The NEHTA Deliverable Silliness Continues.

All of a sudden the NEHTA RSS feed lit up on Friday to let us all know we have some more NEHTA documents to consider.

What was on offer really left me somewhat amazed.

First NEHTA seems to have concluded that Australian Health Software developers need a hand to get their heads around how to code web services based applications. To assist they have thoughtfully provided code on how to implement Web services that conforms with their guidelines using a series of toolkits based on Microsoft and Java technology.

Having however undertaken the task they then cover themselves with the odd disclaimer.

First they say:

“This document is provided for educational purposes only. The method it describes is only one approach; there might be other, equally valid approaches."

Then they point out:

“The code samples in this document are designed for simplicity and ease of understanding, rather than robustness and reuse. They are not written for use in a production system."

A few things strike me about all this.

1. If NEHTA was serious about helping why did they not provide a downloadable working instance of each of these approaches with the source in machine readable form – for testing, review and discussion. Having no reference implementation and being given the code in .pdf form is hardly a real help.

2. On the second page we have the following:

Copyright © 2007, NEHTA.

This document contains information which is protected by copyright. All Rights Reserved. No part of this work may be reproduced or used in any form or by any means—graphic, electronic, or mechanical, including photocopying, recording, taping, or information storage and retrieval systems—without the permission of NEHTA. All copies of this document must include the copyright and other information contained on this page.

So, it seems use of the code is not actually encouraged. Clearly the code should have been released with an appropriate open-source license attached so the clinical community could use, evolve and feed-back suggestions etc.

3. Just what is actually going on with NEHTA feeling the need to provide programming examples? I leave it to others to suggest what is happening here but can’t help wondering if there is not something like a “search for relevance” aspect to all this. I can really think or a whole lot of different ways for NEHTA to be helpful than this.

4. While I have nothing against MS or Sun I wonder why other Web-Services Toolkits are not apparently being encouraged – particularly open-source ones such as the Open Health Framework from the Eclipse Foundation.

Second we have another Clinical Data Specification Document. This one covers the data specification for Diagnostic Imaging and runs to some 228 pages.

The document is entitled Diagnostic Imaging Data Specifications Version 1.0 – July 2007.

What is interesting is that the commencement of the development of this document actually preceded NEHTA’s establishment – having begun in 2004 (i.e. it is a part of the HealthConnect Clinical Information Project which seems to have just continued on regardless). What is it we have been waiting for for about the last three years.

I quote:

“The Diagnostic Imaging (DI) data group specification forms part of a suite of data specifications that NEHTA is developing for the Australian Health Informatics Community. The suite comprises specifications for a range of health topics (represented as “data groups”), which are generally agreed to be of high priority to standardise in order to achieve the benefits brought about by semantic interoperability in the Australian health care setting.”

It is also important to recognise what this document is not: I quote again:

“While this specification defines the data groups and data elements required to support diagnostic imaging requests and reporting, it is important to note that this specification does not cover the following:

• Implementation guide describing how the data groups are intended to be implemented in electronic applications/systems such as Clinical Information/ Electronic Health care Record Systems (CIS/EHRS), Radiology Information Systems (RIS) or Picture Archive and Communication System (PACS).

• Terminologies for diagnostic imaging procedures and reporting, their development and binding to the diagnostic imaging data elements.

• Structured document specifications for diagnostic imaging requests and reporting

• Electronic interchange format specifications for diagnostic imaging requests and

reports.

These specifications may become targets of future NEHTA work programs. The timelines for the further development of diagnostic imaging specifications and relevant extensions to SNOMED CT will be guided by the priorities identified by the NEHTA Board, and the international priorities of the International Health Terminology Standards Development Organization.”

What this is saying is, as I read it, is the following. We started on this project in another era, there is still a lot more work to do, the terminologies required for this to be useful are not developed (and won’t be for a while if ever) but we thought it would be good idea to release it. Oh, and also there is no commitment on NEHTA’s part to do any more on this – i.e. it is probably an orphan and you should use at your own risk (if you choose to ignore it is Copyright © 2007, NEHTA.)

This is made pretty clear in the following from the associated release note:

“Ongoing Development

Because the development of a terminology and data specifications is an iterative process, these specifications will evolve to accommodate changes in healthcare practices and feedback from users that share Diagnostic Imaging information between systems.

The timing of the further development of diagnostic imaging specifications and extensions to SNOMED CT will be guided by the priorities identified by NEHTA’s benefits realisation study and health departments, as well as the directions taken by the International Health Terminology Standards Development Organization.

NEHTA’s current terminology priority is the development of appropriate quality assurance processes, including the use of metrics and automated tools to build, manage and audit data. Such tools will support collaborative terminology development.”

Who in their right mind would take any notice of this specification with that level of commitment from NEHTA. No one with half a brain I would suggest. This is just another piece of useless orphan and probably terminal shelfware!

Third we have a range of documents covering web-services based e-procurement. Now I am not an expert in this area but I was fascinated by the scope of what was made available:

“Of the set of document types identified in the Australian Standard for Health Supply Chain Messaging [HSCM2004], the following subset has been identified as important to the jurisdictions: Purchase Order, Purchase Order Response, Purchase Order Change, Despatch Advice and Invoice.”

What seems to be missing is – to quote again:

“All catalogue, order fulfilment logistics and payment related parts of these processes have been deemed out of scope for the first version of the NEHTA e-procurement architecture.”

So while suppliers are being asked to provide data for the National Product Catalogue (NPC), it is not to be used by the jurisdictions for now and delivery tracking and payment will remain manual as well – so we (the jurisdictions) don’t have to pay our bills too quickly – I assume!

Since I am told many jurisdictions will not be ready to use the NPC until 2009 this may not be a problem, except for the ongoing waste involved in not implementing e-procurement fully.

On behalf of my better half I do have to say, however, I was pleased to note a report she wrote with a good mate years ago, which showed the scale of possible e-procurement savings, was referenced. Pity it has taken seven years for some apparent action.

“[MORE2000] More, E. and McGrath, G.M., Health and Industry. Collaboration: The PeCC Story, Canberra, NOIE, AGP. DOCITA 8/00, May, 2000”

The first time I have managed to drag my wife into the blog !

As a side comment NEHTA also provides Version 1.0 release of the WSDL and XSD files for the E-Procurement Technical Architecture. The Technical Architecture can be downloaded from http://www.nehta.gov.au/.

The disclaimer which comes with it would put a Microsoft or IBM to shame!

“*Disclaimer*

The NEHTA E-Procurement WSDL interfaces and associated XML Schema Files ("the WSDL") are delivered in good faith, free of any charge, and "as is" and without any express or implied warranties. In particular, to the fullest extent permitted by statute and law, NEHTA expressly excludes any express or implied warranties that the WSDL:

* is complete, correct, or error or defect free;

* is of any particular quality or is of merchantable quality;

* is fit or suitable for any particular purpose;

* does not infringe the Intellectual Property Rights of any other person.

Subject to this provision any warranty which would otherwise be implied is hereby excluded. Notwithstanding this limitation where legislation implies any condition or warranty and that legislation avoids or prohibits provisions in a contract excluding or modifying the application of or exercise of or liability under such condition or warranty, the condition or warranty shall be deemed to be included. However, the liability of NEHTA for any breach of such condition or warranty shall be limited to the re-supply of the WSDL.

Without limiting the generality of the above, by using the WSDL, the user is deemed to have agreed with NEHTA:

* that user must assess the suitability of otherwise of the WSDL for the user's purposes; and

* that user assumes all risks and consequences associated with the use of the WSDL or any output or product resulting from the use of the WSDL and, to the fullest extent permitted by statute and law, the user releases NEHTA from any and all responsibility or liability for any risks or consequences of use of the WSDL or any output or product resulting from use of the WSDL and, to the extent not released or not capable of release by user, user indemnifies NEHTA against such risks or consequences.

Copyright © NEHTA 2007

The WSDL contains information which is protected by copyright. All Rights Reserved."

Has anyone else noticed just how obsessive NEHTA is with copyright? I wonder why? An experience DoHA had with the Pharmacy Guild maybe?

David.

Useful and Interesting Health IT Links from the Last Week – 15/07/2007

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

These include first:

iSOFT Shareholders Approve IBA Scheme

Sydney – Monday, 9 July 2007 – IBA Health Limited (ASX: IBA) – Australia’s largest ASX listed eHealth company advises that the iSOFT shareholders have voted overwhelmingly to approve IBA’s recommended offer for iSOFT to be effected by a scheme of arrangement. The acquisition of iSOFT is expected to be effective on 30 July 2007. The following statement was released by iSOFT Group plc on Friday, July 6 2007 on the Regulatory News Services (RNS) in the UK.

Start of iSOFT Statement

6 July 2007

Resolutions passed to approve IBA Scheme

Recommended Offer for iSOFT Group plc (“iSOFT”) by IBA Health (UK) Holdings Limited (“IBA UK”) a wholly-owned subsidiary of IBA Health Limited (“IBA”) to be effected by means of a scheme of arrangement under section 425 of the Companies Act 1985 Results of meetings

The Board of iSOFT is pleased to announce that the shareholder resolutions to approve the recommended offer for iSOFT, by a wholly-owned subsidiary of IBA, IBA UK, to be effected by means of a scheme of arrangement, were duly passed at the Court Meeting and the Extraordinary General Meeting held earlier today.

At the Court Meeting, a majority in number of iSOFT Shareholders, who voted either in person or by proxy and who together represented over 75% by value of the votes cast, voted in favour of the resolution to approve the Scheme. The resolution was accordingly passed.

At the Extraordinary General Meeting, the special resolution to approve the Scheme and provide for its implementation was also passed by the requisite majority.

COURT MEETING The voting on the resolution to approve the Scheme was taken on a poll and the results were as follows:

Number of Meeting Shareholders voting: For: 424 (97.03%) Against: 13 (2.97%)

Number of votes: For: 87,780,362 (99.97%) Against: 25,781(0.03%)

EXTRAORDINARY GENERAL MEETING The voting on the Special Resolution giving effect to the Scheme was taken on a poll and the results were as follows:

Number of votes: For: 89,717,026 (99.97%) Against: 29,814 (0.03%)

----- End Release

This is an important release as it makes it virtually certain that Australia will have its first virtually global Health IT company of significant scale. While wishing the merger and company well (their shares have been good to me!) I am concerned there are real risks associates with this merger that should not be underestimated. Integrating iSoft, which is already the made up of a range of merged companies into IBA will be a non-trivial challenge. It may be that the involvement of CSC is working with the Lorenzo future product will turn out to be a very good thing.

Further details on the two companies can be found here:

http://www.australianit.news.com.au/story/0,24897,22041396-24169,00.html

iSoft takeover bid approved

Ben Woodhead | July 09, 2007

SHAREHOLDERS in beleaguered British software maker iSoft have overwhelmingly backed IBA Health's £140 million ($328 million) takeover bid for its bigger rival.

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

Second we have:

Patient Safety (which has obvious E-Health ramifications) gets a good run this week with two articles:

http://www.theaustralian.news.com.au/story/0,20867,22069490-23289,00.html

Calls for drug monitoring to tighten

• Adam Cresswell
• July 14, 2007

DRUG safety experts have called on the federal Government to tighten monitoring procedures that can detect harmful drug side-effects, saying existing methods remain relatively ineffectual.

More rigorous clinical studies and improved systems for picking up problems that only emerge after a new drug has appeared on the market should all be considered, they say amid claims that a recent controversy over a well-known brand of sleeping pill has exposed flaws in the current systems.

The criticism comes despite a move by the federal Government this week to intervene and save from closure a consumer medicines hotline which provides people with a means to report instances of suspected adverse events while taking drugs.

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

http://www.theaustralian.news.com.au/story/0,20867,22069485-23289,00.html

Blunder bust

• Safety experts say too little is being done to stop patients being harmed or even killed by avoidable errors. Health editor Adam Cresswell reports
• July 14, 2007

PATRICIA Skinner has experienced the sharp end of medical mistakes. She spent 18 months with a pair of 15cm open scissors embedded in her abdomen, after doctors forgot to take them out at the end of an operation.

"It was agony ... my husband would drive over a bump in the road, and I would scream,'' recalls Skinner. "My husband would say, `What's the matter with you?', and I thought I had cancer. I said to my doctor, `I feel like I've been knocked to the ground and someone's been kicking me with steel-capped boots'.''

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

These are both well worth reading. The success of the PDA based system in identifying problems and near misses in anaesthesia is especially interesting. The full report can be found here:

http://www.aihw.gov.au/publications/hse/seiaph04-05/seiaph04-05.pdf

It should be pretty clear that – given the report suggests a total of about 130 or so sentinel events occurred in the whole of Australia in 2004 / 5 – that we are still not capturing for report all such events. Given there are roughly 4.3 million hospital admissions per year it seems very likely a substantial number are still not reported. Better record keeping – especially electronic record keeping – could certainly improve the case finding and subsequent analysis.

Third we have:

Financial data systems garner attention

By: Joseph Conn / HITS staff writer

Story posted: July 9, 2007 - 10:41 am EDT

Part one of a three-part series

In recent years, particularly since 2004, when President Bush created HHS' Office of the National Coordinator for Health Information Technology, most of the federal focus on healthcare IT has been on promoting the adoption of clinical applications and the development of healthcare data exchange. Computerized financial systems have taken a back seat.

Yet the increased interest in and adoption of clinical IT systems is leading some cutting-edge healthcare leaders to take a second look at their financial systems and make plans to replace or reconfigure them, according to industry experts.

One goal is to optimize the integration of their financial systems with their clinical systems, not only to enable more accurate and timely billing, but also to gain synergy for combined clinical and financial process improvement. Additionally, the advent of consumerism and the emphasis on transparency in healthcare pricing is driving needed adaptation of healthcare financial systems to produce information not only for chief financial officers, but also for patients.

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

This is a useful series of articles. The point being made in the third article regarding the need to effectively blend both clinical and financial systems to address the information needs of managing high quality care and reducing the variation in the care that is actually provided to individual patients.

Fourth we have:

http://archinte.ama-assn.org/cgi/content/short/167/13/1400

Electronic Health Record Use and the Quality of Ambulatory Care in the United States

Jeffrey A. Linder, MD, MPH; Jun Ma, MD, RD, PhD; David W. Bates, MD, MSc; Blackford Middleton, MD, MPH, MSc; Randall S. Stafford, MD, PhD

Arch Intern Med. 2007;167:1400-1405.

Background Electronic health records (EHRs) have been proposed as a sustainable solution for improving the quality of medical care. We assessed the association between EHR use, as implemented, and the quality of ambulatory care in a nationally representative survey.

Methods We performed a retrospective, cross-sectional analysis of visits in the 2003 and 2004 National Ambulatory Medical Care Survey. We examined EHR use throughout the United States and the association of EHR use with 17 ambulatory quality indicators. Performance on quality indicators was defined as the percentage of applicable visits in which patients received recommended care.

Results Electronic health records were used in 18% (95% confidence interval [CI], 15%-22%) of the estimated 1.8 billion ambulatory visits (95% CI, 1.7-2.0 billion) in the United States in 2003 and 2004. For 14 of the 17 quality indicators, there was no significant difference in performance between visits with vs without EHR use. Categories of these indicators included medical management of common diseases, recommended antibiotic prescribing, preventive counseling, screening tests, and avoiding potentially inappropriate medication prescribing in elderly patients. For 2 quality indicators, visits to medical practices using EHRs had significantly better performance: avoiding benzodiazepine use for patients with depression (91% vs 84%; P = .01) and avoiding routine urinalysis during general medical examinations (94% vs 91%; P = .003). For 1 quality indicator, visits to practices using EHRs had significantly worse quality: statin prescribing to patients with hypercholesterolemia (33% vs 47%; P = .01).

Conclusion As implemented, EHRs were not associated with better quality ambulatory care.

Author Affiliations: Division of General Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (Drs Linder, Bates, and Middleton); and Program on Prevention Outcomes and Practices, Stanford Prevention Research Center, Stanford University, Stanford, California (Drs Ma and Stafford). Dr Ma is now with the Department of Health Services Research, Palo Alto Medical Foundation Research Institute, Palo Alto, California.

This is an important paper as it shows that implementation of EHR technology, of itself, may not make any real difference in patient outcomes. The authors make the points that at best only 40% of the EHR systems in use had any clinical decision support functionality and that the overall quality of practice in both the 18% that did use EHRs and the 82% that did not was unsatisfactory on the quality indicators being measured. A detailed read of this paper if you can access it via CIAP or a university is recommended.

The following reference from the paper offer useful, and differing, perspectives:

Doran T, Fullwood C, Gravelle H, et al. Pay-for-performance programs in family practices in the United Kingdom. N Engl J Med. 2006;355(4):375-384.

Johnston D, Pan E, Middleton B, Walker J, Bates DW. The value of computerized provider order entry in ambulatory settings. http://www.citl.org/research/ACPOE_Executive_Preview.pdf. Accessed February 14, 2007.

Lastly we have:

http://www.cio.co.uk/concern/alignment/features/index.cfm?articleid=351

Granger: The final word

Janice McGinn

Departing director general of NHS IT, Richard Granger, talks exclusively to CIO UK about the controversial programme, its progress and the bruising media coverage

“Stuff goes wrong all the time. You know, computers do fail. But what we’re seeing is a sort of hysterical coverage. What I should be judged on is whether we’re fixing it quickly and ensuring it’s as good as anything else anywhere on the planet. Measure me on those things and I know we will not be found lacking.”

For a man better known for savaging suppliers, with an apparent ‘lead me, follow me, or get out of my way’ attitude, 42-year-old Richard Granger, director general of IT, NHS, is surprisingly plaintive. We met in Whitehall a few weeks before he announced his departure at the end of this year after five years in what must be the biggest, highest profile civilian CIO job in Europe.

"“There is a little coterie of people out there who are alleged experts and who worked on this programme. They were dismissed for reasons of non-performance or in one case, for breach of commercial confidentiality”"

Richard Granger, director general of IT, NHS

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

This is a long a riveting read about the NHSPfIT. Everyone gets a serve and what Richard Granger says about the problems you face in a project of this scale all rings true to me.

All in all some great reading to start the week!

More next week.

David.

Draft Submission to the BCG NEHTA Review from Dr David G More.

Note: This is a draft – any comments from readers will be considered and may be included in final submission to the BCG – Due on 27 July, 2007

Executive Summary

E-Health in Australia is rapidly becoming a national disgrace and the opportunity cost of not addressing it in terms of both money and lives is rising relentlessly.

The following offers an expert, independent view of NEHTA’s performance to date and recommends two key steps to remedy the currently disastrous situation.

These are:

Urgently the governance of NEHTA needs to change. The Board needs to have 2-3 representative E-Health Experts (from ACHI, MSIA, Industry etc ) and one or two independent experts added with the Jurisdictional representation dropped to 3-4 members. The Board also needs a highly qualified technical and a highly qualified clinical advisory committee with real influence and teeth. Note: The Australian Health Information Council (AHIC) – which should also have broad stakeholder input - is the right entity to ensure NEHTA stays focussed on delivery in the context of an AHIC managed strategy which I recommend below.

Longer term – six months – A consultative, inclusive, national E-Health Strategy, Business Case and Implementation Plan must be developed. This will then need to be reviewed and properly resourced and funded – managing the state / Commonwealth divides etc. NEHTA should then be managed by the governance approach recommended in that strategy and take its priorities from there as well.

Once this is done some hope and certainty may return to the E-Health Domain in Australia.

(I look forward to discussing the contents of this submission with BCG. I can be contacted via my blog by e-mail)

Background of Preparer of Submission.

David MORE MBBS(Hons) BSc(Hons) PhD FANZCA FJFICM AFACHSE FACHI

Much deleted as irrelevant for blog post!

For the last 15 months Dr More has been writing a blog on e-Health in Australia. The blog describes itself in the following terms:

“This blog provides a commentary on the progress (or not) of e-health in Australia from the perspective of some-one who has worked in the field for over 20 years and has become a bit jaded with the lack of apparent progress in a very important field.”

The blog now has over 4700 page views a month and is widely read and discussed by many participants in the e-health arena.

Strategic Analysis of Australian e-Health

E-Health is an overarching term to describe the deployment of ICT to support the operations of and to improve the outcomes (clinical, operational, financial and administrative) of the health system.

Experience from all over the world has shown that the implementation of e-health solutions in the health sector is a major challenge. Writing in the British Medical Journal a couple of weeks ago (BMJ Volume 334(7608), 30 June 2007, p 1373) Joan S Ash got it as close to right as I have ever read when she wrote”

“Why is implementation of health information technology such a universally difficult process? It is because we are transforming health care through information technology rather than simply automating old processes. Workflow and work life must change, which means people must adapt. Such change is deeply disruptive. The related personal and organisational challenges are enormous, yet efforts to manage change receive inadequate attention and funding.”

It is my view that NEHTA, an organisation that has virtually no practicing clinicians working with it and manifests virtually no insight into the way the health system really works, has totally overlooked this reality and has so ensured it is essentially irrelevant to the Australian Health System at large.

NEHTA’s problems have been also made much more dramatic and intractable by the following:

1. NEHTA’s lack of any real customers. The private sector simply ignores NEHTA and the public sector merely pays lip service to NEHTA’s recommendations. They have to get on with business while NEHTA plans to offer some “building blocks” some time in 2009.

NEHTA seems to have an almost ‘Field of Dreams” approach to what it is planning and developing in terms of identity management and terminology. They assume if it is built, they will come. I really wonder how true that actually is?

2. The fact of the Australian Health Information Council (AHIC) vacating the field between 2005 and early 2007 – removing the last vestige of any peak Strategic Planning entity which could guide the technically orientated NEHTA in sensible directions and provide some real-time feedback as to the relevance and applicability of what NEHTA was doing.

There is considerable confusion about the division of responsibility between NEHTA, AHIC, Standards Australia and the e-health component of the Department of Health and Ageing.

3. The lack of clarity about just what NEHTA is a Pty Ltd Company which seems at once to be both a Standards Developer and a Standards Taker, as well as having no real governmental authority.

4. NEHTA was meant to be a core enabler of E-Health progress but its approach has resulted in the deferral in all sorts of potentially useful initiatives while its staff try to understand the complex tiger they now have by the tail.

5. The recognition among a range of stakeholders that progress in E-Health is important and has not gone anywhere near as well as might have been hoped. See my open letter to Minister Abbott:

http://aushealthit.blogspot.com/2007/03/open-letter-to-minister-tony-abbott.html

And the Departmental Response:

http://aushealthit.blogspot.com/2007/06/minister-abbot-responds-to-open-letter.html

6. The blunt, and occasionally almost over the top, media management tactics NEHTA is known to employ and of which I have first- hand knowledge.

7. NEHTA’s failure to appreciate just how sensitive citizens are to retaining control of their private health information. They have not addressed this issue adequately in my expert view.

I have recently (May 2007) summarised my views of NEHTA’s current performance.

See http://aushealthit.blogspot.com/2007/05/nehta-how-far-has-it-come.html

The relevant part of that post is the following:

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

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

What have they and are they doing wrong?

The key things I see as mistakes are:

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

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

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

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

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

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

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

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

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

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

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

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

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

I have also expressed what I believe are significant process issues with the present review. These may be reviewed at the following URL:

http://aushealthit.blogspot.com/2007/06/nehta-review-i-sure-hope-it-helps.html

With that broad overview of my concerns I offer the following specific comments in response to the specific questions asked by the review –while suggesting the scope of the review – which does not appear to address the entire national E-Health Strategy, and NEHTA’s role in it, is just too narrow to have a satisfactory outcome.

Responses to Specific Questions (See Appendices)

Section 1.0

1a. – NEHTA actually commenced operation in November 2004 and so has been in operation over 2.5 years. In answer to “Has NEHTA achieved what was intended for it?”
No – see details in the section above.

1b. “Was NEHTA tasked with the right objectives in the first instance”

No – The absence of an overarching national E-Health Strategy has meant there has been incoherent and unfocussed activity and not much in the way of real outcomes.

NEHTA should have been something like the delivery arm of an E-Health Strategic Implementation Office.

1c. See above

1d. NEHTA has slowed down progress and alienated many of the volunteers who used to undertake standards work. The quality of the work they have done has been excellent but must now be seen as being under threat due to withdrawal of corporate support and other gradual reduction in resources.

1e. See recommendation below

1f. The recent meetings involving the MSIA and others make it clear the engagement model is deeply unsatisfactory. The only ones who are happy are those who are being awarded lucrative contracts by NEHTA as best I can tell.

1g. Significant good outcomes in E-Health will not be achieved with the current investment levels. The investment is not coherent, planned and rational at present. A symptom of the lack of an agreed overarching national E-Health Strategy, Business Case and Implementation Plan.

Section 2.0

I do not believe any of these questions can be addressed in the absence of national E-Health Strategy, Business Case and Implementation Plan. To fiddle around with NEHTA without being clear where all the other actors fit is folly in my view.

Concluding Remarks and The Suggested Way Forward

In my view NEHTA has been a dismal failure which has been characterised the worst possible outcomes for all the key stakeholders.

As I argue elsewhere in my blog there is opportunity to make a real difference in health service delivery without waiting for NEHTA’s long term R&D program to deliver –if it ever does.

See http://aushealthit.blogspot.com/2006/03/australian-e-health-strategy-why-what.html

Urgently the governance of NEHTA needs to change. The Board needs to have 2-3 representative E-Health Experts (from ACHI, MSIA, Industry etc ) and one or two independent experts added with the Jurisdictional representation dropped to 3-4 members. The Board also needs a highly qualified technical and a highly qualified clinical advisory committee with real influence and teeth. Note: The Australian Health Information Council (AHIC) – which should also have broad stakeholder input - is the right entity to ensure NEHTA stays focussed on delivery in the context of an AHIC managed strategy which I recommend below.

Longer term – six months – A consultative, inclusive, national E-Health Strategy, Business Case and Implementation Plan must be developed. This will then need to be reviewed and properly resourced and funded – managing the state / Commonwealth divides etc. . NEHTA should then be managed by the governance approach recommended in that strategy and take its priorities from there as well.

Once this is done some hope and certainty may return to the E-Health Domain in Australia.

Appendices

Appendix 1 - Call for Submissions

The Boston Consulting Group (BCG) has been selected to undertake an independent review of NEHTA, and assess any future role that it should play. As part of the review, BCG would like to receive submissions on:

1. NEHTA’s effectiveness in meeting its objectives during the two years since its inception, including:

a. The consistency of NEHTA’s current role and function with its objectives as laid out in the NEHTA constitution[1] – “Has NEHTA achieved what was intended for it?”

b. The appropriateness of NEHTA’s objectives, given the needs of eHealth development in Australia - “Was NEHTA tasked with the right objectives in the first instance”

c. NEHTA’s goals, strategies and work plan, including any gaps or overlaps with the work of other bodies

d. Progress achieved in deliverables and outcomes, especially with regard to the development of standards and the establishment of core information infrastructure for eHealth.

e. NEHTA’s structure and governance arrangements

6. The consultation and communication process NEHTA has undertaken, including:

§ The engagement process that has been conducted

§ The completeness and quality of the content that has been communicated

§ The outcomes that have been achieved as a result of consultation

7. The funding for, and value for money achieved by NEHTA, including:

§ The balance of resources committed to different activities and objectives

§ The level and mix of sources of funding

2. Possible roles for NEHTA or a similar entity in the context of future eHealth reforms, including:

1. Roles and responsibilities for existing players and/or potential new players, including NEHTA, in eHealth reform going forward

2. Priority next steps in delivering eHealth objectives

3. Vehicles and sources for funding the next steps
   
   
4. Potential governance models
   
   
5. Ongoing operation and maintenance of standards and infrastructure established by NEHTA

Submissions should be received by the 27^th July 2007 by:

Email: addressed to nehta_review@bcg.com

Fax: Addressed to NEHTA Review Team – Fax No 02-9323-5666

Mail: Addressed to: NEHTA Review Team

BCG

Level 28, Chifley Tower

Chifley Square

Sydney, NSW

2000

In addition to collating written submissions, BCG will be scheduling interviews with a number of stakeholders to gather supplementary data.

Appendix 2.

Article 3 of NEHTA Constitution

Objects :

The objects of the Company are all or any of the following:

To provide the critical standards and provide and manage the development of infrastructure, software and systems required to support connectivity and interoperability of electronic health information systems across Australia;

To research, develop and implement national health information projects including (but not limited to):

3.1.1 clinical data standards and terminologies including the development of standards, and common terminologies for health information for clinical service delivery, planning, policy-making and research purposes and communication between health systems in Australia;

3.1.2 patient, provider and product/service standards and directories/indexes that contain information necessary to uniquely identify patients, providers, products and services and other relevant information across the whole of the health sector in Australia;

3.1.3 identification standards to define the data structure and specification for the capture and storage of information required or the identification of patient, provider and product/services in Australia;

3.1.4 a product services directory which contains information for identification of products and services;

3.1.5 consent models governing collection and handling of electronic health information;

3.1.6 EHR standards;

3.1.7 technical integration standards to define the structure and rules by which information is exchanged between systems and users;

3.1.8 supply chain efficiencies, including exploring options such as common forms of procurement, standard contracts and common purchasing processes;

3.1.9 user authentication and access control to ensure compliance with privacy laws and the consent models which have been developed;

3.1.10 EHR secure messaging and information transfer, including identifying and managing the development of a national security model for messaging and information transfer between health care providers' systems;

3.1.11 a knowledge centre, providing knowledge-sharing and expert advice to the public and private sectors on business case development and implementation requirements for health information systems so as to meet national standards and architectures; and

3.1.12 to encourage health information industry reform and to facilitate opportunities in driving technological reform in health information technology, so enabling consistent interoperability and implementation of national health information technology priorities.

Any additional object which 100% of Members determine should be included in this Constitution at a General Meeting.

---

[1] A copy of article 3 of the NEHTA constitution is attached for reference

The UK NHS Health IT Community - An Invaluable Site for Health IT.

Last week , when I received my regular bulletin from the United Kingdom’s NHS Health Informatics Community I realised I had not pointed this site out to those who browse here.

The site can be found at:

http://www.informatics.nhs.uk/

With free registration there is access to a range of invaluable and worthwhile resources.

An example of the sort of useful content that is available is the following.

Management Briefing on the impact of Clinical Physician order entry systems on improving patient safety

In this paper Dr Bates discusses health information technology has many benefits for both organisation and patients. Achieving success for any application implementation depends on a variety of issues and Dr Bates explores some of the problems some groups in America have had in the past. He reviews the failures and successes of the computerised physician order entry (CPOE) system and explores the similarities between what is beginning slowly implemented in America compared to what currently happening in the NHS. The paper closely follows on from the Masterclass Dr Bates gave in May and includes links to other Health Informatics papers.

This is the next in the series of Faculty management briefings, and was overseen with the help of the Faculty of Health Informatics Board. The aim of these briefings is to provide the reader with the essential knowledge of a subject which is important in the world of today’s busy NHS professional.

Our library of topics is getting bigger and covers a wide spectrum which will be relevant to all leaders within the NHS. Previous briefing topics cover such areas as:

UK cross-border transfer of electronic patient information

Knowledge Management

Telehealth and Telecare in England

Leadership within Health Informatics

Any feedback on this or any other management briefing is welcome, along with any suggestions you may have for a future briefing. Keep a lookout for forthcoming briefings on Patient Records and Patient Involvement by Dr Amir Hannan and The EHR the possible dream by Professor Denis Protti. If you wish to contribute to our library of briefings please contact ian.mcgovern@nhs.net

Attachments: (No. of attachments - 1)

65 Kb ETD Management Briefing No 5 - Patient Safety V 1 - (04-Jul-07)

It is really worth registering and having a good look around. While obviously there is a strong UK bias there is plenty for all! Registration also allows you to establish topic based e-mail alerts matched to the areas of your interest.

Enjoy!

David.

Amazing News Announcement from NEHTA

Allowing that the date was meant to be 5 July 2007 (Not June – at least that is when it arrived by my RSS Feed) this is just amazing!

Release Begins.

National recruitment drive kicks off in July

5 June, 2007. NEHTA stages a national recruitment drive as the NEHTA work program gains momentum.

A national recruitment drive is underway as NEHTA’s 2007/08 NEHTA work program gains momentum. The recruitment drive will target high calibre people interested in working in a challenging and rewarding environment and contributing to health reform in Australia. Positions across a number of projects will be available – in particular we will be targeting Business Analysts, Technical Analysts, Project Managers, Solutions Architects, Developers, Relationship / Account Managers, Technical Writers, Policy Officers, plus a variety of Clinical Terminology and Clinical Information roles ideal for clinical or healthcare professionals.

NEHTA, CEO, Dr Ian Reinecke maintains rapid growth has necessitated an aggressive push to add to the highly qualified and experienced people already on staff. ”Many of our key people have Masters and PhD qualifications in various disciplines including information technology and others are specialists from the health and medical research sectors,” he said.

Since NEHTA’s inception, the growth in staff numbers has been rapid and recruitment activity has been constant. However, as the work program has evolved, and as many projects head towards implementation, the need to anticipate unprecedented staffing requirements has increased. “Our ability to recruit and retain the best available talent is pivotal to the delivery of our project commitments,” Dr Reinecke said. “We are confident that we will be able to attract the people we need to get the job done.”

Position details will be posted on the Employment page of the NEHTA website progressively in July and August or enquiries can be sent to careers@nehta.gov.au.

End Release.

Just three comments:

1. Many of these jobs were being advertised on the 21 May, 2007 and are still being advertised 08 July, 2007 (e.g. Integration Manager, Policy Adviser and Pharmacists to undertake Medicines Terminology work). Seems either the pay, conditions, locations or future prospects with NEHTA must be lacking.

Hence the “National Recruitment Drive”!

2. I would have thought that, if the Boston Consulting Group Review did not have a pre-determined outcome that we have yet to be told, recruitment should be rather more conditional than it seems – if large payouts are to be avoided. Do the NEHTA recruiters know something we don’t? It is, of course, possible all these jobs are funded from the COAG money of 2-3 years ago and it just needs to be spent (? wasted if major change is suggested).

3. All the people NEHTA is seeking are likely to be smart enough to be aware of the NEHTA Standard Operating Procedures and Practice ( enforced secrecy, lack of consultation with stakeholders - especially clinical ones, abolition of consultative committees etc) and probably also already have reasonable jobs. They will ask themselves – why move? Without major internal change it is virtually certain many of these jobs will not be filled and the already over extended time-lines will blow out even further.

Wait for announcements of delays and budget blow outs. I suspect they are around the corner.

David.