The Human Services Access Card – What are its Chances?

Just as the Canberra politicians were about to depart for the “long winter parliamentary break” the Minister responsible quietly tabled an exposure draft of the proposed legislation for public consultation until August 21, 2007

The bill is entitled the “Human Services (Enhanced Service Delivery) Bill 2007 No. , 2007 (Human Services) A Bill for an Act to enhance the provision of Commonwealth benefits, and for related purposes” The full text of the bill, some explanatory notes and some fact sheets.

All this can be found and downloaded from www.accesscard.gov.au.

For those so inclined comments can be made by email to: accesscard.bill@humanservices.gov.au.

What I wanted to briefly consider is what this new bill means for the future of the overall project. My overall take is that while some of the rough edges have been knocked off the total package the risk of the Access Card becoming a de-facto national ID card has not been reduced to an acceptable level.

The reason I say this is principally that the Government is still insisting that a human readable number and photograph will be on the front of the card.

On this topic the relevant fact sheet states:

“One of the biggest weaknesses of existing Commonwealth issued benefit cards is their vulnerability to fraud because of their lack of security features. The inclusion of a photograph, card number and signature on the surface of the access card are integral to the ability of the access card system to effectively reduce fraud, protect individual identity, and streamline access to government services.

THE PHOTOGRAPH

The photograph of the card holder taken during the registration process will be stored on the Register, in the card’s chip and will be displayed on the surface of the card.

Only the Office of Access Card and participating agencies will have the software capable of reading the photograph from the chip of the card. This restricted access means that in addition to the legislative provisions and encryption technology protecting the electronic version of the photograph, there will be a further layer of physical security to safeguard the photograph.

A photograph will be displayed on the face of the card to:

• reduce fraud and leakage against taxpayer funded benefits;
• significantly enhance the identity security elements of the card by protecting the card holder’s identity and reducing opportunities for identity fraud and theft;
• increase customer convenience by allowing people to simply and swiftly prove who they are when accessing Commonwealth benefit ts and services both through Government agencies and also through general practitioners and pharmacies;
• improve access to Australian Government relief in emergency and disaster situations by ensuring that there is no interruption to service delivery during periods where terminals are out of service or unavailable;
• secure access to services in a mobile environment such as in rural or remote areas where services may be delivered by a visiting health professional; and
• permit access card holders to use their access cards for such other lawful purposes as they choose.

International accounting firm KPMG has stated that the presence of a photograph on the surface of the card is critical to achieving savings from fraud concession and leakage amounting to some $3 billion over ten years.

This reflects international experience in countries such as France and Germany who, having issued health smartcards without a photograph on the surface of the card, found the card ineffective in combating fraudulent activity. Both countries have now moved to issue cards with photographs.

The five most recent investigations by the Identity Crime Taskforce involving the seizure of fake ID manufacturing equipment have all included templates for making Medicare cards along with thousands of blank plastic cards capable of being converted into Medicare or credit cards.

The absence of a photo on the surface of the card makes it more susceptible to fraudulent reproduction and could result, as occurs today, in a single card being used by multiple offenders to access services and benefits to which they are not entitled.

The Australian Federal Police Identity Crime Task Force’s operational experience has shown that fake Medicare cards feature prominently in 70 per cent of the more serious and organised identity crime investigations.

The use of facial biometric technology will also ensure that only one card is issued per person by identifying duplicate and fraudulent applications. (See fact sheet on Biometrics.)

CARD NUMBER

The access card number assigned to an individual during the registration process will be stored on the Register, in the card’s chip and will be displayed on the surface of the card.

The Agencies within the Department of Human Services, including Centrelink and Medicare, are estimated to deal with over 51 million telephone contacts, 281,000 email contacts and 74 million secured customer transactions each year. The majority of these transactions currently involve the customer quoting a number that is printed on the surface of their existing Medicare, Centrelink or Veterans’ cards.

Maintaining a number on the surface of the access card will mean that these services can continue to be delivered in a streamlined and convenient way. In absence of a number on the surface of the card, individuals would be required to remember their access card number which could be comprised by as many as 12 digits and will change each time a card is reissued.

Without the number on the face of the card, a customer would need to continue to identify themselves by another means, most likely by providing additional personal information which may be intrusive to their privacy.

SIGNATURE

The signature of an individual captured during the registration process will be stored on the Register and will be displayed on the surface of the card. Including the signature on the Register supports customer authentication for claiming benefits when the customer is not physically present when claiming a benefit, for example when a cardholder submits a claim for reimbursement of medical expenses to Medicare.

The signature on the surface of the card provides and additional layer of physical security for the cardholder be enabling a visual comparison of the signature to be conducted at the point of service if necessary.”

Frankly I see this as a lot of ingenuous nonsense. All that has to be done is that the smart card is issued with simply a number on it – and nothing else visible. Then all those who are meant to verify the card have readers which when a card is put in – will display the name, picture and signature for verification.

Indeed it is clear from another fact sheet the readers planned by the government will display the photograph – so just exactly why is it needed on the card as well?

The card cannot then be used by anyone who does not know the associated name and other details either in person or over the phone. By making the personal information strongly encrypted and only readable by a Government reader you create a genuine access key – and not a card that can also be used “for such other lawful purposes as they choose” – i.e. as an identity card. (Function creep if ever I saw it from the Government’s mouth!)

Frankly until the Access Card becomes just that – a access key that is not usable for other purposes I do not believe the Australian public will wear it.

Moreover the Government is being less than honest when it says there will not be a “mega-database”. The central register will contain – another fact sheet states – the following:

“The Register will contain only information that is needed for the card holder to access health benefits, veterans’ and social services. This includes, but is not limited to:

• name, sex, date of birth and address;
• photo and signature;
• registration status, access card number and expiry date;
• concession status and veterans’ information if applicable;
• contact information such as residential address, postal address if applicable, phone and/or e-mail address; and
• whether or not the card holder is a customer with any of the participating agencies.

Individual customer records will continue to be held separately by Centrelink, Medicare, the Department of Veterans’ Affairs and other participating agencies.

Only those people with a legitimate operational purpose will be given approval for access to the Register in line with the confidentiality provisions in the legislation. Access to the information contained in the Register will also be governed by the Information Privacy Principles of the Privacy Act 1988.”

That sounds like a pretty large database to me containing contact information which many different types of miscreants (from violent abusers to debt collectors) would love to be able to access. We know from other incidents such a huge data-base acts as a honey pot for such people and at least some officers will be happy to receive payment for disclosing such information.

All in all, until the Access Card becomes just that, I will continue to see it as a bad idea and continue to hope the legislation just doesn’t quite make it.

David.

e-Health Risk – A Blog After My Own Heart!

Brendan Seaton is doing the e-Health Community a real favour!

For roughly the last six months he has been providing a blog called eHealthRisk. His description of the blog is as follows:

“The eHealthRisk blog is a forum for examining privacy, security, safety, project and business risks associated with the application of information and telecommunications technologies to health care.”

He has created a set of resources which should be carefully reviewed by anyone planning to set sail on any form of e-Health voyage.

Most especially I recommend a close review of all the entries by those responsible for the broad range of State Jurisdictional and NEHTA e-Health initiatives.

The blog can be found at:

http://www.ehealthrisk.blogspot.com/

Enjoy!

David.

Useful and Interesting Health IT Links from the Last Week – 01/07/2007

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.cchit.org/media/press+releases/Certification+Commission+Approves+Final+Criteria+for+Hospital-based+EHR+Certification+Program.htm

Certification Commission Approves Final Criteria for Hospital-based EHR Certification Program

Seeks qualified candidates to serve on Board of Commissioners

CHICAGO -- June 28, 2007 -- The Certification Commission for Healthcare Information Technology (CCHIT) announced today that it has published its approved criteria for certification of inpatient (hospital-based) electronic health record (EHR) products and will begin taking applications for certification Aug. 1. The final certification criteria, test scripts and associated program policy documents are posted on the Commission's Web site, www.cchit.org.

The application period for the first quarterly testing batch will be open until Aug. 14 and the first certified inpatient EHR products are expected to be announced in late October.

“Thanks to a year of intensive work by our volunteer workgroups and supporting staff, we are now ready to bring the benefits of certification to the inpatient domain,” said Alisa Ray, executive director. “Besides covering foundation standards such as security, the inspection of inpatient EHR products will examine clinician electronic order writing (often called CPOE), electronic medication administration (often called eMAR), related clinical decision support, and medication reconciliation. Certified products will have demonstrated their ability to have a positive impact on the quality and safety of patient care.”

A Town Call teleconference for vendors of inpatient EHR products is scheduled for July 12, at 11 a.m. Eastern Time to discuss the inpatient certification program and application process. Details on how to participate in the teleconference will be posted to www.cchit.org.

…..( see the URL above for full article)

This is a useful release and provides access to a valuable set of documents defining the expectation the CCHIT has for inpatient EHR systems. This documents are well worth a browse for all those involved in Hospital computing.

Second we have:

http://www.health.nsw.gov.au/pubs/2007/caring_health_report.html

Caring for our health? A report card on the Australian Government's performance on health care

Summary

Caring for our health? A report card on the Australian Government's performance on health care presents a snapshot on major national health funding in an easy to understand format. This report details where Canberra is spending taxpayers' money. It focuses on Medicare, general practitioners, specialists, medicines, public hospitals, private health insurance and explores health funding needs into the future. It examines whether recent changes in Australian Government policy are directing money where it is most needed. Most of the information is national - there may be some variations in different parts of Australia.

File link : Caring for our health? A report card on the Australian Government's performance on health care
File size: 2944Kb
Type : Report
Date of Publication: 01 June 2007

This is a document developed by the State Governments which tries to demonstrate how badly under-funded the State Health System (Hospitals etc) are. Sadly, while making a few interesting points, there is no suggestion of what might be done to make the most of what resources are already available. Sadly, as would been expected I guess, there is just no mention of what e-health and other technology innovations could offer. A missed opportunity I believe.

Third we have:

http://www.infoway-inforoute.ca/en/News-Events/InTheNews_long.aspx?UID=271

Canadian Implementation of e-Health projects increases by 39 per cent

Initiatives benefiting patients in every province and territory

Toronto, ON -- Canadian patients are benefiting from a 39 per cent increase in electronic health initiatives that are modernizing the way clinicians deliver health care, announced Richard Alvarez, President and CEO, Canada Health Infoway (Infoway).

"In the past year, we've seen tremendous growth in the number of electronic health record initiatives that are delivering enhanced patient care, shorter wait times and a more productive health care system for Canadians," said Alvarez, who recently released Infoway's annual report. "While this growth is encouraging, momentum must be maintained so we can capitalize on the efficiencies generated through electronic health initiatives as our population continues to age and grow."

In 2006-07, Infoway approved investments of $518.9 million in EHR initiatives across Canada, surpassing its target of $335 million. The digitization of diagnostic imaging, Drug and Laboratory Information Systems projects and the interoperable electronic health record made significant progress.

With 227 projects complete or underway across Canada, Infoway and its partners are investing in modern health information systems that are uncovering efficiencies in healthcare settings across Canada. The result is better patient care and outcomes, reduced wait times and cost savings.

Infoway's plan for further electronic health progress is outlined in 2015 -- Advancing Canada's next generation of health care, its long-term strategic vision document. The document is available at www.infoway-inforoute.ca.

Infoway is a federally-funded, not-for-profit organization that is leading the development and implementation of electronic health projects across Canada. Infoway works with provinces and territories to invest in electronic health projects, which support safer, more efficient healthcare delivery. Fully respecting patient confidentiality, these private and secure systems provide health care professionals with immediate access to complete and accurate patient information, enabling better decisions about diagnosis and treatment. The result is a sustainable health care system offering improved quality, accessibility, productivity and cost savings.

About Canada Health Infoway (Backgrounder)

Electronic Health Records: Investments Across Canada (Backgrounder)

Electronic Health Records: Quick Facts

Electronic Health Projects: Examples of Projects Across Canada (Backgrounder)

The case for electronic health records in Canada (Backgrounder)

Infoway's Vision (Backgrounder)

Program Activity Summary (Map)

This is a useful press release that provides an update on E-Health Progress in Canada. Given the scale of investment that is now obviously underway it will be interesting to see how the Canadian Health System performs overall in the next few years as these implementations are completed.

Despite this release it is clear there is still some contention and dis-satisfaction.

http://www.theglobeandmail.com/servlet/story/RTGAM.20070624.wehealth0624/BNStory/National/home

Ontario chided over health records

MELISSA JUERGENSEN

Canadian Press

June 24, 2007 at 9:34 PM EDT

TORONTO — Ontario is far behind other provinces when it comes to implementing electronic health records and it's a problem in need of immediate action, says Ontario's information and privacy commissioner.

“We're the largest province, surely we should be able to figure this out and come up with an action plan,” Ann Cavoukian said in an interview with The Canadian Press.

“Don't give me more strategy on how you're going to do it. We need something right now.”

According to Canada Health Infoway, a not-for-profit agency that helps develop electronic health records, the widespread use of such records can reduce wait times, create fewer adverse drug reactions and provide better prescribing practices.

Still, the Ontario government says it doesn't know when residents can expect a full electronic system that would give every person in the province a health record that all authorized health-care workers can access.

…..( see the URL above for full article)

Fourth we have:

http://www.healthleadersmedia.com/view_feature.cfm?content_id=90581

Healthcare Crisis: EMR Non-acceptance in the U.S.

Bill Bysinger, for HealthLeaders News, Jun 27, 2007

It has been almost 20 years since electronic medical records systems were introduced into medical practices, yet we have the lowest adoption rate of all the developed countries in the world. Most of Europe, Japan, China, Australia and even Russia have adoption rates above 50 percent and in many countries above 90 percent.

We are supposed to be the world leader in adopting technology, but recent studies have put our practice EMR adoption rate at somewhere between 15 percent and 18 percent.

I submit the root cause of the problem is the culture of the healthcare industry. Healthcare in the U.S. especially at the practice level is a cottage industry. Medical practices don’t make business decisions based on productivity or process improvement, which dominates other industries. Instead, they make decisions based on how much money do they have to spend and what will it do for the providers personally (and immediately).

…..( see the URL above for full article)

This article offers one commentators view as to how EHR adoption could be accelerated in the US environment. Some of the suggestions around linking EHR use to the cost of medical liability insurance and providing higher payment for services delivered when an EHR is used bear consideration.

Lastly we have:

http://www.eurekalert.org/pub_releases/2007-06/uom-uom062707.php

U of M researchers assess effectiveness of computerized physician order entry system

Medication errors are reduced in hospitals that utilize the system

MINNEAPOLIS / ST. PAUL (June 27, 2007) — The incidence of medication errors can be reduced by implementing a computerized physician order entry (CPOE) system, according to a review of several studies conducted by researchers at the University of Minnesota.

The review, recently published in the online journal Health Services Research, analyzed 12 studies conducted between 1990 and 2005 that compared the number of handwritten and computerized medication errors made by hospital physicians. Medication errors, which include prescribing the wrong drug, ordering an inaccurate dosage, or administering a drug at the wrong time, dropped by as much as 66 percent in United States hospitals that switched to a CPOE system. Illegible handwriting and transcription errors account for more than 60 percent of medication errors.

“Patient safety is our final goal,” said Tatyana Shamliyan, lead review author and a research associate at the University of Minnesota School of Public Health. “Evidence from these studies show that computerized systems can reduce mistakes, but unfortunately less than 50 percent of hospitals have implemented these systems. There is a lot of work to be done in the future.”

The rate of medication errors experienced by hospitals has skyrocketed from only 5 percent in 1992 to nearly 25 percent today. The review found that of these hospitals, CPOE systems were most beneficial when the rate of medication errors was more than 12 percent.

The Institute of Medicine has already identified medication errors as a major threat to patient safety and has endorsed electronic prescribing of medication as an effective method in correcting the problem. “Medication errors are a central aspect of improving hospital safety. CPOE can help that process,” says Robert Kane, M.D., review co-author.

“Hospitals would be short-sighted not to use it.” Kane also notes that CPOE systems can be combined with existing computerized medical records, creating a central location for physicians to efficiently enter and view past and present patient prescriptions and medical history.

While the review found that the number of medication errors dropped as a whole, the incidence of one type of error, prescribing the wrong drug, did not decrease. In five of the twelve studies, the number of adverse events from drugs errors did not decrease. More than one-half million patients suffer injuries or death from adverse events, causing up to $5.6 million annually per hospital, according to the review.

###

The Academic Health Center is home to the University of Minnesota’s six health professional schools and colleges as well as several health-related centers and institutes. Founded in 1851, the University is one of the oldest and largest land grant institutions in the country. The AHC prepares the new health professionals who improve the health of communities, discover and deliver new treatments and cures, and strengthen the health economy.

Further coverage of the findings of the study is available here:

http://www.theglobeandmail.com/servlet/story/RTGAM.20070628.wlprescribe28/BNStory/specialScienceandHealth

Doctors' poor penmanship can have deadly results

ANDRÉ PICARD

From Thursday's Globe and Mail

June 28, 2007 at 9:50 AM EDT

The abysmal handwriting of physicians is the stuff of legend among nurses and pharmacists. But the result - frequent medication errors due to drug names and dosages misread from doctors' chicken scratch - is deadly serious.

New research has driven home just how harmful badly written prescriptions and other transcription errors can be.

The study, published in the journal Health Services Research, shows that having doctors write electronic prescriptions - by typing them into a computer rather than writing them by hand - reduces medication errors by a staggering 66 per cent.

"These medication errors are very painful for doctors, as well as the patients. Nobody wants to make a mistake," said Tatyana Shamliyan, a research associate at the University of Minnesota School of Public Health, and the lead author of the paper.

…..( see the URL above for full article)

This is a useful review and supports the urgency for the implementation of systems that can clearly reduce errors and suffering.

All in all quite an interesting week!

More next week.

David.

Labor Fails to Join The Dots!

Today Kevin Rudd released an overview of a key element of the Rudd Labor Party Health Policy.

The essentials of the policy release can be understood from the following:

“Mr Rudd launched Federal Labor’s New Directions paper - Fresh Ideas, Future Economy: Preventative health care for our families and our future economy.

Mr Rudd said Federal Labor will:

• Develop a National Preventative Health Strategy to provide a blueprint for tackling the burden of chronic disease currently caused by obesity, tobacco, and excessive consumption of alcohol. The Strategy will be supported by an expert Taskforce.
• Shift the focus from so-called “six minute medicine” in general practice by beginning a reform process to provide incentives for GPs to practice quality preventative health care;

• Broaden the focus of the major health care agreement between the Commonwealth and the States and Territories beyond hospital funding by developing a National Preventative Health Care Partnership; and

• In its first term, commission the Treasury to produce a series of definitive reports on the impact of chronic disease on the Australian economy, and the economic benefits of a greater focus on prevention in health care.

The cost of providing health care and the cost of rising demand for health care is expected to spiral. Federal Government spending on health care will increase from 3.8 per cent of GDP in 2006-07 to 7.3 per cent in 2046-47.”

The full media release can be found at the following URL:

http://www.alp.org.au/media/0607/mshealoo280.php

The full document can be found here:

http://www.alp.org.au/download/fresh_ideas_future_economy___preventatve_health_care.pdf

All this I must say is totally rational, appropriate, needed, pragmatic, practical and sensible.

However, in the ALP Draft Policy Platform one finds the following:

ALP National Platform and Constitution 2007

Harnessing New Technology and Managing Patient Information

“67. Labor sees major opportunities for new technology to make health services more effective, more accessible and more consumer friendly. Technological change needs to be carefully managed with close attention to the social and ethical implications and the need for privacy for personal health records. Labor will ensure that commercial interests do not subvert intended health outcomes and that decisions are made on the basis of clinical and cost effectiveness determined by the best available research evidence.

68. Labor will, in collaboration with State and Territory governments, build information technology and communication infrastructure and systems that improve the decisions made by consumers, clinicians and health service managers about care, service delivery and policy. The purpose of this investment will be to:

• build accessible knowledge bases from quality data systems, libraries of research evidence and the experience of consumers and professionals;

• enhance online communication between consumers and professionals, and primary and acute care settings, regardless of location, to improve health outcomes and service quality; and

• create data management systems that monitor population health and the safety, quality and efficiency of health services.

69. Labor will ensure that appropriate training is undertaken by health professionals to develop and maintain the skills necessary to use these knowledge bases, health records and communication systems.

70. Labor believes the development and implementation of health knowledge management systems that include electronic health records and decision support systems for evidence based practice are central to improving the safety and quality of health services. However, these new tools cannot be widely used until satisfactory arrangements are in place to protect security and privacy.

71. Labor will ensure every Australian has a personal electronic health record that is privacy protected. Labor will develop a strong privacy regime built around a unique patient identifier based on the Medicare card. Legislation will prohibit this number being used for any other purpose and access will depend on authorisation from both the patient and the doctor. A range of other safeguards will be incorporated in legislation, which will be developed after a public inquiry into all the issues.

72. It is critical that health providers can communicate effectively with each other while maintaining patient confidentiality. Labor will provide leadership in the development of national, secure health data standards and will establish a common framework for health record systems. The delay in establishing this infrastructure is inhibiting the delivery of quality health services in Australia and contributing to unnecessary adverse events.

Specifically Labor will ensure:

• the use of tele-health to give rural clinicians direct access to city based specialists and the resources of major teaching hospitals;

• the use of secure electronic networks to give clinicians and pharmacists access to high quality drug information sources; and

• the use of electronic prescriptions to speed up and reduce errors in communications between clinicians and pharmacists.

73. Labor will give Medicare Australia greater powers to analyse data to examine variations in practices, to enable the promotion of professional practice based on the best available evidence from research. Clinicians will be supported in their evidence-based practice through the development of appropriate, accessible clinical guidelines and pathways of care.”

Again, this is music to those who see further development in e-health as fundamental to better health care safety, efficiency and quality.

What is missing from the announcement is a section that makes the link between effective computerisation of General Practice and delivery of consistent quality GP care – which is what is needed to actually have more preventive care undertaken. Intelligent advanced decision support for GPs is a major way to make sure all relevant interventions are scheduled, undertaken and followed up.

An extra sentence or two would have made me a much happy camper – knowing the link between e-health deployment and better preventive care was fully appreciated at the top!

In the interests of balance – interested reader who wish to understand Government Policy on the Topic can visit.

http://www.ama.com.au/web.nsf/doc/ween-6l76qj

This contains the proceedings of an e-Health Forum conducted by the AMA in 2006 where there were a number of senior government officials and Minister Abbott contributing.

Minister Abbott said at the forum (Jan, 2006) that:

“Just over two years ago, the first scripted speech I made as Health Minister was about the importance of creating an E-Health system. At that time, in my inexperience, I declared that it must be possible to bring about such a self-evidently worthy goal within five years. Despite the hard lessons since, I'm more convinced than ever of the importance of this project for the long-term good of the health system. It may never be the most pressing task for the people running our system but it may be the most important practical measure policy-makers can pursue to make it more efficient and more responsive to patients.”

This seems to be the most recent Ministerial statement available – other than the recent letter from the Department of Health and Ageing which was published here a few weeks ago. (Let me know if there is a later source!)

I leave it to readers to review and decide what approach they prefer and how credible each is.

David.

Is HealthSMART as Smart as it Claims?

It is funny how things come back to haunt you. In the 2003/4 Victorian Budget an allocation of aadditional funding of $138.5 million was provided budget for a Health Information and Communication Technology (ICT) Strategy to roll out an integrated approach to the implementation and ongoing support of business applications and their underpinning technical architecture.

The full cost of the Health ICT Strategy was estimated at $323.5 million. This included $138.5 million over four years provided in the 2003–04 budget, with the remaining funds to be contributed by hospitals and existing information and communication technology funding from the Department of Human Services.

The additional funding is as follows:

Health ICT Strategy (Additional Funding)

2003/4 18.5M

2004/5 38.0M

2005/6 40.5M

2006/7 41.5M

Total = 138.5M

This means that had things gone as planned the investment would have been finished a day or so from now and all would be wonderful – Health IT wise – in the great Southern State.

Under the Health ICT Strategy, the Government was to remove obsolete, aged products and invest in modern proven systems, based on accepted interoperability standards covering hospital administration systems, clinical systems and electronic medication ordering.

Of course that was never going to happen. We now find that – to quote from the HealthSMART website:

“HealthSMART is a $323M technology program operating across the public health care sector funded through the 2003-04 Victorian State Budget. Initially a four-year program, it is now running over six years from 2003 - 2009.”

To be frank even this timeline looks more than optimistic. Why do I say this?

First, it seems that with clinical systems HealthSMART has adopted the approach of developing State-Wide Builds of the Cerner Software. Experience elsewhere has shown that this can be very problematic (just look at the UK NHS) – as the users don’t see they are getting the system they need that really suits them – rather they are getting a compromise – to them – state-wide solution.

One only has to see that the State-Wide System is being driven by a committee representing 13 different health systems (from major to minor hospitals and from cancer to paediatric hospitals) with over 40 members to recognise that getting agreement on what is to be done will be both slow and tricky to achieve.

Second if one reviews the time-lines provided in each of the progress reports (Roadmaps as they are called) it is clear that with each update issued the time-lines are extending.

Third my making the choice to implement Cerner clinical applications on top of an iSoft Patient Management System they have greatly complicated the operations of each and have lost many of the key benefits of integration that the Cerner system offers.

This is especially true given their approach is to integrate patient administration, outpatients, emergency, laboratory, pharmacy and radiology (at least) onto a Cerner core repository. I believe this is a plain stupid strategy. The amount of context switching from source systems (lab, pharmacy etc) that many clinicians will be forced into is likely to be both time-wasting and annoying.

Fourth with the some of the system selections made there must be the suspicion that adequate financial due-diligence was not undertaken given the difficulties being experienced at present by iSoft.

Fifth, any Health IT strategy that takes six-seven years to implement in the Public Sector has a high risk profile no matter what else goes well initially.

It seems to me that sadly this strategy is facing some existential threats. I hope it can prosper and deliver but it is looking less likely to me as of late June, 2007.

Clearly I am not the only one who has noticed there are a few issues:

http://www.theage.com.au/news/national/health-revolution-stalls-over-mass-funding-blowout/2007/06/23/1182019436711.html

Health revolution stalls over mass funding blowout

Jason Dowling
June 24, 2007

AN UPGRADE of the health system's computer network — which the Government says will "revolutionise" the way hospitals and surgeries deal with patients — has blown way over budget and is years behind schedule.

The upgrade program has cost $363 million so far — $40 million over budget — and is two years behind schedule. It also has been scrutinised by auditors amid allegations of conflicts of interest involving a contractor employed by the Department of Human Services.

…… (see URL for full article)

The stories of contract irregularities, budget blow outs and compulsion of clinicians etc bode very badly indeed.

I suspect that by the time 2009 rolls around I will be seen to have been quite prescient – time will tell.

David.

The NEHTA Review – I Sure Hope it Helps!

Yesterday it was announced that the Boston Consulting Group have been engaged to review NEHTA. The full text of the release is as follows:

BCG wins tender to conduct the NEHTA Review

25 June, 2007. The NEHTA Board today announced that the Boston Consulting Group (BCG) has been selected via open tender to conduct the NEHTA Review.

NEHTA Ltd was established in July 2005 and funded jointly by all federal, state and territory governments for a three-year period to accelerate e-health in Australia. NEHTA’s constitution requires Directors to commission an independent review of NEHTA’s future direction two years after the company’s formation.

BCG is due to commence the review process in July.

“I am confident that BCG has the capacity to conduct an independent and thorough review of NEHTA. They have a superior understanding of the e-health environment in Australia and overseas and have the knowledge to comprehensively review the work undertaken by NEHTA to date,” said Uschi Schreiber, NEHTA Chair and Director-General of Queensland Health. “BCG’s team also has the capability to succinctly consider and evaluate any ongoing role for NEHTA beyond 2007/08 and the benefits and risks of alternate governance arrangements under which NEHTA, or its successor, could operate.”

The review will address the effectiveness of NEHTA in meeting its objects, as set down in the constitution, including whether these objects remain valid and appropriate.

BCG will gather information on NEHTA’s operations from:

· NEHTA and its Directors;

· Jurisdictions;

· Key stakeholders; and

· Independent research.

In addition, the review will consider the future direction for e-health reform and the most appropriate vehicle(s) for future directions, including the future role for NEHTA Ltd, or similar organisation.

There will be the provision for stakeholder input into the review. Contributions to the review can be forwarded by email to nehta_review@bcg.comThis e-mail address is being protected from spam bots, you need JavaScript enabled to view it .

The findings of the review will be provided to the Directors in the first instance. A General Meeting of Members will be called within two months of the review being completed, to consider and vote on the future of NEHTA. The review process is planned to conclude before the end of 2007.

----- End of Release.

Well this is a good thing to be happening as the BCG is a consulting group of considerable reputation and expertise.

I do have, however, a number of concerns.

First, given the study is to commence in July and be completed before the end of 2007, I am concerned that the time frame may be some-what compressed. The last thing we all need when “the review will consider the future direction for e-health reform and the most appropriate vehicle(s) for future directions, including the future role for NEHTA Ltd, or similar organisation” is to take inadequate time to address all the issues.

I am quite concerned the time frame allowed for the review (looking like being only 4 months or so actual elapsed work time) may not allow for an in-depth review of all the aspects of Australian e-health and ensure we are not yet again in the situation where we are essentially starting again without having learnt all the lessons of the past decade. The learning aspect of this engagement is vital. We don’t have an infinite number of chances to get this right!

Second, given that NEHTA is the organisational and operational outcome of a BCG consultancy conducted three years ago (2004), I think I would have preferred someone else to review the outcome of the BCG work some three years later. (Booze Allen Hamilton or McKinsey spring to mind).

Third I am concerned at just what will be defined as “key stakeholders”. At the very least the process must be conducted in a transparent and consultative way and includes gathering the views of all relevant parties including consumers, the MSIA, Health IT Vendors, the AIIA, AHIC, medical, nursing and like colleges and organisations and Academia as well as the Jurisdictional Sponsors of NEHTA. One gets the sense from the press release this level of breadth is not actually contemplated.

Fourth, the lack of commitment, in the press release, to public release of a draft document for comment before the document and recommendations is finalised is of some concern as it the statement that "The findings of the review will be provided to the Directors in the first instance. A General Meeting of Members will be called within two months of the review being completed, to consider and vote on the future of NEHTA. The review process is planned to conclude before the end of 2007." Consideration of the review by the public does not seem to be contemplated in this. If we are to have another report done in secret by consultants bound by ‘commercial in confidence’ constraints it will be a serious travesty.

Fifth, one is really forced to ask why the actual “Terms of Reference” for the BCG engagement are not included with the release. Not sure that presages a good outcome.

Sixth, it needs to be realised this is a Board who has selected a consultant on the basis of an evaluation conducted by its staff and executive. It seems to me there is already a major conflict of interest involved as it would be extremely unlikely – although possible I guess – that the Board, unaided by NEHTA staff made the selection.

Seventh, I see no commitment in the Press Release to the full outcome of the review being made public. One certainly hopes it will be so the relevant lessons can be learnt by all!

Eighth, I hope a significant part of the review will be based on what was, and was not achieved, based on the objectives set out in the 2004 recommendations.

Last I also note the press release does also not make clear just what interaction there will be between the review team and AHIC in the determination of forward e-health strategy."

Further commentary on the NEHTA review can be found in an older posting:

Here We Go Again!

We all have to be concerned that the BCG will find themselves reporting to the people who would see a bad report as an existential threat. The governance of the project should really be made public so we can all be re-assured such a problem does not exist.

As an experienced consultant, who has worked in the real world, I know only too well the subtle pressures a client can exert to get the report they want – especially when it is the client who will pay the bill. I know the BCG are and will be well aware of all these risks and issues but it would be good to know they have been properly protected organisationally from such pressures and risks before the project starts. Ideally some-one other than NEHTA should be responsible for accepting each of the deliverables and agreeing to payment.

We can all await events and prepare submissions as suggested in the release!

David.

How Could e-Health Help in the Northern Territory.

Unless readers have been hiding under a rock over the weekend they will be aware the Prime Minister has declared the situation with sexual abuse of children in the Aboriginal Community to the a “National Emergency”. All sorts of actions are planned to address the problem – among them being a compulsory “health check’ for the approximately 23,000 Aboriginal children under 16 in the Northern Territory (NT).

Estimates I have seen suggest that to undertake this task will require about four times the number of doctors who presently work in the NT. This will inevitably bring a range of informational and continuity of care issues into stark relief as many of the doctors who assess the children will be on a ‘fly-in / fly-out’ basis.

Just as the emergency of Hurricane Katrina provided an opportunity to show how e-health could make a difference – leading to the implementation of a now operational permanent emergency medication management system – it would be a valuable outcome if the same thing could happen out of this emergency.

The issues that seem to need to be addressed include:

1. Ensuring the consistency and quality of the clinical examinations provided by what will inevitably be a transient medical workforce – at least in the first instance.

2. Ensuring that there is ease in follow-up of any clinical problems identified by having a sharable standardised record which will be used by all clinical care-givers

3. Ensuring there is appropriate collection of information to guarantee the clinical outcomes of the children can be assessed and tracked to ensure the interventions are making a real difference to the health status of those being intervened upon.

4. Ensuring capture of relevant clinical information at the source of its creation to ensure observational accuracy and reliability.

To be successful any proposed solution will need at least to have the following attributes:

1. Be easy to use for the relevant clinicians

2. Be deployable ‘well of the beaten track’. (i.e. it will need to utilise satellite internet or some equivalent)

3. Be portable as far as the clinical user is concerned.

4. Provide structured information capture to ensure all relevant checks and assessments are made. (The information contents to be captured should be developed by experienced Paediatric Clinicians from the NT such as Dr Paul Bauert, who is spokesman for the Paediatrics and Child Health Division of the Royal Australasian College of Physicians and head of Paediatrics at Royal Darwin Hospital).

5. Be able to facilitate quality co-ordination of care when there is no stable local GP to play that role.

6. Address the issues associated with the identification of Aboriginal individuals who have a view of names and identity that is rather more fluid than while Australia.

While not wishing to be prescriptive I would see the use of something like the openMRS (http://openmrs.org/wiki/OpenMRS) which has proven itself to be a very viable approach to the management of a reasonably defined clinical domain in areas such as Africa.

(An example is reflected in the following news item from the site:

Happy Anniversary to the AMRS team! 14-Feb-2007 is the one year anniversary of the OpenMRS implementation in Eldoret, Kenya. To date, the system has stored close to 10 million patient-level measurements on 43,000 patients who have accumulated ~450,000 visits. Congratulations.).

Another possibility would be the use of the HL7 CDA or similar standard to define the information content to be captured. The openMRS approach may be preferred because of its dual layer data-model but this is extreme detail at this point.

I believe this or some similar approach could and would address the issues I identify, is practically achievable and would make a huge difference!

The advantages of a web-based system used in the field to collect, enable action upon and measure the outcomes of interventions are compelling to me and I suspect to anyone else who understands just how complex the clinical information logistics of this intervention would be if undertaken on paper.

There is a very short window to act..I would be interested to know what others think. This looks like an opportunity to make a difference to me!

Corrections, comments and other suggestions welcome. (This is a work in progress and may change depending on feedback)

David.

Useful and Interesting Health IT Links from the Last Week – 24/06/2007

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

These include first:

http://www.news.com.au/heraldsun/story/0,21985,21948702-662,00.html

Smartcard bill released on Parliament break-up

Article from: AAP

By Sandra O'Malley

June 22, 2007 01:25am

THE Federal Government has released a 200-page draft bill of its controversial access card just hours before Parliament took a six-week break for winter.

Human Services Minister Chris Ellison will give the community two months to comment on the draft legislation, which was released late yesterday.

It almost guarantees that the Government won't introduce the contentious new card before the next federal election, due to be held in October or November.

The access card is intended to replace the Medicare card and up to 16 other benefit cards, streamlining access to a wide range of government health and welfare services.

The exposure draft is a consolidated bill containing legislation previously introduced to Parliament and new changes that flowed from public and parliamentary scrutiny of the original laws.

…..( see the URL above for full article)

Full details can be found here:

http://www.accesscard.gov.au/legislation.html

The site notes:

“The period for public comment on the draft Bills closes on Tuesday 21 August 2007. All comments will be given careful consideration and form the basis to provide advice to the Minister for Human Services who will decide whether the Bill will be amended prior to introduction into the Federal Parliament.”

The Ministerial Press release is found here:

http://www.accesscard.gov.au/media/070621-exposure-draft-of-access-bill.html

On a quick read it seems the Government has taken on board some of, but not all, of the suggestions of the Access Card Privacy Taskforce. I plan to devote some time to closer review of all the documentation over the next week or two. The fact sheets describing the new legislation provide an easy way to understand the major issues.

Second we have:

http://www.computerworld.com.au/index.php?id=1524791164&eid=-44

Semantic Web: Stuck in neutral

Semantic Web technologies are not just a pipedream

James Kobielus (Network World) 21/06/2007 09:54:08

Ubiquitous semantic interoperability is like world peace: It's a goal so grandiose, nebulous and contrary to the fractious realities of distributed networking that it hardly seems worth waiting for.

In most circumstances we can assume that heterogeneous applications will employ different schemas to define semantically equivalent entities -- such as customer data records -- and that some sweat equity will be needed to define cross-domain data mappings for full interoperability.

Nevertheless, many smart people feel that automated, end-to-end, standards-based semantic interoperability (where computers exchange not just data but the data's meaning as well) is more than a pipe dream. Most notably, the long-running Semantic Web initiative of the World Wide Web Consortium (W3C) just keeps chugging away, developing specifications that have fleshed out Tim Berners-Lee's vision to a modest degree and gained a smidgen of real-world adoption.

…..( see the URL above for full article)

This is a useful brief review of just where this superficially attractive idea has gone in the real world. It seems to be moving forward only slowly.

Third we have:

http://www.silicon.com/publicsector/0,3800010403,39167548,00.htm

Richard Granger's NHS IT legacy

News Analysis: Will the £12.4bn project be viewed as a success or a failure?

By Andy McCue

Published: Monday 18 June 2007

After five years in charge of the biggest IT project in the world NHS IT director-general Richard Granger has announced he is to step down later this year.

The former Andersen and Deloitte management consultant came to the NHS IT post on the back of his successful stint delivering the London Congestion Charge scheme, becoming the UK's highest-paid civil servant - a silicon.com Freedom of Information request last year revealed he earns around £280,000.

It has undoubtedly been a turbulent five years and opinion is strongly divided on whether his time in charge of the £12.4bn NHS computerisation programme - also known as Connecting for Health - has been a success.

While Granger's hard-headed and no-nonsense approach meant tough new contracts for suppliers, which would only get paid for systems they actually delivered, it also led to accusations of a project being imposed on the NHS with little input from the doctors, nurses and patients who would be using it.

…..( see the URL above for full article)

This is a useful summary of the present status of the UK Health IT National Program for Health IT and is well worth a read. I think I will wait a few years before forming a final view on this enormous project. We can only wish Richard Granger well in his next role. I suspect he has suffered enough at the hands of Health IT.

Further comment is found at:

http://politics.guardian.co.uk/publicservices/story/0,,2106234,00.html

Ailing project at heart of NHS

Loss of IT chief is only the latest setback in ambitious scheme to computerise records
Simon Bowers
Tuesday June 19, 2007
The Guardian

And here:

http://www.computerworlduk.com/management/government-law/public-sector/news/index.cfm?newsid=3580

NHS IT chief warns contractors could seek compensation

Granger claims his departure could force contract renegotiations

By Tash Shifrin

And here:

http://www.e-health-insider.com/comment_and_analysis/index.cfm?ID=232

The end of the beginning?

Fourth we have:

GAO cites HHS for not establishing IT milestones

By: Joseph Conn / HITS staff writer

Story posted: June 21, 2007 - 1:14 pm EDT

Part one of a two-part series:

In an update of a January report, the Government Accountability Office has again criticized HHS for failing to have an integrated approach to developing a national privacy policy for healthcare information technology. In testimony before a congressional oversight subcommittee Tuesday, the GAO also cited HHS for not establishing milestones to measure its own progress toward that end.

But the GAO itself came in line for some harsh words, this time from a pair of privacy advocates who charge that the congressional watchdog has kept its head in the sand when it comes to the current privacy environment and the lack of protection afforded by a key federal privacy rule.

Meanwhile, the head of a coalition composed mostly of healthcare systems and pharmaceutical manufacturers and resellers testified in defense of the Health Insurance Portability and Accountability Act privacy rule, while warning against adding privacy constraints to it and calling for eliminating by federal pre-emption the more stringent state privacy laws that HIPAA now allows. And, a privacy expert who worked on developing HIPAA during the Clinton administration, chided the Justice Department and HHS for failing to enforce the act's existing privacy provisions.

…..( see the URL above for full article)

This two parter covers the various views expressed by the various interest groups in the “Privacy of Electronic Health Records” debate. It provides a useful overview of the range of opinions held in the US at present. There is certainly a diversity of views!

Lastly the iSoft / CSC / IBA Health seems to be moving to conclusion:

http://australianit.news.com.au/story/0,24897,21924858-16123,00.html

CSC drops iSoft complaint

Ben Woodhead | June 18, 2007

OUTSOURCER Computer Sciences Corporation has dropped its opposition to Australian medical software developer IBA Health's £140 million ($352 million) takeover of iSoft

The move ends weeks of uncertainty around the all share offer for iSoft that was triggered by a letter last month from CSC to iSoft that said the outsourcer would block the proposed acquisition.

CSC is iSoft's largest customer and has the right to block changes in ownership of the software company under a contract linked to the UK National Health Services £12.4 billion National Program for IT (NPfIT).

However, iSoft has had to sacrifice about 5 per cent of the revenue it would have received from its work on the NPfIT to make the deal happen.

"This agreement is a great outcome for both iSoft and CSC," IBA executive chairman Gary Cohen said in a statement to the Australian Securities Exchange.

"For iSoft it reduces the risk of the (NPfIT) and strengthens its financial position in the early years of the program."

…..( see the URL above for full article)

The full announcement – dated June 18, 2007 can be found here:

http://markets.news.com.au/Newscorp/Company/Announcements.aspx?SecId=IBA

It needs to be said this will make IBA one of the largest – if not the largest – software company in Australia. The hope is that having CSC manage the development of the core NHS system (Lorenzo) will mean IBA will have a good outcome from the merger. No matter how this is sliced or diced the move is a ‘bet the company’s future’ move. (Disclaimer – I do hold some IBA shares).

Other useful finds this week include:

1> http://e-caremanagement.com/connecting-the-dotsgoogle-health-promises-to-create-and-dominate-next-generation-phrs/#more-109

Connecting the Dots…Google Health Promises to Create AND Dominate Next Generation PHRs

Posted by Vince Kuraitis on June 20, 2007 · Filed in Companies, DM Megatrend #5: Technology, EHRs/PHRs · Comments

Google Health (GH) could be the event of the decade in advancing health care reform — not just healthcare information technology (HIT) reform, but health care system reform. GH promises simultaneously to create AND dominate the market for next generation personal health records (PHRs). There is nothing else in our solar system or in the entire universe like it.

2 > http://www.tbo.com/news/nationworld/MGB30KO483F.html

FDA Approves Computerized Pillbox

Skip directly to the full story.

The Associated Press

Published: Jun 22, 2007

All in all quite a busy week!

More next week.

David.