Does the Doctor Really Know Best?

The following rather horrifying article appeared recently in the American Journal of Managed Care.

Reasons Provided by Prescribers When Overriding Drug-Drug Interaction Alerts

Amy J. Grizzle, PharmD; Maysaa H. Mahmood, MS; Yu Ko, MS; John E. Murphy, PharmD; Edward P. Armstrong, PharmD; Grant H. Skrepnek, PhD; William N. Jones, MS; Gregory P. Schepers, PharmD; W. Paul Nichol, MD; Antoun Houranieh, PhD; Donna C. Dare, PharmD; Christopher T. Hoey, PharmD; and Daniel C. Malone, PhD

Objectives: To investigate prescribers’ rationales for overriding drug–drug interaction (DDI) alerts and to determine whether these reasons were helpful to pharmacists as a part of prescription order verification.

Study Design: An observational retrospective database analysis was conducted using override reasons derived from a computerized system at 6 Veterans Affairs medical centers.

Methods: Data on DDI alerts (for interactions designated as “critical” and “significant”) were obtained from ambulatory care pharmacy records from July 1, 2003, to June 30, 2004. Prescribers’ reasons for overriding alerts were organized into 14 categories and were then rated as clinically useful or not to the pharmacist in the assessment of potential patient harm.

Results: Of 291 890 overrides identified, 72% were for critical DDIs. Across the Veterans Affairs medical centers, only 20% of the override reasons for critical DDI alerts were rated as clinically useful for order verification. Despite a mandatory override reason for critical DDI alerts, 53% of the responses were “no reason provided.” The top response categories for critical and significant DDI alerts were “no reason provided,” “patient has been taking combination,” and “patient being monitored.”

Conclusions: When given the opportunity to provide a reason for overriding a DDI alert, prescribers rarely enter clinical justifications that are useful to order verification pharmacists. This brings into question how computerized physician order entry systems should be designed.

(Am J Manag Care. 2007;13:573-580)

The full text for the article is available for no cost at the following URL.

http://www.ajmc.com/Article.cfm?Menu=1&ID=4380

This is really a very important article as it shows that the human factors are the ones that may be the most important in getting the anticipated benefits from clinical decision support. If the systems do not provide a compelling reason for an alert to be taken seriously virtually all of the time then it seems the human and knowledge engineering of the systems under evaluation must be very suspect.

While the focus of the paper is to see how usefully physicians explain their decisions to override alerts in the eyes of the dispensing pharmacist that there were 292,000 alerts generated and then overridden, by just six hospitals in a calendar year, which works out at 130 overridden alerts per hospital per day, seems – on the face of it – to be quite high. It is not clear just what the common range of alerts were for and this would have added greatly to interpreting the paper.

That said it seems to me that careful consideration needs to be focused on the balance between ‘alert fatigue’ and patient safety. This study suggests that the VA system in 2003/4 had not got the balance quite right.

The suggestions made towards the end of the paper all deserve careful consideration.

Given the results of this study, it is clear that additional attention is needed to provide solutions that will improve the prescriber’s ability to communicate with the pharmacist and to ensure optimal patient outcomes with every medication prescribed. The following is a list of suggestions for improving patient outcomes related to exposure to DDIs:

1. A feedback mechanism should be incorporated into the DDI alert process. Reducing the frequency of clinically irrelevant alerts increases the importance of the remaining alerts. How prescribers and pharmacists respond to these alerts is then increasingly important. Override reasons (or, most important, the lack of response) need to be reviewed and an educational process used to modify practices that compromise patient safety.

2. The patient’s medication history should be incorporated into the DDI alerts. For each patient, systems should recognize responses to previous alerts and prescriber responses. This information could be presented to prescribers at the end of the order entry process.

3. Once an acceptable override reason is provided for a particular patient, repeat alert messages on refills are eliminated.

4. Drop-down menus could be used to more clearly and efficiently communicate override reasons.

5. Mandatory override reason responses could be expanded to include more than the most severe DDIs (in this case, requiring override reasons for significant and critical interactions).

6. Alternative management strategies should be available to prescribers when DDI alerts are first issued. This would provide opportunities for timely decisions to make changes in medication selection.

7. When guidelines require patient monitoring, automatic generation of reminders for laboratory tests and office visits should occur.

I commend this paper to all those interested in clinical decision support as very useful food for thought.

David.

Useful and Interesting Health IT Links from the Last Week – 21/10/2007

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

These include first:

Pfizer becomes latest to partner with fast-growing online doctors' forum Sermo

October 15, 2007 - 2:50PM

A year-old online forum where 30,000 doctors swap medical observations has lined up a partnership with Pfizer Inc. _ an alliance that runs counter to the site's founding ideal to give doctors a place to communicate without the pharmaceutical industry listening in.

Under a collaboration to be announced Monday with Cambridge-based Sermo Inc., Pfizer will work with the fast-growing Web venture and its participating doctors to agree on terms allowing Pfizer's hundreds of staff doctors to view postings and reply.

Rules are to be worked out in online "town hall" meetings involving Pfizer and Sermo's physician members. But it's expected any postings by Pfizer's medical staff must be clearly identified as coming from a Pfizer source logging onto the system securely from an office computer, said Daniel Palestrant, Sermo's CEO.

When the service began in September 2006, it was intended as an advertisement-free forum for communication among doctors about topics such as drug side effects _ in effect, a sanctuary from the influence of pharmaceutical industry and its sales staffs.

But recent online polls and focus groups involving Sermo members indicated a clear desire to seek industry participation in a controlled fashion, while continuing to bar ads on the site. The findings led to the collaboration with New York-based Pfizer, the world's largest pharmaceutical company, Palestrant said.

"These doctors are saying, 'We want to have a different type of relationship with the industry,'" said Palestrant, a former surgery resident at a Boston hospital. "Doctors in our focus groups would say, 'In many cases, the most timely and interesting information on drugs comes from the industry. But I want that information on my terms.'"

Continue reading here:

http://www.smh.com.au/news/breaking-news/pfizer-becomes-latest-to-partner-with-fastgrowing-online-doctorsforum-sermo/2007/10/15/1192300663232.html

This is a fascinating innovation that may very well be useful to many – especially younger – clinicians who are comfortable with an on-line technology enabled practice

It is well worth having a look at the on-line demo of how the system works which is found here.

I must say I am not sure sponsorship from a major drug company is a good thing – but I guess we will see.

Second we have:

Labor to dump Access Card

Karen Dearne and Ben Woodhead | October 16, 2007

A LABOR government would scrap the contentious $1.1 billion Access Card project, human services shadow minister Tanya Plibersek has confirmed.

Labor would scrap the proposal entirely, says human services shadow minister Tanya Plibersek

"We have said all along that if the Access Card had not been introduced by the time of the election we would not proceed with it," Ms Plibersek said.

"So, yes, we would scrap the proposal entirely."

Touted by the Howard Government as a health and welfare smartcard and anti-fraud measure, the scheme has met with sustained opposition as a de facto identity card. Originally proposed and promoted by then minister Joe Hockey in April 2006, the project has been in limbo since July, following a series of legislative and procurement stumbles.

Human Services Minister Chris Ellison was forced to withdraw enabling legislation in March, after the draft bill was rejected by an all-party Senate committee.

Continue reading here:

http://www.australianit.news.com.au/

This is a useful summary of where the various government IT initiatives are presently situated and makes it clear that the Access Card project is on fairly thin ice at best

Further reporting is also found here

http://www.cio.com.au/index.php?id=1135473785&eid=-601

Labor to dump billion dollar Access card if it wins federal election

Democrats welcome move but say response was too slow

Sandra Rossi (Computerworld) 16 October, 2007 11:26:28

Third we have:

Reporter's Notebook: Tales from the AHIMA Crypt

By: Joseph Conn

Story posted: October 15, 2007 - 5:59 am EDT

Privacy, like beauty, is in the eye of the beholder, and at the American Health Information Management Association’s (AHMIA) annual convention last week, privacy in its varied interpretations was a recurrent theme, including a daylong “privacy institute” the day before the show officially opened for its three-day run in Philadelphia.

I can’t tell you any more about the institute, because it was, well, private, for AHIMA members only. It was probably pretty interesting, given the organization’s long-standing reputation as an advocate for patient privacy and its involvement (through an affiliate organization) in recent years as a government contractor on several projects with direct and indirect privacy implications.

Once the convention got under way, though, there were several, more readily accessible educational sessions devoted to privacy and one general session address. One was a panel discussion, provocatively titled, “Tales from the Crypt—HIPAA in the Real World.” The convention guide said of the session: “HIPAA is not for the faint of heart. Practical solutions to real problems that can bring a potential nightmare to a satisfactory end.”

As billed, there were plenty of Health Insurance Portability and Accountability Act horror stories from the four panelists, who all work in the trenches as medical-record managers for healthcare organizations. They also made mention of the recent, highly publicized breach of actor George Clooney’s medial records by hospital workers in New Jersey, which, according to an Associated Press account, involved between 27 and 40 workers, including physicians, who were suspended after illegally viewing his medical records.

Perhaps there were some Clooney fans on the panel who felt empathy with the punished, because they conducted a theoretical discussion about whether a young and foolish healthcare worker, fired for a privacy violation such as unauthorized peeking, should ever be rehired. If, for example, the panelists pondered, the person had been sacked for looking at a record, and then, after a suitably long period of penitence, say, completing a nursing training program, wanted to resume a career in healthcare, should the earlier indiscretion be forgiven? The panelists left the question unanswered.

Pam Dixon, executive director of the San Diego-based World Privacy Forum, was in the audience with me for this session and we talked about it later. Dixon, herself a devout privacy advocate, gave a general session presentation on medical identity theft. She said she was struck with and pleased by the passion the panelists evidenced for privacy protection, how vigilant they were and how seriously they took their responsibilities. Later, in a talk to attendees, Dixon said AHIMA would be just the group to take the lead in raising public awareness of medical identity theft and helping crafting an industry response.

Perhaps they needn’t have bothered. The Clooney episode has clearly entered the zeitgeist. As I was driving to work the morning after the AHIMA show ended, a local Chicago radio personality commented on the actor’s situation and then on broader healthcare privacy threats. Employers, he noted, are asking workers to sign up for personal health records, but from a privacy standpoint, he said it probably wasn’t such a bright idea.

Continue reading here:

http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20071015/FREE/310150008/1029/FREE

The Clooney episode certainly has sparked concern all over – showing just how hard it is – in the real world – to have apparently rational people – behave decently with respect to others’ privacy. This article also provides a useful summary of the other matters discussed the AHMIA annual conference.

Fourth we have:

Computers that talk to docs transform medicine

At some clinics, costly electronic record systems can give advice and challenge physicians' decisions.

By Maura Lerner, Star Tribune

Last update: October 13, 2007 – 7:10 PM

A few years ago, Dr. Alison Peterson might not have noticed if one of her patients skipped an appointment. Or forgot to fill a prescription. Or missed an important lab test.

Now, all she has to do is ask her computer.

And if, by chance, she tries to prescribe a drug that could cause an allergic reaction, her computer may flash a warning: Are you sure you want to do that?

At Peterson's office in Cottage Grove, the old patient charts have been replaced by the latest in medical technology: an electronic record system that's ushering in a whole new era in medicine.

Once mainly a high-tech way to track doctors' orders and patient visits, the newest generation of electronic records popping up across the Twin Cities seems to have a virtual mind of its own.

It not only stores information, it also eagerly prods doctors to make decisions based on the newest research. Clinics throughout Minnesota are scrambling to convert to the pricey systems.

The Allina clinic where Peterson works, for example, scrapped its yellowing paper files for an electronic system a year ago.

Now Peterson, a family physician, can call up the chart of a patient with pneumonia or heart disease, and see experts' tips on the best way to treat it.

She can push one button to see what questions to ask, and another to find out what medications are recommended.

Ideally, she shouldn't even have to worry about potential drug interactions because an alert should pop up and warn her if she tries to prescribe drugs that don't mix well.

Continue reading here:

http://www.startribune.com/1244/story/1482960.html

This is a useful article to give to those who are unsure just why the EHR is important and why – once the pain of implementation is over – life can be both easier and safer.

Lastly we have:

http://www.ehealtheurope.net/news/3113/nhs_scotland_ready_for_national_pacs_roll_out

NHS Scotland ready for national PACS roll out

12 Oct 2007

The Scottish Executive has announced that national deployment of Picture Archiving and Communications Systems (PACS) across Scotland will begin this month after successful pilots in hospitals across Glasgow and Dumfries and Galloway.

Over the next two years every hospital in Scotland will receive a new system from Carestream Health [formerly Kodak Health], which will eventually lead to a national database of digital x-ray images for every Scottish citizen.

A Scottish Executive spokesperson told E-Health Insider: “The national PACS programme is to support the seamless acquisition, storage, retrieval and display of digital patient images within and between clinical sites across Scotland. To enable this, the national archive will support access for sites that do not have the national PACS solution.

“The introduction of PACS in NHS Scotland enables the delivery of a range of benefits to patients. Clinicians will be able to access images taken at stages along pathways and readily access relevant patient records. This will streamline care and speed up diagnosis and treatment.”

The system is in place at hospitals across Scotland including the Southern General, Victoria Infirmary, Gartnavel General, Royal Hospital for Sick Children and, just recently, the Western.

Continue reading here:

http://www.ehealtheurope.net/news/3113/nhs_scotland_ready_for_national_pacs_roll_out

Now if Mr Abbott is really going to take over all those hospitals – here is something he could do which would really make a difference – as shown by the experience in England and now Scotland!

All in all not a bad start to the week!

More next week.

David.

Last Opportunity to Contribute to the HISA E-Health Strategy Development!

Here is the invitation!

“With the election called and a renewed focus on the state of the Australian healthcare system, we have a window of opportunity to raise the debate and advocate for what we believe is the most effective element of any healthcare reform in Australia; the better use of information and information technology.

This online survey is aimed at establishing a Health Informatics Society of Australia (HISA) position on E-Health strategy and national policy. The results of the survey will be used in our approach to the political parties before the election.

We have used the 'E-Health Blueprint Framework' recently developed as part of the E-Health Initiative (see www.ehealthinitiative.org ) to structure the survey, and supplemented that with questions to extend the structure for the Australian healthcare environment. The Blueprint describes how E-Health systems and processes can catalyse the required transformation of Healthcare.

The survey is divided into six focus areas (each with an associated vision statement). They are:

• Engaging Consumers
• Transforming Care Delivery at the Point of Care
• Improving Population Health (Data sharing capabilities and initiatives)
• Aligning Financial and Other Incentives
• Managing Privacy Security & Confidentiality
• Policy and Implementation

In all, there are 42 questions, where you are asked to rate individual aspects of a proposed E-Health strategy. This is an important opportunity to influence the direction of E-Health in Australia and we invite your participation.

The survey is only open until Wednesday October 24, so get online now, just click on the link below and you will be taken straight to the HISA survey site.”

Now for non-HISA members we have a special offer..you can also have your say!

We have now built a page that records the person’s name and email address and then takes them to the survey site.

Please go to go to www.hisa.org.au/ehealthstrategy

You can then enrol and contribute!

Do it now!

David.

IBA Health Has One Chance At This!

Last week E-Health Insider published quite a long interview with Gary Cohen, the CEO of IBA Health which has all but completed its takeover of iSoft.

IBA boss: battle has just begun

11 Oct 2007

Gary Cohen, the Australian chief executive of IBA Health, has good reason to celebrate - IBA Health is now poised to take control of Britain's iSoft.

In an exclusive interview he spoke to E-Health Insider last Thursday, the day iSoft shareholders almost unanimously accepted IBA Health’s bid that will see the company taken over by its far smaller one time rival.

It’s an audacious move that will propel IBA Health – at various stages written off in the takeover battle - from being a company with revenues of less than £40m a year to almost £250m, and going from 700 staff to 3,500. “David conquered Goliath,” he jokes.

It’s a personal triumph for Cohen who five years ago saw IBA shut out of the NHS market with the introduction of the NHS IT programme, and sell its UK operations. Now he is poised to take control of his one time greatest rival and, with the merged IBA/iSoft, will be at the centre of the NHS IT project.

“If you look at process of iSoft that started a year ago we were nowhere, they didn’t even rate us, we were not even on the short-list. When CompuGroup came in we were written off and nobody from the board or the advisors gave us a hope in hells chance of coming back. Yet look at the end point,” says Cohen.

He acknowledges that the really tough battle – to integrate the companies and deliver the Lorenzo product – has only just begun. It was the cost and delays in developing Lorenzo that cost iSoft its independence.

“We’ve got to be honest and demonstrate that our position is earned. We’ve got to show people we can do it, use the acquisition of iSoft as the beginning of a journey,” says Cohen. He stresses that IBA and iSoft are an excellent fit, both having deep health domain expertise and strong experience in “socialised medicine”.

Continue reading here:

http://www.e-health-insider.com/comment_and_analysis/264/iba_boss:_battle_has_just_begun

Now, without wishing to put a jinx on things Mr Cohen is dead right when he says the battle has just begun – to get these companies integrated and working as a coherent whole is a huge job of itself – to say nothing of the challenge faced in getting a workable version of Lorenzo out the door.

There is however another problem Mr Cohen needs to attend to – now that the battle has been won over iSoft – and that is to repair IBA’s working relationships in Australia.

As previously disclosed I am a small IBA shareholder and I am less than impressed when I consistently hear reports of IBA Health being un-helpful, uncooperative and lacking customer focus with Australian clients of a number of different sizes.

It could be it is only the unhappy who get in touch, but I think IBA would be well advised to do a careful review of its customer satisfaction levels. From what I am hearing they may not like what they find.

David.

Clinician Involvement – Avoid at Your Peril!

I came upon this article from the magazine ADVANCE for Health Information Executives a few days ago.

Importance of Physician Leadership in EHR Selection

Employees need to be actively involved in EHR implementation to ensure smooth integration.

By Gary Kennedy

In the whirlwind daily life of medical practices, electronic health record (EHR) implementation is often met with great skepticism and resistance. But the old mantra of “no budget, no time, no IT resources,” is no longer a good enough excuse for practices hoping to keep up with increasingly sophisticated patients and the federal regulations. In coming years, the EHR will become commonplace, and probably mandated.

The EHR can be as useful to the solo practice, as it will be to the group practice. The problem is two-fold: (1) how to guarantee that your practice selects the right EHR, and, more important, (2) how to leverage it to ensure that doctors make better decisions.

The EHR selection committee

To avoid an aborted or delayed selection process, or a failed implementation, make sure that your practice’s most influential business drivers are on the selection committee -- led by the physician sponsor. Ideally, the executive physician or chief medical officer appoints members to this committee, establishing clear lines of ownership and accountability. Keep your enemies close: Remember partners or key employees who could easily derail the process, invite them to participate, give them committee responsibility and make them your allies.

A physician who is intimately familiar with the software and has oversight where changes and adjustments need to be made can enhance the quality of communications with the vendor. This individual must be willing to put in extra, possibly uncompensated, hours doing research and management tasks. If this individual is not the physician sponsor, all the better. You may be surprised at how different practice stakeholders can collaborate to accelerate return on investment. Identify the goals for the EHR before beginning the search, then evaluate the EHRs by how they meet these goals, and by value added beyond specific goals.

For example, Barry L. Fisher, MD, led the efforts of his employer, IASIS Healthcare LLC, headquartered in Franklin, Tenn., to adopt RemedyMD’s BariEHR in a system-wide effort to achieve Center of Excellence certification for bariatric surgery across its hospital system.

IASIS, a company heavily invested in electronic data collection and retrieval, already had an in-house electronic records system accessible through its intranet and had experienced all the data headaches that came with its implementation.

According to Dr. Fisher, selecting BariEHR was based on RemedyMD’s ability to retrieve, maintain and analyze the data, its flexibility to respond to specific needs at each site, and to utilize shared information for system-wide quality improvement. The selection culminated months of effort and evaluation with input from the executives at IASIS.

Continue reading the article here:

http://health-care-it.advanceweb.com/editorial/content/Editorial.aspx?CC=98690

Four things struck me about this very frank article – other than that the authors points about clinician engagement were fundamental.

First I was surprised some one had gone out and developed and EHR for Bariatric (Obesity) Surgery hospitals.

Second I was very surprised that there was not more discussion of the need to involve all clinical staff (nurses especially) in the selection and implementation processes – right from the very start.

Third that it was just assumed that improved Health IT could assist in acquiring the desired Center of Excellence certification for bariatric surgery. I fear we have a way to go to reach the situation where such an assumption would be buried in accreditation and certification criteria in Australia.

Fourth was the implicit plan to use the Health IT to facilitate quality feedback and continuous improvement using information resources. What an excellent idea that we would all like to see more of.

Well worth a read for all the clinician engagement tips and tricks.

David.

The e-Health Initiative Shows How It Could Be!

This week we had a major blueprint released by the e-Health Initiative.

The following report on the release appeared a day or so ago.

E-Health Group Unveils IT 'Blueprint' For Health-Care Industry

The 107-page report recommends a "shared vision" and timeline to guide health-care players in how to improve quality and accessibility of health care.

By Marianne Kolbasuk McGee, InformationWeek

Oct. 10, 2007

Non-profit industry organization eHealth Initiative on Wednesday released a blueprint on how IT and information can be used for improving health and health care delivery.

The report represents agreement on several key issues among a varied group of 200 health-care industry stakeholders, including hospitals, clinicians, consumer groups, pharmacies, labs, health IT suppliers, health-plans, insurance companies, public health officials, government agencies and employers.

"The biggest accomplishment of the blueprint is reaching consensus across diverse stakeholders" to come up with a strategy and action to move forward in improving quality and safety of health care through IT, said eHealth chairman Janet Marchibroda during an event in D.C. to unveil the report.

The 107-page blueprint represents a "shared vision" and timeline to guide health-care players in how to improve quality and accessibility of health care through information and IT, and not how to implement IT, says Christine Bechtel, eHealth VP of public policy and government.

Entitled "Building Consensus For Common Action" the blueprint includes "principles, strategies and actions" focused on five key areas.

Continue reading here:

http://www.informationweek.com/news/showArticle.jhtml?articleID=202400982

On their web site the vision is outlined as follows:

Our Shared Vision

We envision a high-performing healthcare system, where all those engaged in the care of the patient are linked together in secure and interoperable environments, and where the decentralized flow of clinical health information directly enables the most comprehensive, patient-centered, safe, efficient, effective, timely and equitable delivery of care where and when it is needed most – at the point of care.

In our vision, financial and other incentives are aligned to directly support and accelerate all of the key elements of transformation — engaging consumers, transforming care delivery at the point of care, and improving population health — in a secure, private, and trusted environment.

Vision for Engaging Consumers:

Patients will be fully engaged in their own healthcare, supported by information and tools that enable informed consumer action and decision making, working hand-in-hand with healthcare providers. Tools that support consumer engagement are well designed and customized to the diversity of consumers. These tools are integrated into the delivery of care, and are conveniently available outside healthcare settings as well.

Vision for Transforming Care Delivery at the Point of Care:

Patient care is high quality, patient-centered, for a lifetime, and reflects a coordinated and collaborative approach. Complete, timely and relevant patient-focused information and clinical decision support tools are available, as part of the provider’s workflow, at the point of care. High quality and efficient patient care is supported by the deployment and use of interoperable health IT and secure data exchange between and across all relevant stakeholders.

Vision for Improving Population Health:

Electronic healthcare data and secure health information exchange are utilized to facilitate the flow of reliable health information among population health and clinical care systems to improve the health status of populations as a whole. Information is utilized to enhance healthcare experiences for individuals, eliminate health disparities, measure and improve healthcare quality and value, expand knowledge about effective improvements in care delivery and access, support public health surveillance, and assist researchers in developing evidence-based advances in areas such as diagnostic testing, illness and injury treatment, and disease prevention.

Vision for Aligning Financial and Other Incentives:

Healthcare providers are rewarded appropriately for managing the health of patients in a holistic manner. Meaningful incentives help accelerate improvements in quality, safety, efficiency and effectiveness. Quality of care delivery and outcomes are the engines that power the payment of providers.

Vision for Privacy, Security and Confidentiality:

In a fully-enabled electronic information environment designed to engage consumers, transform care delivery and improve population health, consumers have confidence that their personal health information is private, secure and used with their consent in appropriate, beneficial ways. Technological developments are adopted in harmony with policies and business rules that foster trust and transparency. Organizations that store, transmit or use personal health information have internal policies and procedures in place that protect the integrity, security and confidentiality of personal health information. Policies and procedures are monitored for compliance, and consumers are informed of existing remedies available to them if they are adversely affected by a breach of security. Consumers trust and rely upon the secure sharing of healthcare information as a critical component of high quality, safe and efficient healthcare.

----- end Vision.

Also of interest is that while all the broad principles of what is needed to move forward there were two areas where the detail was contentious. As the report states:

“The most challenging issues that arose during the development of the Blueprint centered on two key areas: the design of financial incentives to support improvements in healthcare and policies for information sharing.”

This is not unexpected since one of these goes to the question of “who pays?” and the other goes to the issue of “who will I share with?” and “how much can and will I share?”

Overall it is my view that to develop strategies and tactics to address the five areas identified here (as has been done in the full document for the US) would be an enormous leap in Australia as well.

It is fascinating reading the reasons the Initiative believed a Blueprint was needed.

“eHealth Initiative’s discussions with multiple stakeholders across the healthcare system at the national and local levels reveal that there is not clarity regarding the incremental steps that must be taken. With all of the change, and the multitude of activities taking place at the national, state, and local levels, healthcare leaders find that it is often hard to keep track and make sense of what is happen­ing, and understand the concrete actions for improving the quality, safety and efficiency of healthcare through information technology.”

They could have just as well have been writing about a place we all know much better! The analysis works as well for Australia as it does for the US as far as I am concerned. This is the reason we need a Plan!

The process used to develop this consensus document involving 200 or so major organisations is a model as to how things should be done – compared with the obsessive secrecy and lack of vision we see coming from the entire official e-Health leadership in Australia.

With examples of this quality available the time has come for a total revamp and a “falling on their respective swords” of the current crop of dismal bureaucratic dimwits. A whole new generation of leadership needs to be encouraged to emerge. The current lot failed us all and need to go!

To grasp just how bad it is just compare the e-Health Initiative document to the disgustingly pathetic strategic products produced by our Australian Health Information Council – they are clearly just a joke in comparison!

David.

Note: As part of a project to stimulate work on a similar project in Australia the Health Informatics Society of Australia (HISA) is conducting a survey of its members – asking their views of the applicability of this vision and strategic framework to Australia.

If you are not a member of HISA and would like to respond to the survey please contact the HISA CEO (Dr Brendan Lovelock) at brendan.lovelock -at- hisa.org.au and he will send you an e-mail invitation to participate in the survey.

Thanks

David.

Election Policy – E-Health Ignored by the Liberals so Far!

With the election now having been called we have been given the Liberal Health and Aged Care Policy (presumably with a few sweeteners to come during the Campaign)

From the Document entitled “Australia: Strong, Prosperous and Secure” we get the following on Liberal statement on health and aged care.

Health and Aged Care

Around one-fifth of the national budget is spent on health and aged care services. The Coalition has invested record amounts in ensuring Australia maintains a high-quality, affordable and sustainable health care system. We have also increased substantially investment in aged care with reforms designed to ensure more aged care places, better quality care and improved skills for the aged care workforce.

A Graphic then shows total Commonwealth Spend has risen from $20B to $52B over 11 years.

The Coalition is committed to a strong Medicare and, through our commitment to private health insurance, is the only side of politics which actively supports Australians having real choice over their health care.

A well-funded, comprehensive Medicare system is the cornerstone of health care in Australia. All Australians have the right to universal access to the three pillars of Medicare: a universal Medicare rebate for medical services; a universal Pharmaceutical Benefits Scheme (PBS); and universal access to free public hospital care.

In the last Health Care Agreement with the states and territories, the Coalition committed a record $42 billion to public hospitals for 2003-2008. We are also taking pressure off public hospitals through private health insurance rebates, support for after-hours GPs (including clinics co-located with public hospitals) and funding for the National Health Call Centre Network.

Strong economic management has allowed the Coalition to introduce a series of other measures to improve our health system. These include:

• bulk-billing incentives which have seen GP bulk-billing rates increase to 78.2 per cent in the June quarter 2007, the 14th consecutive quarterly increase;

• the Medicare Safety Net which covers 80 per cent of out-of-pocket non-hospital costs above certain thresholds;

• expanded treatments on the PBS so Australians have access to new and innovative medicines;

• Round-the-Clock Medicare which delivers higher Medicare rebates for GP services provided after hours; and

• a new Health and Medical Investment Fund (initially $2.5 billion) with earnings directed to new facilities and the latest medical equipment to treat diseases and save lives.

We are working to expand Australia’s health workforce with more medical and nursing places. The number of new medical students has risen by more than 50 per cent since 2003. Since 2000, seven new medical schools have been established in Australia and another two are preparing to open in 2008.

In September 2007, we announced a $170 million investment in 25 Australian Hospital Nursing Schools to deliver hospital-based training for enrolled nurses in major public and private hospitals across the country.

This complements university-based training with nursing places in universities set to increase to 10,100 by 2011.

Recognising that prevention is always better than cure, the Coalition has significantly expanded funding on preventative health care. With higher rates of child immunisation and cancer screening, for example, more Australians are leading healthier lives. Through the Australian Better Health Initiative, we are working cooperatively with the states and territories on disease prevention and early intervention.

The 2007 Budget included major new investments to strengthen the role of prevention and address chronic and preventable disease in Australia. The Coalition’s new dental plan, at an estimated cost of $385 million over four years, will ensure about 200,000 Australians with poor oral health associated with chronic and complex conditions gain necessary dental treatment. We have also committed $103 million over four years to the fight against Type 2 diabetes.

The Coalition has brought to the fore the issue of mental health and committed $1.9 billion to a national mental health action plan, including increased psychologist, psychiatric and GP services through Medicare.

We have ensured Australia is at the leading edge of global health developments with a massive investment in medical research over the last decade. This investment will reach $695 million by 2009-10 (a five-fold increase since 1995-96). It is supporting Australia’s world-leading scientists, researchers and medical pioneers searching for break-throughs to combat heart disease, cancer, depression and chronic diseases such as diabetes and asthma.

Alongside Medicare, private health insurance is an important element of Australia’s health system, providing choice and relieving pressure on public facilities. The Coalition restored the viability of private health insurance by introducing the 30 per cent Rebate and Lifetime Health Cover. More than 10.5 million Australians are now covered by private health insurance.

The ageing of the population, with the number of Australians aged 70 and over expected to double in the next 20 years, creates new challenges and spending pressures for Australia. The Coalition has committed to ensuring that Australia provides the care and support needed and wanted by our older people. From $3.1 billion in 1995-96, expenditure on ageing and aged-care activities has increased to an estimated 8.6 billion in 2007-08 – real growth of almost 180 per cent.

This has allowed significant growth in both residential and community-based aged care services so that older Australians can access the right level of care when they need it. We are also committed to a rigorous system of checks and accreditation to ensure the highest standards of care provision.

The Coalition’s additional investment of $1.5 billion announced in February 2007 ensures that the agedcare industry can deliver quality, choice and affordability with more aged care places, more training and better care.

End Policy.

What is missing. Anything that addresses the core problems in my view.

First, it is clear the Government came very late to the need to do something about the ageing medical and nursing workforce. They were much too late.

Second the sudden interest in training more nurses and doing something about dental services have the same feel of a ‘death-bed’ conversion as do the announcements on the place of the Aboriginal Peoples in our country.

Third, there is not even a hint of any policy to address the blame and cost shifting between the Commonwealth and the States.

Fourth, the lack of real focus on GPs and Prevention is obvious and sad.

Fifth somehow the silliness of taking over State Hospitals and creating hospital boards is just not mentioned.

And last, not a word on Health IT! (at least Labor’s platform gives the topic a few quite sensible paragraphs)

Very average in my view, but what would I expect.

For those wanting to review Labor’s approach – so far announced.

The ALP Policy Platform can be found here – Chapter 10 is the important bit for this blog.

Labor’s plans to address the Commonwealth State divide are found here.

Enjoy the next six weeks!

David.

Useful and Interesting Health IT Links from the Last Week – 14/10/2007

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

These include first:

US MS HealthVault requires suspension of disbelief

The idea actually is not too bizarre -- although there are very real problems with Microsoft's approach and the concept itself.

Scott Bradner (Network World) 10/10/2007 08:10:52

In what at first glance seems to be a bizarre move, Microsoft recently announced HealthVault, a service that wants you to upload your most private heath records so that they can be accessed by others.

The idea actually is not too bizarre -- although there are very real problems with Microsoft's approach and the concept itself. However, it is strange for Microsoft to think that people will trust the company widely disparaged as a prime cause of security problems on the Internet today.

Records are created every time we go to a doctor, dentist or any other healthcare professional. Records are also created when we buy prescription drugs, get medical tests, etc. Over the years a person can wind up with a lot of records in a lot of places. These days many of the records are electronic, but that is relatively new, and even when the records are electronic, the data formats are often very different.

Electronic health record standards have been developed, and over time I expect new systems will wind up with compatible databases. But even with that, it will be a very long time before most medical records about anyone over the age of 10 will be in any standards-based electronics form.

There has been a push for a long time to get medical records into a form that can be quickly accessed by, for example, emergency room workers so that appropriate treatment can be provided when a patient shows up on the doorstep. (Read an example here.)

This does sound quite important, but many of the people pushing for this only focus on solving their own problems and tend to ignore or at least downplay other issues, such as privacy.

One way to make medical records available is to put them in one place and then let approved people access them there. Along comes Microsoft to propose that very thing. HealthVault is a service that lets a user upload and maintain medical information in a Microsoft server, then enable specific people to access the information. As announced, this "service" will flop. For example, the idea that anything like a reliable and useful set of records could be created and maintained by individuals without getting records directly from the healthcare providers that create the information is laughable.

Continue reading here:

http://www.computerworld.com.au/index.php?id=1880576812&eid=-180

This is a more than worthwhile discussion of some of the issues that may dog Microsoft’s HealthVault initiative. It will be fascinating to see how it plays out and which, if any, of the currently free Personal Health Record (PHR) services actually develops a critical mass.

Second we have:

iSoft plans to deliver Lorenzo downunder

Newspaper report: iSoft plans to launch Lorenzo locally in the second half of 2008

By Renai LeMay, Sydney | Wednesday, 10 October, 2007

On the eve of its acquisition by Australian rival IBA Health, UK-headquartered e-health software supplier iSoft has revealed plans to launch its controversial Lorenzo application in Australia.

The software is at the heart of the UK National Health Service’s troubled £12.4 billion (NZ$33.4 billion) Connecting for Health technology overhaul, which has run into high-profile problems in the past five years involving conflicts with the suppliers — now CSC and iSoft — after global services group Accenture walked away from its role last year.

ISoft Australia and New Zealand managing director Nigel Lutton told the Australian Financial Review recently his company was planning to launch Lorenzo locally in the second half of 2008.

Mr Lutton says iSoft had not launched the software here yet because it had felt the local market’s needs had been served by the company’s existing product suite. This situation has changed because iSoft has begun to use the NHS example to sell Lorenzo in countries such as Germany and the Netherlands. iSoft views Lorenzo as its next-generation platform to provide customers with more flexible and pragmatic e-health solutions than had previously been available.

The e-health supplier’s move comes as iSoft’s primary public sector market in Australia starts to heat up. State health departments were poised to splurge more than A$1 billion on new technology in the next few years as they ramp up plans to replace and link core patient and clinical information systems.

Continue reading here:

http://computerworld.co.nz/news.nsf/news/AA7CC21B8B9D83E3CC25736A007D7F99

Isn’t it wonderful what rubbish one hears from software vendors. Australia is too primitive and backward for his product! Bollocks..truth is that he does not have a product yet and that anyone who buys Lorenzo just at the moment is buying a non-existent future. A year from now it may be different, but right now caveat emptor!

I sure as hell would not consider the product until I could see, touch and feel a fully operational system in at least 3-4 sites and have a good chat with the actual users to be assured all works as desired.

Third we have:

Health Information Technology Chaos: Some Down Under Get It

After noting some Australian hits on my website "Sociotechnologic issues in clinical computing: Common examples of healthcare IT failure", I tracked the hits to an entry on the Australian Health Information Technology blog by "Aus HIT Man", a.k.a. Dr. David More MB, PhD, FACHI.

Dr. More referenced my site and has an excellent summary of the reasons why healthcare IT projects "go bad." It is clear this is an international phenomenon unrelated to the type of healthcare system (e.g., socialized vs. private sector model), and that the root causes are similar.

The reasons cited by Dr. More from his website are (emphases mine on the key phrases):

Continue reading here:

http://hcrenewal.blogspot.com/2007/10/health-information-technology-chaos.html

This is a useful commentary on the points I raised last week and it is great to see some consensus of views on some important issues out there is the blogosphere!

Fourth we have:

Man's kidney removed by robot

Article from Sunday Telegraph

By Clair Weaver

October 14, 2007 12:00am

IT sounds like science fiction - but a NSW man has become the first person in the southern hemisphere to have a kidney removed by a robot.

Aleksa Zurkic agreed to allow his surgery to be performed by the da Vinci robot last week after eight large kidney stones caused irreversible damage.

Continue reading here:

http://www.news.com.au/dailytelegraph/story/0,22049,22579719-5001021,00.html

The thing that impressed me about this report was how long it has taken this technology to make its’ way to Australia given there are now over 200 of these surgical systems in use in the USA, Europe and Japan.

There is little doubt this technology really works and indeed frequently makes the impossible possible surgically.

Lastly we have:

Advertising, data sales subsidize EMR products

By: Joseph Conn / HITS staff writer

Story posted: October 8, 2007 - 5:59 am EDT

When you're out shopping for bargains, free is as good as it gets—except in healthcare information technology, where for many physicians, even free hasn't been good enough. Bucking that conventional wisdom, several developers of electronic medical-record systems have announced plans to offer free EMRs to office-based physicians. The costs for the systems will be subsidized by sales of dynamically linked advertisements on the EMR screens. One vendor says it plans to sell patient data as well.

The ad-driven approach is something of a mash-up of a couple of earlier ideas, subsidized EMRs delivered via the Web using the application service provider, or ASP, delivery model. Back in the dot-com heyday of the late 1990s and early 2000s, there were dozens of vendors of rudimentary clinical IT systems targeting physicians with systems that were either backed directly by pharmaceutical or insurance companies or by developers who sought to make money by chiefly serving the interests of drugmakers or payers. Many were ASP-based or offered physicians free personal digital assistants, such as Palm Pilots or Pocket PCs, loaded with electronic prescribing software systems. The handheld computers were synched periodically with the vendors' remote databases.

But the free systems also gathered data on a physician's prescribing habits, touted the sponsor's favored drugs or otherwise did their master's bidding. Most of those firms and their systems died when they failed to attract a threshold level of physician adoption or their venture capital ran out.

Continue reading here:

http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20071008/FREE/310080003/1029/FREE

It is interesting that this article appears just the day before I wrote the comments on the issue of secret collection of prescription data. Clearly there is more to come in this debate and the place of advertising supported software in the larger scheme of things.

All in all not a bad start to the week!

More next week.

David.