Medicare, NEHTA and Your Privacy.

A week or so ago a quiet bit of regulation making occurred in the Federal Parliament. The following regulation was tabled under the Ministerial Authority of Senator Chris Ellison.

Here is the title of the Direction.

Medicare Australia (Functions of Chief Executive Officer) Amendment Direction 2007 (No. 2)

Medicare Australia Act 1973

I, CHRISTOPHER MARTIN ELLISON, Minister for Human Services, make this Direction under paragraph 5 (1) (d) of the Medicare Australia Act 1973.

Dated 8 August 2007

CHRISTOPHER MARTIN ELLISON

Minister for Human Services

The full text is downloadable from here. (It is only a page or two in .pdf format and well worth a read)

In plain language what this does is, without any contestability or assessment of value for money, have Medicare Australia scope, develop, build and test the NEHTA UHI (as defined in the regulation).

It also authorises them to make a copy of the two key identity databases supported by Medicare Australia (as defined in the .pdf file - essentially the client and the provider databases) and use them to provide an identity service.

This is really an amazing thing to be authorised. What seems to have happened is the despite the prohibition in the Commonwealth Privacy Act (2000) of personal information being used for purposes other than for which it was collected by Government Agencies it has been decided that information that was collected to enable Medicare benefits to be paid is to be used to operate the NEHTA UHI.

The implications this has for the trust the population will have in Medicare Australia to keep their private information private must be profound.

There are all sorts of questions this authorisation raises – such as:

1. Are the Consumer Directory Maintenance System and the Provider Directory System operated by Medicare Australia ‘fit for purpose’ in the role of electronic health record identification and linkage? (I think not).

2. How are those whose information is on this copy of the register able to see what is held and how accurate it is?

3. How will this information be protected from un-authorised or unwanted disclosure or look up. It seems every healthcare provider in the country will be able to search the customer data-base to find an associated UHI – this is a really terrible idea and will have victims of domestic violence and the like just terrified?

4. How are the Medicare and UHI data-bases going to be kept in synch as one or the other is updated? If a ‘snapshot’ of the databases is taken – how will the data’s currency be maintained into the future?

5. Where is the Privacy Impact Assessment that validates this approach?

6. Who is going to be responsible if there is a security breach or someone’s details are released and an individual is damaged or harmed. Is it the private company NEHTA or the Government through Medicare Australia?

7. Who is actually going to run the proposed service – NEHTA, Medicare Australia or someone else? Does anyone else notice a certain irony in a private company contracting a Government Agency for the delivery of services – as seems to be the case?

8. Why is such a potentially privacy destructive regulation just slipped through the House of Reps and the Senate with no public announcement etc?

It seems clear to me this proposal represents the health identifier you have when you are not prepared to pay for an identifier that one can be sure is fit for purpose in terms of safety and integrity.

Frankly this is a disaster in my view and should be aborted before it even gets started. If we are to have a UHI service (and I think it is vital) it should be based on privacy and security protections that are appropriate for clinical record linkage.

David.

Note: Comprehensive coverage on the basics of this issue is found in an article by Karen Dearne in the Tuesday Australian IT section of 28^th August, 2007. This can be seen on line at the following URL.

http://www.australianit.news.com.au/story/0,24897,22318001-5013040,00.html

Ellison unlocks Medicare databases

Karen Dearne | August 28, 2007

MEDICARE patient and provider databases will be the key sources of a healthcare identifier regime being introduced to support a shift to e-health programs.

Records belonging to 99 per cent of Australians are contained in Medicare's Consumer Directory Maintenance System, considered to be the most up-to-date and accurate government repository of personal information.

Although the law prevents the use of Medicare data for other purposes, Human Services Minister Chris Ellison has unlocked access via a legislative amendment tabled in Parliament on August 16.

Senator Ellison has authorised Medicare's chief executive to enter into a contract with the National E-Health Transition Authority and provide resources in support of the Unique Healthcare Identifier program.

Progress on the individual, healthcare provider and health organisation directories was flagged by NEHTA chief executive Ian Reinecke at MedInfo 2007 in Brisbane last week.

Dr Reinecke said NEHTA had established an operational governance model for contracting a universal identifier services operator, expected to be Medicare Australia.

….. (see URL above for full article)

D.

Minister Abbott’s E-Health Report Card – Hunt the Spin!

The following are the prepared notes for a speech the Health Minister gave last Monday – reviewing the progress that has been made in e-Health in the four years since the Minister took up the reins.

My comments are inserted in the text in italics.

http://www.health.gov.au/internet/ministers/publishing.nsf/Content/sp-yr07-ta-abbsp200807.htm?OpenDocument&yr=2007&mth=8

An E-Health Report Card - Speech Notes for the Australian Health Summit, Sydney

20 August 2007

In November 2003, my first scripted speech as Health Minister concerned e-health. I stated that an electronic health record, communicated electronically among health care providers, would mean safer, better, more convenient and more efficient health care. For doctors and other professionals, it meant less repetitive taking of histories; for governments and other funders, it meant less duplication of diagnostic tests; for patients, it meant more access to their health records and more capacity to manage their own health; for everyone, it meant fewer potentially disastrous mistakes because of avoidable ignorance.

Failure to establish an electronic patient record within five years, I said, would be an indictment against everyone in the system, including the Government. I hope to be judged against that somewhat rashly declared standard; not because it is likely to be fully met but because it would mean that, come next year, I remain the Health Minister!

Clearly the Minister has a high level understanding of the benefits of e-Health – sadly he really has not made substantial progress in reaching his desired end state for e-Health

Back then, my thinking was that people in the health system were at least as capable as those in the finance system. If EFTPOS could link billions of bank accounts and financial institutions around the world, it should surely be possible for every Australian patient’s file to be copied, indexed, stored and securely made available to the patient and authorised treating professionals via the internet. In retrospect, I had underestimated the difficulty of shepherding independent professionals and insular institutions through the thickets of patient privacy and sheer force of habit. Still, although not yet very obvious to patients, much has been achieved in the past four years.

It is a worry that the Minister takes just three paragraphs to start blaming clinicians, rather than understanding that all successful change needs to deliver benefits to those who are asked to change, or the change will be resisted. In a fee-for-service professional payment environment the incentive to use technology, which typically slows a practitioners productivity – at least initially – is very low. Given it is patients and the Government who stand to benefit from more Health IT use, the payment and incentives need to come from those who will benefit.

Since the late 1990s, the federal Government has provided more than $700 million – or about $40,000 per full-time doctor – to support the use of information technology in general practice. There are still doctors taking case notes on cards, hand-writing prescriptions and relying on receptionists to find files in cabinets in the time-honoured way. There are also hospitals such as the Epworth East where each bed is equipped with a computer screen and keyboard so doctors’ and nurses’ notes instantly integrate into patients’ records. Some health funds are beginning to offer their members personal health records that will enable the storage of diagnostic test results as well as treatment records and general health information. Doctors especially still tend to be much more enthusiastic about clinical than administrative technology, even though both are equally necessary for effective clinical practice. Even so, a rightly conservative but highly perceptive profession is adapting to change because it’s in doctors’ own and their patients’ best interests.

Last year, according to data published in the Medical Journal of Australia, 94 per cent of general practices had a computer (up from 15 per cent in 1997 and 70 per cent in 2000). Of GPs with a computer, 94 per cent used it for prescribing, 82 per cent to write referral letters, 70 per cent for some medical records functions, and 68 per cent to create management plans. Of GPs with a computer, 33 per cent had fully computerised their patients’ medical records while 78 per cent of GPs worked in practices that used computers for scheduling appointments or recalling patients.

This is good news – but clearly there is more to do!

Cultural shifts take time but over a decade the computer on doctors’ desks has gone from expensive paperweight to an all-but-essential part of medical practice. Of course, it’s one thing to use a computer for internal practice purposes; another to make use of IT for ordering tests or sharing information. Last year, only 53 per cent of GPs with a computer used it for email. Still, progress in this area makes e-health possible if not inevitable.

As well, the Government’s $100 million investment in HealthConnect has helped to facilitate the electronic transfer of admission and discharge information between some GPs and public hospitals in Tasmania, South Australia and Western Australia. In Sydney’s west, up to 50,000 patients at Westmead Hospital are being offered a Shared Electronic Health Record accessible to their specialists and GPs. In Bendigo, a link between GPs, specialists, allied health professionals and community care providers is improving the management of chronic disease. These trial projects, among others, are exploring potential best practice for what should become standard arrangements in the future.

Neither Healthelink (the NSW Site) or the Bendigo site have been evaluated as yet. The earlier $100 Million investment was essentially totally wasted – and given all that has been published is a summary report that essentially said it looked promising but did not work as yet.

The federal Government has also invested in initiatives to support clinical practice such as electronic publishing of the Pharmaceutical Benefits Schedule and the Medicare Benefits Schedule. The Government has worked with the states and territories to remove legislative barriers to electronic prescribing and referring. It has negotiated a subscription to the online Cochrane Library to provide Australians with free access to evidence-based information on best practice.

The federal Government has committed $69 million to providing broadband access for GPs and pharmacists. More than 90 per cent of pharmacies have broadband and 78 per cent of doctors work in General Practices with broadband access. The most recent Pharmacy Agreement gave pharmacists 40 cents a prescription for using PBS Online, a real time record keeping and eligibility checking system.

The federal Government has committed $98 million to Medicare Australia for services such as EasyClaim. At participating practices, a card swipe can provide patients with their Medicare rebate on line from their doctor’s surgery. The Government is now talking to the AMA about incentives, similar to those offered to pharmacists, to encourage privately-billing doctors to give this convenience to their patients.

These are really just general investments in the provision of basic infrastructure. The EasyClaim project is, of course, stalled as the AMA has realised that use of the system will increase practice workloads and costs, for no financial reward. Increasing practice costs – without re-imbursement – was never going to be a winner!

Finally, the federal Government has committed $79 million towards the National E-Health Transition Authority (NEHTA) which is developing unique IDs for patients and providers and developing a common language so that particular terms have the same clinical meaning across different record systems.

These comments are interesting. It would have been difficult for the Minister to say less about NEHTA – especially given it is spending $79 million on it over the next three years. Hardly an enthusiastic endorsement of what NEHTA is doing.

It would be fair to say that policy-makers have been impatient to see an operational return on these investments rather than a proliferation of trial projects and pilot schemes. A particularly successful one has been the Shared Electronic Health Record trial in the Katherine region of the Northern Territory involving nearly 12,000 patients. This has been an important means of delivering better health care to a mobile population subject to high levels of chronic disease. This Shared Electronic Health Record currently includes a health profile (with blood type, chronic conditions and allergies), an individual event summary (visits to the GP, emergency department presentations and hospitalisations) and pathology results.

This is very interesting – as when the project was evaluated a year or so back the level of usage and clinical content was not as is indicated here. It would be good to get a new public evaluation of progress to date here – so we can assess how sensible further investment is. It could be that great success has been achieved – and if so it would be good if this information was shared. Without such sharing I remain just a trifle skeptical.

Today, I can announce that the federal Government will fast-track the roll-out of a Shared Electronic Health Record throughout the remote parts of the Northern Territory. This should help to ensure that the health issues identified through child health checks are properly followed-up. A comprehensive health record is absolutely necessary if the goodwill and hard work of visiting and resident professionals is to resolve identified health problems and prevent their recurrence.

With consent, the Shared Record will be accessible to any authorised health professional in the NT. This means that after the initial health check, a patient’s health information will be available to professionals in general practices, community health centres or hospitals, so that effective follow-up care can be delivered. The Shared Record will support ongoing care by triggering recalls and reminders as children advance through life.

A child with a Shared Record will have his or her health information updated, if the infrastructure is available, at the point of the health check. A child without a Shared Record will have one created, if the infrastructure is available, at the health check. If the infrastructure is not available, a paper record will be created at the health check and the information will be used to update or to create a Shared Record. One way or another, all remote area indigenous children will have the opportunity to gain a Shared Health Record.

A good idea – and suggested on this blog within days of the ‘Emergency Intervention’ being announced.

As the British Government has discovered, it’s much easier to spend money on health IT than to produce a functioning e-health system. So far, despite its 15 billion pound budget, the NHS HealthSpace is far from fully operational. On line access to a full electronic primary health care record is still only being trialled in a limited number of practices. Few practices offer their patients on-line booking or prescription re-ordering. Only some patients have some access to a limited range of specialist records.

I think this is more dismissive than current progress suggests – and I suspect this is because of concern as to how much it might cost to do things properly!

In Australia, the Government eventually decided against creating a single, national comprehensive electronic health record designed and managed by officials. The ordinary difficulties associated with government projects are magnified, it seems, in such a protean field. The Eclipse experience shows how hard it is for governments to design systems for a myriad of users rather than to encourage people to devise systems which work for them.

Has anyone told NEHTA that the National Shared EHR has been cancelled? I note how long it has taken for this decision to become public. Pity there is no clarity regarding what is now planned in the area of clinical information sharing.

In health IT, the Government’s role is to remove regulatory barriers, provide incentives for change, promote “inter-operability” of systems and explain to the public how and why e-health can improve their health care experience. Its job is not to build complete systems from scratch or to impose uniform infrastructure on health providers but to make it more realistic and affordable for healthcare providers to move into the IT age.

In the short term, the Government will introduce more Medicare items to support telehealth services. There’s already a rebate for psychiatry consultations over the phone. The Government is considering a rebate for dermatologists consulting remotely with patients in GPs surgeries via a diagnostic camera. The Government will foster the development of one or more secure repositories for personal Electronic Health Records. It will begin to link the various existing illness or health registers so that information on significant diseases, screening and immunisation can be incorporated into a patient record. Eventually, this work will provide a foundation for much more effective monitoring of the performance of drugs and health devices.

It’s likely that, in the next two to five years, the Government will make access to Practice Incentive Payments or even the MBS itself subject to best practice in health record-keeping. For instance, team care plans should be a standard feature of primary health care for people with chronic disease and complex care needs. It would be almost impossible to create and monitor these care plans effectively without the use of IT. In the years to come, effective use of IT should be as much a part of professional practice as the provision of suitable premises. It could be expected, even mandatory, in much the same way as continuing professional education.

This is the sort of approach – the so called “pay for performance” approach with an Australian flavour – which might work. Of course there are all sorts of hurdles to be addressed and all sorts of issues about the sort of information collection infrastructure that may be required.

In the near future, routine follow-up after an initial consultation, subsequent consultation as part of a broader care plan, and lifestyle modification advice for people with chronic illness could readily be delivered by phone or over the net. Of course, some issues would have to be resolved first, such as whether these items could only be provided by the patient’s usual doctor or whether a face to face consultation would be required prior to tele-consultations or e-consultations. Clearly, this would be more feasible for some specialities than others and there are complex billing arrangements that would need to be sorted through. Still, it’s hard to imagine that health care delivery in the years ahead won’t make much better use of convenience technology.

To help meet these challenges, the Government has established an e-health Ministerial Advisory Council. It’s chaired by Roger Allen, a former Deputy Chairman of Austrade and IT entrepreneur. It comprises leading representatives of medical and health organisations and is meant to ensure that government e-health initiatives are actually making a difference to health practice not just providing business openings for the IT industry. If e-health doesn’t help practitioners and patients, it’s hardly worth doing.

Oh dear – another committee. I wonder where this E-Health Ministerial Advisory Council fits in between AHMAC, ACHI, NEHTA etc. I wonder is this Council have a go at developing a plan – some-one sure needs to!

A pre-requisite for a functioning e-health system is secure messaging. From next month, the Government will be working with Divisions of General Practice to offer GPs public key infrastructure. This will provide them with the ability to transfer information and images safely and securely between computers. Participating practices will receive a CD to download the necessary software and individual GPs will receive a PIN plus a personal data stick for their computer to verify identity. This offer will also be made to allied health professionals registered with Medicare. The system will provide users with the assurance that information comes from a trusted source and has not been tampered with. It will enable GPs to order laboratory tests, X-rays and other diagnostic procedures, prescribe drugs and other remedial treatments, and issue recalls, reminders and referrals confident that the information will not go astray or be misused.

As long as this is highly usable and works well this is a great idea.

The Government will also provide expanded access to on-line health information through the purchase of additional access licenses for recognized health learning resources. This will give health professionals throughout Australia accessible, authoritative and up-to-date information and should help to promote best practice health care. The Government will work with the professions to identify the clinical guidelines, on-line journals and on-line reviews that can best help.

Excellent idea – just spread the NSW Health Clinical Information Access Program nationally would be a good start!

The Government will soon to go tender for organisations to facilitate, in a particular region or community, a comprehensive e-health environment. Successful organisations will be expected to work with local GPs, aged care facilities, hospitals, diagnostic providers and other health professionals to ensure that they can electronically share information. Importantly, payment to these organisations will depend upon the volume of clinical information electronically transmitted.

This adopts a key suggestion this blog has been on about for a good while. Start locally and simply and progress at a pace those involved can accept and utilise.

Finally, I can announce today that by early next year, every Australian will be able to access his or her comprehensive Medicare claims history on-line. Patients will have secure access via the Internet to a full record of their Medicare rebates. There will also be a layman’s guide to item descriptors so that patients can readily appreciate the services they have received. Within 12 months, there will be similar arrangements to allow patients on-line access to their PBS claims history.

The first step towards a Personal EHR for Australians. Good idea and, strategically , possibly the core of a Shared EHR that might work.

The new measures announced today will cost about $25 million in total over the next three years.

Note this is an investment of a little over $8 Million a year. Given the Australian Health Budget is about $80 Billion a year – pretty trivial I must say.

These measures will not, of themselves, mean that every Australian has a personal, securely accessible comprehensive electronic health record by the 2008 deadline I once set. Nevertheless, it is substantial progress and is starting to be noticeable to patients. I am reluctant to set a new deadline but am confident that, within a few years, most Australians will be able to access a comprehensive electronic health file that is kept automatically updated by health service providers.

Since 2003, the Government has learned that the best can easily be the enemy of the good, at least in this area. As a funder and organizer, the Government looks likely to achieve far more than it could as an e-health builder and director. As is so often the case in Australia’s health system, the Government has turned out to be much better at funding services that other people deliver than at delivering services itself.

ENDS

Thus far the Commonwealth has hardly funded or organised anything in e-Health to any significant degree. I wonder will that change as the election approaches?

Final comment – the quote “best can easily be the enemy of the good, at least in this area” is very true – sad that NEHTA does not realise this and get on with providing some practical easily implemented solutions to major the problems we all understand. I would not want to be accused of “reading between the lines” but I have the distinct feeling NEHTA is not much in favour with the Minister. If they were would there be a new Advisory Council now commissioned?

All in all this really is a very sad report card – and has hardly moved much from my earlier report card which is found here.

As ever the issue is that the Minister is articulating a dis-coordinated set of little initiatives which will make little difference in the absence of a coherent National Plan. Another missed opportunity!

David.

Useful and Interesting Health IT Links from the Last Week – 26/08/2007

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.australianit.news.com.au/story/0,24897,22287756-16123,00.html

IBA charges back into iSoft fight

Ben Woodhead | August 22, 2007

IBA Health has upped the ante in the fight for control of iSoft, increasing its offer to £166.3 million ($410.7 million) and moving to grab a 24.3 per cent stake in the British medical software maker.

IBA's Gary Cohen went back to former employer Allco Finance for new iSoft bid funds

The revised bid, which gives iSoft shareholders a choice of accepting cash or IBA shares in return for their stock, is aimed at pulling the rug out from under rival suitor CompuGROUP.

Germany-based CompuGROUP previously gazumped IBA with a recommended £160 million cash offer for iSoft.

IBA's new offer was enabled after Allco Equity Partners (AEP) agreed to stump up as much as $300 million to take a cornerstone investment in IBA and provide funding for the tilt at iSoft.

"The strategic logic for this merger remains compelling and the merits of the transaction are further endorsed through AEP's cornerstone investment," IBA executive chairman Gary Cohen said.

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

Interesting to see IBA has struck back – we now have a distinct second phase of all this. How it plays out and where it finally ends will be fascinating. It would be good to have a financially robust e-Health provider in Australia I believe so I hope they don’t overpay for iSoft. (Disclaimer : I have a few IBA Shares)

More details can be also found here:

http://www.australianit.news.com.au/story/0,24897,22291659-5013046,00.html

IBA gets Britain's green light

Bryan Firth | August 23, 2007

IBA Health's revised offer for iSoft Group Plc breaks new ground in Britain as it's the first time Britain's Takeover Panel has let a company announce a scheme offer that has not already been agreed to and received the recommendation of the target board.

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

Second we have:

http://www.theaustralian.news.com.au/story/0,25197,22296864-23289,00.html

$2m crusade targets treatment mistakes

Clara Pirani, Medical reporter | August 25, 2007

MEDIBANK Private is spending $2 million on measures to reduce medication errors and prevent adverse events in almost 60 private hospitals.

The projects were developed to prevent falls, reduce hospital-acquired infections and address adverse events in an attempt to improve patient care -- and cut the cost of treating patients requiring ongoing care because something went wrong while they were in hospital.

"The amount of money we spend on these incentives is hopefully only a small portion of costs that we save," Medibank Private managing director George Savvides. "One figure that has been around suggests that about $2 billion is wasted on adverse events from errors, infection and readmissions. These projects will ensure better health outcomes for all patients."

Private hospitals are invited to develop programs they believe will improve patient safety and apply to Medibank Private for funding to trial them.

Medibank Private is currently reviewing results of the first initiatives trialled in 35 hospitals last year.

"We see this as a long-term initiative that will benefit the hospital operator and patients," Savvides said.

The incentive scheme, now in its second year, attracted a 50 per cent increase in applications from last year, with 120 hospitals applying.

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

This is a very interesting article from two perspectives. First we see a private health insurer recognising that there are benefits for the insurer if hospital performance in the quality and safety arena can be improved – and second we see the trialling of e-Health approaches to address the need to reduce medication errors and improve patient safety.

Third we have:

http://www.ama-assn.org/amednews/2007/08/27/bil20827.htm

E-mail means fewer patient calls and visits

Despite concerns that online consults are not usually reimbursed, e-mail advocates say the technology offers greater practice flexibility, time efficiencies and marketing power.

By Pamela Lewis Dolan, AMNews staff. Aug. 27, 2007.

---

A Kaiser Permanente study showing that physicians who e-mailed with patients saw a drop in visits raises the specter that online communication might reduce revenue.

But doctors who were early adopters in e-mailing patients -- and who didn't participate in the study -- say that even though such communication might keep some patients out of the office, it opens up more space for patients who might have a more pressing need to come in. And they say patient e-mail reduces the amount of time they spend on the telephone with patients -- which Kaiser's study also found to be true.

Jasmine Moghissi, MD, a family physician in solo practice in Fairfax, Va., has been e-mailing patients for several years. She said that although it hasn't reduced the amount of work in the office, it's made the same amount of work easier to handle.

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

This is an interesting report of a study which examined the impact of the use of e-mail to and from patients on clinical practice. Well worth a browse

Fourth we have:

http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20070822/FREE/308220001/1029/FREE

'Next generation of information technology': report

By: Jean DerGurahian/ HITS staff writer

Story posted: August 22, 2007 - 5:59 am EDT

Patient data can be used in more robust ways in hospital clinical systems to improve quality and patient safety, according to findings released by First Consulting Group, Long Beach, Calif., a healthcare research organization.

Dubbing it the "next generation of information technology," the report states there are even more ways to make patient electronic data work for hospitals. The systems that hospitals have spent so much money to implement are not being used to their full potential, said Jane Metzger, research director in First Consulting's applied research department.

The findings suggest hospitals should implement what First Consulting calls "clinical surveillance," through which patient data can be manipulated in real time across all hospital functions. Clinical surveillance can be most effective in preventing adverse drug effects, managing healthcare-associated infections, and monitoring quality and public reporting, according to the report. First Consulting's clients include health insurance plans, providers, pharmaceutical companies, government agencies and health IT vendors.

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

This report makes the rather concerning point that at least some hospitals are making significant investments in Health IT but not then taking full advantage of the information they are now able to gather and analyse.

The report is available here after registration with the First Consulting Group.

Fifth we have:

http://www.digitalhcp.com/hitw/newsletters/2007/08/21/winona-rhio/

A Tale of RHIO Success

By Neil Versel

August 21, 2007 | BRISBANE, Australia — Nearly as fast as regional health information organizations (RHIOs) cropped up a couple of years ago, they have started to disappear or at least scale back their plans due to financial difficulty. But there are some success stories to be found for those who look hard enough.

Try, for example, Winona, Minnesota, where a small network is thriving. At MedInfo 2007, the triennial congress of the International Medical Informatics Association, at a first-ever international symposium on nursing informatics leadership on Monday, the world got a tale of success from Winona Health.

When the United State’s first health-IT czar, David Brailer, called for interconnecting clinicians with what he called RHIOs in 2004, Janice Turek, clinical director of information systems at Winona Health, knew exactly what he was talking about. “We had already connected a region,” said Turek, a registered nurse. “We have been able to sustain and develop informatics in a small community.”

Indeed, the nonprofit health system in southeastern Minnesota has brought together six competitive, independent organizations onto a single health-IT system. It wasn’t easy, but leadership, from clinicians all the way up to the executive suite, saw it as a means of survival.

“It was a competitive issue,” Turek explained, because a lot of small, community-based healthcare organizations had been going bankrupt or simply shutting their doors. “We didn’t want to be one of them.” And Winona had the added disadvantage of being just 40 miles from the Mayo Clinic’s main Rochester campus.

The strategy for Winona Health was quite different from most other provider organizations. Winona started in 2000 with a Cerner patient Web portal and personal health record (PHR) to build the foundation for an electronic health record (EHR).

“This is when we actually married the Cerner Corp., and it’s been a wonderful marriage,” said Turek. Winona Health also helped other organizations in and around the town of 30,000 become Cerner customers because a common system would facilitate data sharing.

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

It is nice to see global e-health reporting coming from Brisbane and our own Medinfo2007. The message is also interesting in supporting the keep it simple and more incrementally approach.

Other Medinfo Reporting is here:

http://www.digitalhcp.com/hitw/newsletters/2007/08/21/medinfo2007/

Optimism Marks Opening of the MedInfo 2007

By Neil Versel

August 21, 2007 | BRISBANE, Australia — In case anyone hasn’t noticed, health care is undergoing a shakeup. Again.

“We’re in the middle of the third health care revolution,” said Sir Muir Gray, director of clinical knowledge in England’s National Health Service (NHS), during a keynote address Tuesday to MedInfo 2007, the 12th world congress on health informatics.

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

Lastly we have:

http://www.nzherald.co.nz/topic/story.cfm?c_id=255&objectid=10458955&ref=emailfriend

$100m bid to end drug deaths in hospitals

5:00AM Tuesday August 21, 2007
By Martin Johnston

The Health Ministry wants hospitals to spend more than $100 million on computer systems and bedside barcoding of patients to reduce fatal and disabling drug errors.

A discussion document obtained by the Herald under the Official Information Act shows the scheme would cost up to $114 million over 12 years.

The proposal is for all public hospitals to introduce fully electronic drug-prescribing systems or computerised patient medication records and connect these to the hospital pharmacy. Drugs would be re-packaged into single-dose packs carrying barcodes, and patients would wear bracelets containing their own unique barcode.

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

An interesting article to re-confirm the view there are some good things in the e-Health domain going on in our little Southern friend – despite all the sheep.

All in all not a bad lot to start the week!

More next week.

David.

And an extra I could not leave out – showing the potential of data to improve post marketing drug safety surveillance.

http://www.sun-sentinel.com/features/health/sfl-flrxmeds0823nbaug23,0,963815.story

UM researchers to review files of 11 million Humana patients for drug problems

By Bob LaMendola

South Florida Sun-Sentinel

August 23, 2007

University of Miami researchers will scour the medical files of 11 million Humana Inc. patients looking for dangerous effects from prescription drugs, under a new project unveiled Wednesday.

Using the huge database of real-world medication experience, the research collaborative aims to detect risky drugs and prescribing practices sooner, which could prevent side effects, medication errors and deaths, university officials said.

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

Enjoy

D.

Summary of NEHTA Issues for the Boston Consulting Group.

Here is a summary of the position I put to the BCG Re NEHTA and the future. These are personal views and reflect careful consideration as to what is needed for the e-Health Agenda in Australia to progress.

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

The following is a summary of the issues that I plan to explore with the BCG. I plan to proceed based on the assumption that the BCG is now fully aware there is very considerable disquiet about the way NEHTA is performing and behaving.

It seems to me there is very little disagreement with the findings of the HISA and ACHI submissions and that the key issue is what is to be done to remedy the situation.

I offer the following suggestions as to what needs to be done:

1. The CEO needs to be replaced by someone who better understands both the Health Sector and Health IT and how the former can be assisted by the latter.

The culture that has been developed at NEHTA of organisational arrogance, secrecy and authoritarianism needs to be fundamentally changed in NEHTA is to have any chance of success – and the present CEO is not the one to manage that transformation – given it is clear from his actions he is of the firm belief he is doing the right thing and has all the answers (which he clearly doesn’t).

2. The NEHTA Board needs to be restructured to have enough technical skills to manage an organisation which has a focus on delivery of e-Health co-ordination.

3. The Australian Health Minister’s Advisory Council and the Council Of Australian Governments need to determine – with the BCG’s advice – just what the governance arrangements for e-Health in Australia. The ideal in my view would be a genuinely expert Australian Health Information Council (AHIC) with relevant clinical, e-health and technical stakeholders being the Strategy Development Entity with NEHTA being a strategy implementation arm. NEHTA should be restructured and renamed to recognise this and AHIC should be supported by a strategically focussed and expert secretariat.

4. AHIC needs to be charged with developing a National E-Health Strategy, Business Case and Implementation Plan which is agreed with Department of Health and Ageing (DoHA) and COAG for appropriate funding and support.

This plan needs to have (at least) the following attributes:

• Comprehensive Coverage of Whole Health Sector (Public / Private / Specialist / GP / Hospital / Public Health etc).
• Focus on Short to Medium Term Deliverables with High Benefits Impact initially.
• Recognition that the purpose of E-Health is to support improvements in the quality, safety and efficiency of the Health Sector.
• Ensure coherent long term outcomes and value through appropriate blend of Standards based and Point Solutions.
• Recognise who should pay for the technology are those that receive the benefits. Provision of appropriate incentives will be necessary and need to be factored in to the thinking.
• Delivery of the right blend of local autonomy and control vs. the need to national coherence and standardisation.
• Recognise there is no real place for a ‘command and control’ approach to management of change within the Health Sector.

5. NEHTA needs to stop pretending to be a Standards organisation and start genuinely working with Standards Australia in developing the Standards required for e-Health in Australia.

6. NEHTA needs to “spin off” the SNOMED-CT management and delivery functions into a separate public sector entity which is fully funded by the public purse.

7. NEHTA needs to be de-corporatized and moved fully back into the public sector.

8. All business case documentation developed by NEHTA needs to be comprehensively reviewed and assessed for quality, feasibility and validity. Each functional unit within NEHTA needs to be independently justified as being a sensible investment – recognising that is some cases infrastructure synergies need to be considered.

9. Each of NEHTA’s operational units needs to identify just who its customers and users are and develop a plan – which is reviewed at Board Level – as to how it will best engage with and serve them.

10. All NEHTA working documents and plans need to become subject to the standard Commonwealth Freedom of Information laws and rules.

If all these steps were taken it is just possible NEHTA could become an important and useful player in the Australian E-Health domain. Without changes along the lines outlined here – we will have another decade of failure and lost opportunity.

David.

Another NEHTA Readathon!

Oh joy, oh wonder! NEHTA has just given us some more reading material!

This time we have an endless series of documents on Identity Management (IdM).

What a wondrous collection they are.

Included are:-

Framework for Analysing, Planning and Implementing Identity Management within E-Health v1.0 (76 pages)

Authentication Assessment Methodology v1.0 (55 pages)

Identity Management Discharge Summary Authentication Assessment v1.0 (28 pages)

Identity Management Glossary of Terms v1.0 (48 pages)

Identity Management Resource Set Building Blocks Layer v1.0 (36 pages)

Identity Management Resource Set Guidelines Layer v1.0 (39 pages)

Identity Management Resource Set Standards Layer v1.0 (19 pages)

Identity Management Resource Set Templates Layer v1.0 (33 pages)

Total = 334 pages.

What does all this mean and amount to?

I think the core of what is being outlined here can be seen in the following three quotes:

Identity Management

NEHTA sees Identity Management (IdM) as:

“an integrated system of policies, processes, and technologies that enables health organisations and the E-Health Community as a whole to facilitate and control users' access to applications and information resources while protecting confidential personal and business information from unauthorised users.”

When applied in a consistent and systematic way across a healthcare community, identity management underpins:

• identification of parties involved in healthcare activities – providers, patients, organisations and locations;
• authorised access to resources;
• confidential transmission and receipt of private or sensitive information;
• integrity of information transferred between parties; and
• traceability and audit of activity between transacting parties.

And

Identity Management Program

“NEHTA’s Identity Management initiative is developing a national approach and an alignment framework to guide the Australian health sector toward a uniform and comprehensive approach to managing digital identities and their access to E-Health applications and information resources.

This requires that healthcare providers, across the board, migrate practices and systems to the point where they meet the interoperability and ‘security’ requirements necessary to build a trusted national approach to E-Health.

…..

The Identity Management work program is intended to support the migration of organisations and applications from the broader sector into the National E-Health community.

Inside the E-Health Community, identity management ‘systems’ will need to be aligned with the principles described in the NEHTA Interoperability Framework (IF) and Enterprise Architecture (EA) documents. It is anticipated that the sector will adopt a Services Oriented Architecture (SOA) approach based on Web Services. Such systems will generally be developed as ‘greenfields systems’, filling a new role or acting as a migration target.

Identity management systems of varying complexity exist outside the E-Health Community in the broader Australian Health Sector. Over time such systems will need to become more aligned with the directions being developed by NEHTA. These migration projects may not be initially fully compliant and conformant with the NEHTA Interoperability Framework and Enterprise Architecture, but will be able to adopt key principles and approaches from the Identity Management Framework that will ensure that future work can continue the transition towards a fully realised E-Health implementation.”

Further clues are found in the Business Principles to be Applied to IdM (from the Guidelines Document)

“2.1.1 Business Principles

2.1.1.1 Maximize Benefit to Health Care

Statement: Decisions about electronic health infrastructure components must always maximise the quality of care.

Rationale: Where there is any conflict or uncertainty in making decisions about infrastructure specifications and services, the goal of providing better quality of care should take precedence.

Implications:

• The benefit to health care provided by an infrastructure specification or service must always be identified.
• Decisions about technology should be driven by health care needs rather than technological or other concerns.
• A simple solution that provides immediate benefit to health care organisations is preferred over a technologically better solution.
• The Institute of Medicine quality of care principles [IOMQOC] should be applied to such decisions, that is, health care should be safe, effective, patient-centred, timely, efficient and equitable.

2.1.1.2 Service-oriented Approach

Statement: A service-oriented approach to the development of specifications and services will be applied.

Rationale: A service-oriented approach requires that specifications and services provide an identifiable, relevant and cost-effective service to businesses using the infrastructure. The business-level service definition becomes the point of alignment between business, information and technical

perspectives.

Implications:

• The business-level relevance and benefit associated with services must be identified.
• Service usage is captured in process definitions that specify the interaction between service providers and service consumers. Processes might be as simple as request/reply or even a one-way message but can also be considerably more complex.
• The business-level responsibilities of both service providers and service consumers must be identified in a process.
• Processes provide the basis for agreement between service providers and service consumers, and as such, should reflect the concerns of all parties involved in an instance of service usage. These concerns should be reflected in the services.
• Services identify information (data) associated with service provision and use. In a service-oriented approach, an information model must be associated with business services using that model to identify the benefit to the business. Information models should not be specified without the context of one or more services.”

It is really important to stand back from all this and to see just what is being provided here. We are being told that – although there is a huge amount of work and consultation still to be undertaken – that here is the IdM Framework that is to be used by the Australian Health Sector.

Can I suggest that for any organisation to make a call of that magnitude it really should have a track record of delivery in such a complex arena. Additionally any entity planning to adopt the framework and all the associated complexity would want substantial assurance regarding the stability, utility, cost effectiveness and practical implementability of what was being offered. I really can’t see that either pre-condition is true.

On the basis that NEHTA has NO track record of successful delivery of anything of this complexity that assurance would have to be based on pure faith rather than any experience.

Given the funding to start work on Identifiers was announced in February 2006 and all we now have is a “Framework’ which needs a vast amount of further elaboration to reach any state of practical usability it seems unlikely much will actually be delivered before the money runs out in 2009. All this just shows how terribly slowly progress is being made (if at all). It really seems to me that NEHTA are quite unlikely to deliver in any sensible time-frame.

Also missing from all this is any business case that justifies doing all this. That surely must be done before anyone would bother investing in such a complex and unwieldy process as the one outlined here.

Lastly, one is forced to wonder just how much of this has been discussed with and aligned with the IdM plans that Medicare Australia and the Office of the Access Card have. As best I can make out the IdM Framework is assuming that Jurisdictions and Medicare will be registering providers and individuals to the standard NEHTA desires. I suspect this may come as news to these entities – given the level of IdM that is required in many e-Health transactions to ensure security and privacy. Who will bear the registration costs one wonders?

One also wonders whether becoming a registered professional or acquiring an Access Card is all that is needed – or does such registration need to be verified / repeated by NEHTA?

Before closing I must comment on the Business Principle to “Maximise Benefit to Health Care”. Read carefully and I am sure you, like me, will say that this is pure motherhood and will also be able to think of a legion of different situations where the Principle is just silly. (Hint. I think the third point is just wrong and the second is very much dependent on the circumstances. Re the first point – the bottom line is that some infrastructure just has to be (i.e. exist) for anything else to be able to happen)

Another un-consultative clunker I believe.

David.

Where Do We Re-Start with e-Health In Australia and how Do We Pick Up the Pieces?

As regular readers will recall submissions to the Boston Consulting Group (BCG) review of NEHTA closed on the 27^th July, 2007.

Since that time there have been a number of interesting developments.

First (slightly late) submissions to the review have been submitted to the BCG from an additional range of organisations including the Health Informatics Society of Australia (HISA) and the Australian College of Health Informatics (ACHI). Both these submissions – as well as a number of individual submissions have strongly supported the view put in this blog regarding NEHTA and its gross and continuing underperformance.

Interestingly these submissions have achieved a real first. They caused the NEHTA Chair to issue a press release. This release and my initial comments on which can be found here.

What I did not specifically comment on in the release was the following first sentence.

To quote:

“7 August, 2007. The Board of the National E-Health Authority welcomes public debate about the important role NEHTA plays as the peak e-health body in Australia.”

Am I the only one who missed the announcement that informed the health sector that NEHTA is the “peak e-health body in Australia”? Does anyone know when the Council of Australian Government or Health Ministers determined and then announced this reality?

I must say that, if this is true, then the job facing the BCG is really much larger than I suspect they envisaged as they have the job of getting the strategy and governance for the whole e-health space in Australia back on track.

For me the key things we need to sort out to get things back on the rails are:

First to determine how the ICT infrastructure for the Health Sector in Australia is to be governed given the complexity of our Federal / State / Private Sector accountability boundaries.

Second we need who is to be responsible for what and how accountability and responsiveness to the needs of the sector can be engineered. (There are a large number of actors to be co-ordinated including COAG, AHMAC, AHIC, NEHTA, the Clinicians in all their different forms, Standards Australia, Consumers and so the list goes on). A key issue here is deciding what the role of local vs. state and national entities is to be.

Third we need a list of achievable priorities and time-lines based on an assessment of the current state and an understanding of where the most good can be achieved and how with what additional investment. (i.e. we need an agreed strategy and investment plan and associated business case).

Fourth we need to stop the waste and mismanagement that is sponsoring the non-strategic and investments that a going on in an un-coordinated fashion all over the country.

Other interesting recent developments have included:

• The announcements by Switzerland, Lithuania and Ireland of major National e-Health initiatives.
• A continuing stream of strategic announcements from US standards entities showing the emerging organisation and standardisation of initiatives in that country.
• Continuing reports of useful progress being made in a range of other European countries (Germany most recently).

All in all the rest of the world is on the move. Pity we are not doing as well at present. I hope the BCG Review can change all that! In the next few days I plan to expand on the actions I see as being vital to flow from the review.

David.

ps. This is post number 250 for the blog – and it seems like yesterday it started. Thanks to all who read and I hope at least some enjoy!

D.

Yippee! A Win for the Common Sense!

On June 25, 2007 – just after the emergency intervention following the “Children and Sacred Report” release, I wrote an article entitled How Could e-Health Help in the Northern Territory.

When I wrote the article I e-mailed it to relevant people in the appropriate branch of the Department of Health and Ageing.

While not wanting to take credit for stating the ‘bloomin’ obvious’, it is wonderful to see something is actually happening.

The following article provides some detail.

http://www.australianit.news.com.au/story/0,24897,22274844-16123,00.html

Remote e-health plan unveiled

August 20, 2007

THE federal Government says a new internet-based health system for remote areas will ensure health issues identified in Aboriginal children are properly followed up.

At the Australian Health Summit in Sydney, Health Minister Tony Abbott announced an electronic health record initiative for remote indigenous towns.

An investment of $25 million over the next three years would see the Medicare records and health concerns of more Australians dealt with online, Mr Abbott said.

Better equipped GPs would be able to receive lab results and X-rays via the internet, as well as sending referrals and writing prescriptions online.

However, Mr Abbott admitted the government had not been moving quickly on this issue, because he had urged similar internet streamlining in his maiden speech as health minister in November 2003.

….. (see URL for full article)

It will be fascinating to see how the implementation is approached. We have all had a lot of time to consider the issues surrounding Shared Electronic Records and it would be good to see this present initiative carried out in the light of all the learning and experience in thinking about the issues is available.

I will be following this with the keenest interest indeed!

Well done to those who got the idea up with the Minister. I hope they read the older blog article carefully for some alerts and insights on what needs to be carefully considered, in my view, as a project of this type is begun.

I do not believe it will be at all easy to deliver this project promptly as is ideally required. DoHA seems to recognise this – given that the funding is to run over three years. A careful review of proven solutions from overseas that I mentioned previously is certainly warranted as rapid results are possible with those proven tools.

David.

Some Brief News Follow-Ups – All Good News!

MedInfo2007 is in full swing for the next few days. I hope all those attending in Brisbane have a profitable and intellectually stimulating time. I look forward to hearing all about it!

I have had great reports on the First World Congress on Pathology Informatics which ran on
August 16 -17 August, 2007.

For those who are interested there is a rich store of downloads of presentations available for download here.

I am told the key outcome from the Congress (the Conference Communiqué ) made three major points:

1. There will be an increased reliance on the laboratory (including genetics) and medical imaging and these will converge as disciplines and do things that humans cannot do without informatics.

2. Pathology informatics is a discipline in its own right and training is required – but policy makers do not know what they don’t know.

3. There is going to be an enormous workforce problem.

I must say – having browsed many of the presentations – how true this is!

It seems the next Congress is to happen in two years (somewhere in the USA) and that IMIA is going to offer support with the creation of a specialist working group.

It is great to be able to report there were 134 attendees from a zillion different places at the Congress and that in addition to all the tutorials etc 15 new scientific papers were also presented.

Well done to the organising team!

Lastly I need to report the usage of the blog passed 20,000 visits since March 2006 on the weekend with well over 33,000 page reads in the same period. Obviously more than my Mum is reading!

Thanks for all for the support.

David.