developers were stunned to learn that NEHTA had declined to attend, citing late notice, as the event was supposed to be a relationship-building exercise.

NEHTA communications manager Lisa Smith wrote a letter advising that the agenda placed "an emphasis on reviewing NEHTA's activities, so it would have been appropriate to seek our input into the agenda, and confirm our involvement, prior to its public circulation".

Ms Smith said "NEHTA would like to encourage the MSIA to take a positive and collaborative approach", but "given the circumstances, we are not in a position to contribute speakers or attendees at this late stage".

….. (see the site for full article)

And

http://australianit.news.com.au/story/0,24897,21810270-5013040,00.html

Working group on medi-ware

Karen Dearne | May 29, 2007

THE Medical Software Industry Association has formed a working group on messaging systems to overcome interoperability problems.

Health informatics consultant Peter MacIsaac said commercial messaging providers were offering reliable services, but "their systems are based on a range of communications standards and business models".

"Vendors will work on a technical solution so that GPs, specialists, pathology and radiology services and hospitals can contract with one messaging provider and have interoperability with all parties," Dr MacIsaac said.

….. (see the site for full article)

While the first article describes, in graphic detail, the session where some quite passionate criticism regarding the current performance of NEHTA was made (including a small contribution from yours truly) I believe the second piece of news is far more important – despite the fun that was had by almost all with ‘NEHTA bashing’. (Late Update - it seems the May 29 NEHTA Vendor Forum has done little if anything to improve things.)

In a communiqué released after the meeting shows that the vendor community is so sick of the way they are not being led by NEHTA they are moving on their own.

Essentially, for the first time Medical Objects, HealthLink, eClinic and Argus are going to work to ensure that a HL7 message carrying clinical information from one messaging provider can reliably be delivered to users of the other clients – so that – once the work is done – the practitioner will need only one messaging client and all will benefit.

At present the open working group is being sponsored by MSIA, the Health Informatics Society of Australia (HISA) and HL7 Australia. I understand the developers of Medical Director Software (HCN) are also now involved.

The approach to achieving interoperation is via the Integrating the HealthCare Enterprise (IHE) methodology. This approach emphasises the use of current, proven standards and rigorous testing via so called ‘Connectathons’ to ensure connectivity is fully and reliably achieved. I also understand the Australian Healthcare Messaging Laboratory (AHML) will assist in certification of communication safety and reliability.

Initially the scope of the messaging will be pathology and radiology messaging but this can be expected to expand (to cover prescribing and referrals for example) once initial success is achieved.

The planned time frame to achieve a final demonstrable outcome is the August 2008 HISA meeting.

I see this development is wonderfully and unequivocally good news (amidst a range of other more gloomy goings on) and I wish the working group all possible success. Of course it will be vital that the promises made are actually delivered – I hope so..but it won’t be easy!

David.

SA HealthConnect – What are they Thinking?

The SA HealthConnect team held a vendor briefing last for the South Australian Care Planning Project on May 14, 2007.

They have now been asked about the requirements on which their Request For Proposal (RFP or Tender) is based.

“Q - On page 22 of the RFP, it states that the business requirements will be made available to the preferred respondent. Is there any reason why they are not yet available?

A – The functional specification on which the tender was based is now available to all respondents via the HealthConnect SA website http://www.healthconnectsa.org.au/Default.aspx?tabid=84 as is the presentation given at the Industry Briefing Session.

In response the following was made available on the 22^nd of May.

The document is titled as follows:

South Australian Health Department

SA HealthConnect Program

High Level Business Requirements for Electronic Care Planning including Decision Support

Supporting the Management of Chronic Disease (Final Report)

Trilogy Information Solutions (International) Pty Ltd. (January 2007)

The document was actually converted to a .pdf format on 16 May, 2007. Just how closely this document resembles the report provided by Trilogy is open to conjecture.

Even more fascinating are the contents of the document.

Early on we learn that the plan for this high level document is as follows:

“1.5 Intended Audience & Next Steps

This document will be reviewed by a small group of stakeholders with an interest in progressing electronic care planning support for chronic disease management in the first instance. The document will be revised following feedback from stakeholders and will form the basis of a more detailed requirements document and information technology procurement for a CPS in the second half of 2006.”

The implication of this is clear, this present document is a draft which has not been fully reviewed by relevant stakeholders and it is not the detailed requirements document that should be available to enable procurement.

A second implication is that this document was completed in the first half of 2006 or even earlier if the following timing is accurate.

According to the requirements GP Management Plans, which are said to be recently introduced are a driver for the Shared Care initiative These were introduced in July 2005 as can be seen at this site:

http://www.adgp.com.au/site/index.cfm?display=5260

Thus, it is more than possible this requirement document is over eighteen months old and I must say this is confirmed by all the references to the National HealthConnect project which is well known to have been placed in the deep freeze almost two years ago now.

It seems pretty clear this document has been hastily retrieved to fill an obvious yawning gap in the RFP that has been issued and that essentially SA HealthConnect, in their haste to spend their money, has not bothered to refine and clarify their thinking as to what they want to procure.

The timing of the development of this document is further confirmed by there being no mention of the NEHTA UHI Initiatives which were announced in August 2006. All that is referred to is the now obsolete HealthConnect Number – whatever that is.

Interestingly the scope of the requirements document also covers all sorts of entities which do not seem to be part of the present RFP. Those missing seem to include:

• Community Health Providers
• Aged Care Providers
• Metropolitan Domiciliary Care
• Department of Education and Children’s Services
• Children, Youth & Family Services

It really makes one wonder is this document actually the specification on which the RFP was based?

Lastly it is also of concern are the rather flexible and vague controls that are required for provider access to consumer information. Essentially this part of the specification says we would like proper individual provider access controls but that will probably be too hard so we will provide organisation based access. So much for audit trail based capability to detect abuse of personal consumer information. Searching for consumer details does also not seem to be specified in a way that would now be seen as providing an acceptable level or protection against misuse.

Unless I badly miss the mark the SA HealthConnect project simply have not produced a current specification to match their tender and, when asked, have cast around for the nearest they could find which turns out to be conceptually and technically obsolete compared with their now stated requirements (witness all the NEHTA compliance issues cited in the tender and not mentioned in the requirements etc).

There is little doubt this entire project is a disaster waiting to happen and the SA Health Minister should put an end to this process and insist his staff undertake a proper process and do all the work necessary before issuing such a flawed RFP.

I think I should e-mail this and the previous article to the SA Health Minister to see if some sense can prevail. Maybe some of the SA Health subscribers to the blog (4 at the last count) could maybe let him know of my concerns?

David.

Useful and Interesting Health IT Links from the Last Week – 27/05/2007

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.modernhealthcare.com/apps/pbcs.dll/article?AID=/20070521/FREE/70521005/1029/FREE

PHR data overload, legal liability concern docs

By: Andis Robeznieks / HITS staff writer

Story posted: May 21, 2007 - 10:56 am EDT

Part one of a two-part series

Like a recurring dream about having to take a test they didn't study for, some physicians view the idea of patients with electronic personal-health records as their own personal nightmare.

Visions of patients handing over a computer disk containing years' worth of blood-pressure readings taken every four hours along with random recollections of rashes and muscle strains that physicians are required to somehow make sense of and memorize are followed by thoughts of being sued because there was a kernel of important information missed in the deluge.

"That's why folks like me are terrified of personal health records and what patients will bring to us," internist Michael Zaroukian said earlier this year during a panel discussion at the Integrating the Healthcare Enterprise Connectathon, an event that brings electronic medical-record vendors together to solve interoperability problems (and sponsored by the Healthcare Information and Management Systems Society, the Radiological Society of North America and the American College of Cardiology).

While Zaroukian, who is chief medical information officer at Michigan State University, is now backing away from the word "terrified," he still maintains "there are certainly lots of reasons to be concerned."

The reasons for concern that Zaroukian cites include: the accuracy, completeness, usefulness and volume of the records physicians receive from patients; the hours of uncompensated work it will take to slog through them; and the potential for a misdiagnosis if something important was overlooked.
…..

This article raises a large number of the potential concerns from clinicians when a medical record is shared between a range of clinicians and the patient themselves. This discussion needs to carefully reviewed by anyone interested in electronic patient information sharing for lessons that can be learnt before commencing such projects.

Second we have:

http://www.washingtonpost.com/wp-dyn/content/article/2007/05/21/AR2007052101701.html?hpid=topnews

Doctors, Legislators Resist Drugmakers' Prying Eyes

By Christopher Lee
Washington Post Staff Writer
Tuesday, May 22, 2007; A01

Seattle pediatrician Rupin Thakkar's first inkling that the pharmaceutical industry was peering over his shoulder and into his prescription pad came in a letter from a drug representative about the generic drops Thakkar prescribes to treat infectious pinkeye.

In the letter, the salesperson wrote that Thakkar was causing his patients to miss more days of school than they would if he put them on Vigamox, a more expensive brand-name medicine made by Alcon Laboratories.

"My initial thought was 'How does she know what I'm prescribing?' " Thakkar said. "It feels intrusive. . . . I just feel strongly that medical encounters need to be private."

He is not alone. Many doctors object to drugmakers' common practice of contracting with data-mining companies to track exactly which medicines physicians prescribe and in what quantities -- information marketers and salespeople use to fine-tune their efforts. The industry defends the practice as a way of better educating physicians about new drugs.

Now the issue is bubbling up in the political arena. Last year, New Hampshire became the first state to try to curtail the practice, but a federal district judge three weeks ago ruled the law unconstitutional.

…..

This is an issue that has travelled below the radar for a good while and which needs more scrutiny. While the US and Australian approaches to collection of such data differ there are certainly similar data collection and data mining processes happening based on Australian GP prescribing records.

Third we have:

http://public.cq.com/docs/hb/hbnews110-000002509528.html

Medicare May Begin Contacting Inefficient Doctors in Mid-2008

By John Reichard, CQ HealthBeat Editor

The Medicare program has the data and the computer capacity to identify individual doctors who are inefficient compared with their peers and may begin contacting them as soon as mid-2008 to goad them to become more efficient, a top federal official testified Thursday.

“It’s an ambitious goal, but I think we need to set ambitious goals if we’re moving forward in this important reform area,” said Herbert Kuhn, acting deputy administrator for the Centers for Medicare and Medicaid Services.

Kuhn testified at a hearing called by House Ways and Means Health Subcommittee Chairman Pete Stark, D-Calif., to find new ways to control the growth in the volume of office visits, tests and procedures that doctors order for Medicare beneficiaries. There’s widespread agreement that the current method for doing that — cutting payments if volume exceeds a yearly spending target — isn’t working.

…..

This has a bit of the flavour of ‘Big Brother’ about it. Readers will be aware that Medicare Australia is already using similar techniques to identify practitioners who may benefit from ‘counselling’ regarding their approach to medical practice.

Care with the use of such information is clearly important and it seems reasonable that there be reasonable disclosure of what approaches are being adopted.

Medicare Australia provides an report of its compliance program which is found here:

http://www.medicare.gov.au/resources/national_compliance/national_compliance_program_2006-07.pdf

There is also a site for the Professional Service Review Agency which is found here:

http://www.psr.gov.au/

Fourth we have:

http://www.ehiprimarycare.com/comment_and_analysis/index.cfm?ID=218

An independent view

22 May 2007

On one level, it’s a no-brainer that whenever and wherever an NHS patient is taken ill, the clinicians caring for him or her should be able to access crucial information – especially in potentially life-threatening situations. My son, for example, is allergic to penicillin and about to go off to university. If he’s unlucky enough to be rushed to hospital semi-conscious with meningitis, I’d want the doctors involved to learn of his allergy promptly and alter their treatment plan accordingly. The Summary Care Record – a central repository of key data on all patients, derived from our NHS medical records – is designed to address precisely this situation.

But as we all know, there is a major downside to placing personal health information on a central server intended for rapid, easy access in unscheduled care situations. Despite strict data protection legislation in this country and abroad, examples of harm arising from lapses of one sort or another in so-called ‘secure’ information systems are not difficult to find. Nobody is going to refuse you a mortgage for being allergic to penicillin. But what if my son were HIV positive, or taking methadone as part of a drug rehabilitation programme that nobody outside the family knew about? These data items might prove equally crucial to him receiving life-saving treatment in an emergency, but they are private and sensitive in a way that a penicillin allergy isn’t. Potentially stigmatising conditions such as mental health problems, domestic violence, epilepsy or a past termination of pregnancy often map closely to the things a doctor needs to know about when someone gets taken ill unexpectedly.

…..

Professor Trisha Greenhalgh OBE, University College London

The good professor has expertise in evidenced based medicine and her full comments in this opinion piece are well worth a careful review.

The odd thing is that she is working towards a Final Report, to be published in May 2008 (with some interim deliverables planned). The report is to address such issues as

• What, if anything, do stakeholders value about the Summary Care Record?
• What exactly are their hopes and fears?
• And, in what circumstances, the Summary Care Record is a ‘good thing’.

The odd thing about all this is that one would have thought these questions would have been sorted out well before this. I wonder what this review presages?

Lastly we have

http://www.health-itworld.com/newsletters/2007/05/22/tepr-ccr

Health PDF to Link Healthcare Providers

By Neil Versel

May 22, 2007 | DALLAS — After a couple of years of flying under the radar, a data standard known as the Continuity of Care Record (CCR) is starting to prove its worth to healthcare providers as an easy-to-use interoperability tool. And a modified version of the ubiquitous PDF is poised to do the same.

“It could be that the CCR is the only business model that works for a RHIO,” suggested St. Charles, Ill., family physician Stasia Kahn at the 23rd annual Towards the Electronic Patient Record (TEPR) meeting here this week.

Kahn talked about how she and other physicians in the Chicago area are building the foundation for a regional health information organization with the help of the CCR — an XML data set of essential information for when patients move between care settings — and encouraged other practitioners to adopt the standard. “There’s a lot of providers still waiting, and my message to you is there’s no reason to wait any longer,” said Kahn, who called the CCR the only real way to send secure, electronic clinical data from provider to provider right now.

But that may soon change, as a health-specific version of the Portable Document Format, known as PDF-H, is on its way, thanks to a collaboration between PDF inventor Adobe Systems and computer chip-maker Intel, with support from several medical specialty societies.

“Raise your hand if you can open a PDF document on your computer,” instructed Steven Waldren, director of the Center for Health Information Technology of the American Academy of Family Physicians. After pretty much everyone in the room complied, Waldren said, “That’s the use case.”

…..

This is just a fascinating development and – given the scale of the sponsors – it will be interesting indeed to see what, if anything comes from it. The full article provides more details and is, again, worth a read.

See also for more details:

http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20070523/FREE/70523004/1029/FREE

HITS @ TEPR: Marrying the CCR, PDF

By: Joseph Conn / HITS staff writer

Story posted: May 23, 2007 - 11:25 am EDT

Other interesting URLs include:

http://www.dmreview.com/editorial/newsletter_article.cfm?articleId=1083057

Electronic Medical Records: Hospitals Harnessing the Power of Service-Oriented Architecture

by Kevin Kelley

Summary: Replacing paper with eletronic medical records could help hospitals define the next generation of SOA applications for the health care industry.

http://www.egovmonitor.com/node/11077

Are all government IT projects doomed to fail?

Date: 22 May 2007 - 10:47

By Eleanor Passmore, Researcher, The Work Foundation

http://www.eweek.com/article2/0,1895,2136105,00.asp

More Work Prescribed for Medical Info Network By Patrick Hoffman

May 25, 2007

All in all quite a bumper week!

As a reward for the reader who makes it to the bottom of the blog who can confirm or deny the following scuttlebutt?

Who else has heard?

1. Major changes in the leadership of NEHTA are in the wings.

2. There is a somewhat covert group in Minister Abbott’s office trying to work out just what to do with e-health before the election (NOT AHIC).

3. That at some point in the next little while we will get to know who is actually on the Australian Health Information Council and what they are really doing.

All tips welcome – if you are game!

More next week.

David.

Guest Article on Health IT Privacy in Pulse +IT Issue 4 – May 2007

Visit the website for more information, many free articles, back articles and subscription information.

http://www.pulsemagazine.com.au/

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HEALTH INFORMATION PRIVACY: WHAT DO DOCTORS AND PATIENTS WANT AND NEED?

Dr David G More MB, PhD, FACHI

In the last few weeks we have had a number of reminders that management of the privacy of patient records remains a contentious and difficult area.

The first key reminder came in late February 2007 when Paul Feldman, co-chair of the American Health Information Community’s (AHIC) Confidentiality, Privacy and Security Workgroup, submitted his resignation to the interim National Coordinator for Health Information Technology at the Department of Health and Human Services (HHS).

AHIC (which has the same role as the Australian Health Information Council – also rather co-incidentally AHIC) is the peak health IT policy advisory board in the US and provides advice directly to the US Secretary for Health and Human Services (the equivalent of our Federal Health Minister).

In his resignation letter Feldman writes that the workgroup “has not made substantial progress toward the development of comprehensive privacy and security policies that must be at the core of a National Health Information Network (NHIN).”

Given this resignation comes after six meetings and many months of work, the degree of difficulty in reaching a consensus between parties is obvious.

The second reminder came with the April 2007 release of a survey conducted among UK GPs regarding the sharing of clinical records electronically with the UK NHS ‘Spine’ – which is a secure repository of shared electronic patient records which – under appropriate conditions – can be accessed to assist in patient management anywhere in the UK.

In summary the article in the UK Pulse magazine [not affiliated with Pulse+IT] survey found:

• About one-third of physicians said they will allow full sharing of their patient records;

• Four out of 10 physicians say they will opt out completely from the program and allow none of their records to be shared;

• 80% of physicians surveyed still think that sharing electronic health records can threaten patients’ confidentiality, despite a government marketing campaign to promote the IT program; and

• 67% of General Practitioners oppose the implied consent “opt out” model, which has formed the basis for the program to be rolled out.

If what is found in this survey is truly reflective of the views of practitioners, and I have no reason to assume it is not, then the implications for electronic sharing of health records by GPs is profound. What seems to be clear from these results is that a policy approach that makes practitioners feel secure and confident about the control of patient information, both for themselves and as agents for their patients, needs to be evolved.

A third reminder has come as recently as early May 2007 with multiple articles appearing in the E-Health Insider Primary Care - Issue No 116, 2 April 2007 reviewing the difficulties being faced by the UK Connecting for Health Program in getting acceptance for their ‘opt-out’ consent plans for electronic record sharing. More details can be found here:

www.ehiprimarycare.com

It seems to me there is one organisation and advocacy entity in the US that ‘gets it” and that is the Patient Privacy Rights Foundation which is a tiny non-profit entity led by Deborah Peel, an Austin, Texas-based psychiatrist.

As reported on the US Modern Medicine website, her views are as follows:

“Peel’s Patient Privacy Rights Foundation, meanwhile, has become a ubiquitous proponent for privacy controls in the growing debate over patient rights and healthcare data usage. On Tuesday, the Coalition for Patient Privacy, of which the foundation is a member and Peel serves as chairwoman, presented to a meeting of the HHS IT advisory panel, the American Health Information Community, an 11-point list of basic privacy principles. The principles also incorporate the definition of privacy developed by the National Committee on Vital and Health Statistics and presented to HHS Secretary Mike Leavitt last year that states: “Health information privacy is an individual’s right to control the acquisition, uses, or disclosures of his or her identifiable health data.” The principles include using technology to allow patients the right to opt-in or opt-out of electronic systems, giving patients control over access, providing for complete audit trails and allowing patients to segment sensitive information. In a letter to the AHIC over Peel’s name, she wrote, “Technology can create far stronger privacy protections and granular control over access to records than is possible in paper systems.” She called on AHIC to “facilitate the creation of an electronic health system that patients will trust by using ‘smart’ technology to build ironclad privacy protections into system designs up front.” The full article can be found here:

http://tinyurl.com/yuzodm

The core points she makes, and what I think is getting to be the minimum acceptable position, are the following:

1. To have acceptable health information privacy rights it is necessary that the individual control the acquisition, uses, or disclosures of his or her identifiable health data.

2. The principles that need to be implemented include using technology to allow patients the right to opt-in or opt-out of electronic systems, giving patients control over access, providing for complete audit trails, and allowing patients to segment sensitive information.

3. That with proper planning aforethought it is possible to design systems that meet these standards. It is not the lack of capacity to design privacy compliant systems it is the lack of will to do so that is the problem.

4. Clinicians need to keep uppermost in their minds that individuals provide information to them, trusting it will not be abused. If that trust is not honoured, no electronic record sharing system will succeed I believe.

With this said, it is also true that if you explain the purpose behind, and the benefit to be derived from, health information sharing, and make it clear only authorised or de-identified information sharing will occur, the vast majority of the population are comfortable and content. As long as they are asked for consent beforehand, and can opt-out if they choose, resistance melts away. This is especially the case among patients with chronic disease who receive treatment from a range of carers who need to be better co-ordinated than they are now by and large.

Also it needs to be said that the surreptitious sharing of patient information – even if de-identified – is a totally unsatisfactory practice and where it occurs it is to be condemned. The bottom line here is that people like to be asked, and if asked will usually agree. If not asked annoyance soon emerges – think un-invited telemarketing calls!

Public perception of the security of their information is also very important in this regard. The rising incidence of identity theft in the country is lessening the confidence of the public in technology to protect financial information and most people see their medical record as a more private document than their bank statement.

I also believe it is not good enough to take the position that paper and electronic records should be treated identically from a policy, technical and privacy perspective. The goal of record protection may be the same but the methods of implementation are clearly different. You have to try hard to disclose the information in multiple paper records due to their cumbersome nature and size. Not so with electronic records where we have seen tens of thousands of records disclosed with the loss of a single laptop or unencrypted DVD.

It seems to me there needs to be much more acceptance on the part of both system designers and clinicians that maintenance of health information privacy is an ‘elephant in the room’ that can truly derail the best technical approaches to information sharing. GPs, Specialists, Service Providers and Hospitals all need to keep this in mind as we move forward. Of course none of the above diminishes the need for awareness and action on the part of clinicians in their individual practices to also protect all internal records as well – be they paper or electronic. The hiccups with which I opened this article show what happens if you don’t. Once public trust is lost it will be very hard to regain. The bottom line of all this is that any e-health project that fails to get its approach to privacy right greatly increases its risk of failure - it is really that simple. What is needed is clear, so there is just no excuse!

Dr David More is an Independent Health Information Technology consultant and blogger who has been working in the e-Health domain for over twenty years. He is concerned at the lack of clinician and patient focus in much of what is happening in e-Health in Australia.

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David.

Talk about an Absolute Load of Rubbish!

In the august British Medical Journal of April, 21, 2007 an article entitled LESSON OF THE WEEK: Information technology cannot guarantee patient safety appeared. The article was by Saskia N de Wildt, Ron Verzijden, John N van den Anker, and Matthijs de Hoog and the reference is BMJ 2007; 334: 851-852. (doi: 10.1136/bmj.39104.625903.80)

The article provided commentary on the following case report:

“A 3 month old infant who arrived at the emergency department of a small regional hospital had clinical signs of meningococcal sepsis with petechiae, purpura, and shock. The infant was subsequently transferred to our paediatric intensive care unit. During transfer the patient was given infusions of dobutamine and noradrenaline by the transferring intensivist. The concentrations of 12 drugs that might be needed for infusion during transport had previously been calculated in the intensive care unit by the resident. This had been done by entering the patient’s weight into a preprogrammed PocketExcel sheet for a personal digital assistant (handheld computer).

When the patient arrived at the unit all running drugs were ordered using our electronic patient data management system (a bedside computer application). This system uses the patient’s weight and the desired infusion rate to calculate concentrations of solutions for infusion. However, the concentration of noradrenaline calculated was sevenfold lower than that calculated previously, so that the patient had received a sevenfold higher dose of this drug than intended for at least two hours.”

In simple terms what had happened was that a spreadsheet based drug dosage calculator had been found to have misled a tired resident at 4.00am in the morning. The reason this was possible was that a simple spreadsheet running on a hand held computer was used and the spreadsheet did not have functionality to ensure constants were not overwritten and the child’s weight was entered into the wrong column.

On the basis of this the article concludes – as indicated in the title – that “Information Technology Cannot Guarantee Patient Safety” I could equally validly conclude that amateur spreadsheet authors should not be permitted to program computing tools they did not fully understand or even that doctors should be compelled to use pencil and paper to calculate drug dosage regimens.

William T Stevenson, a Consultant Radiologist of the Royal Lancaster Infirmary LA1 4RP gets it oh so right in a letter to the editor stating:

“Pretty soon we can expect a Lesson of the Week emphasizing that it's a bad idea to remove the wrong kidney.

The point here is that if a bunch of zombies (presumably members of the group who believe that information from the Internet must be reliable, that walking along the street engrossed in a mobile phone is an activity worthy of a sentient being and that counselling and mentoring are good ideas) are permitted to entrust all responsibility for a simple calculation with a potential deadly effect to a calculator, things are apt to go wrong.

It is a truth universally acknowledged that people who operate on hearts know which way the blood goes round; people who wish to inject dangerous drugs are expected to be able to find out how much to inject. They are not permitted to claim "I was never any good with figures"-if that's too tough they need to look for a job in Ethics or something.

You take a piece of paper, round the numbers to integers, get the powers of 10 correct, and get the rough answer. Then see if it's reasonable. Then use the calculator, spreadsheet or supercomputer, if you can't rid yourself of the delusion that the more decimal places the better. Surely the combination of A-levels, years at medical school and MMC can achieve this without pleading that we are helpless victims of those terrible computers.

Isn't the Public entitled to expect that a little thought has gone into 'fail-safing' these systems, in view of the inevitable failure of components? I suggest a little notebook with writing in it. “

For a major, refereed clinical journal to publish such an article just leaves me speechless and plays to the prejudice of the one or two Luddite practitioners who are still out there and seem to be found within the walls of the BMJ editorial offices.

The BMJ and its editors are guilty of the most amazing logical over-reach I have seen in years and are to be condemned for their stupidity.

This said, of course any computer program that is used in clinical care delivery needs to be robustly tested before deployment and the use of facilities such as range-checking and so on are vital – as is usability and safety testing to ensure safe program operation. The lesson here, if there is one, is that any programs used to support clinical care delivery need to be professionally and responsibly evaluated both for clinical and technical safety before deployment. Creation of such tools is not something to be done by enthusiastic but technically limited amateurs who do not appreciate the possible risks they run.

David.