Shared Electronic Health Records – Coming at Last to the UK!

Finally, it seems to be really coming!

The following appeared a few days ago in e-Health Insider.

Summary Care Record launched in Bolton

24 Oct 2007

The first 48,500 summaries of patient records have been uploaded to the NHS Spine and out-of-hours staff in the Bolton pilot area will start using them over the next few weeks, Connecting for Health announced today.

Bolton in North-west England was the first primary care trust to take part in the NHS Care Records Service Early Adopter Programme. Final staff training is underway at the town’s out-of-hours service which deals with, on average, over 5,500 calls per month from patients who require access to a GP outside of their own surgery’s opening hours.

Connecting for Health (CfH) estimates that - with the current upload figure - around 900 calls per month could be from patients with NHS Summary Care Records (SCR).

Announcing the milestone in the NHS Summary Care Records programme, CfH said: “The records, which contain key medical information, including current medications, allergies and previous bad reactions to medication, have been uploaded from eight GP practices.

Please continue reading here:

http://www.ehiprimarycare.com/news/item.cfm?ID=3145

The importance of this achievement is not to be underestimated. That it has taken almost a decade shows – as I have often said – just how hard a national shared EHR is to implement!

And, what a battle it has been, however to get this far. Seeing the reports of the first clinical records being sent to the NHS ‘Spine’ made me think back to 1998 and the excitement I felt when I realised the UK Government was actually serious about all this.

The seminal document for me is the document entitled:

Information for Health

An Information Strategy for the Modern NHS 1998-2005

A national strategy for local implementation

The document was written by Frank Burns who was at that time seconded from a major management role in the NHS to a position as Head of IM&T for the NHS, NHS Executive.

You can see from the table of contents – and the title – that Frank really understood Health IT in a way I would suggest simply no one in the present health bureaucracy does in Australia some 10 years later. Parenthetically, he also knew you need a plan!

The main chapter headings were:

1 An information strategy for the modern NHS places the strategy in the context of broader Government policy, and describes the strategic information objectives and targets

2 Supporting patient care sets out how electronic patient and health records will be developed to support the healthcare process

3 Supporting integrated care through NHS-wide standards and infrastructure identifies the national infrastructure that must be in place to support local action

4 Information for improving health and more effective management addresses what must be done to improve the flow and use of information for health improvement, clinical governance, performance management and national service frameworks

5 Meeting public and patients’ needs addresses how the information needs of patients and the general public will be met

6 Making it all happen outlines what needs to happen at national and local levels

7 Implementation programme sets the scene for detailed implementation guidance by discussing resources and local implementation timescales

The full document can be downloaded from here.

Now, almost 10 years later we are seeing all sorts of things flow..partly at least because of the sponsorship of the effort by a rather determined young prime minister who also got it! The forward to the strategy says it all!

Information for Health - Foreword by the Secretary of State for Health

"The challenge for the NHS is to harness the information revolution and use it to benefit patients."

Rt. Hon. Tony Blair,
All Our Tomorrows Conference, Earls Court, London. 2nd July 1998

Following the General Election of 1997 we took over responsibility for the National Health Service and took on the task of modernising it so that it can provide top quality treatment and care in every part of the country. We are determined to ensure that in future the buildings, plant and equipment in the NHS match the excellence of the staff.

Our White Paper The new NHS: Modern • Dependable set out a demanding ten year programme. It is designed to ensure that the NHS provides a universal, prompt, high quality service which is as close to people’s homes as can be achieved safely with current and developing levels of expertise and equipment. Clearly, information technology has a crucial role to play.

Up to now the use of IT in the NHS has not been a success story. Far from it. Lots of money has been wasted. Some important data has not been collected and used. Other data has been collected but not used. There has been too much emphasis on financial data to support an internal market at the expense of IT systems which could directly benefit patients. As a result, clinicians working in the NHS came to see data collection not as a help but as a hindrance to their work.

The Information Strategy we are launching in this report is not intended merely to put that right. It is a radical programme to provide NHS staff with the most modern tools to improve the treatment and care of patients and to be able to narrow inequalities in health by identifying individuals, groups and neighbourhoods whose healthcare needs particular attention. Our new information strategy will help staff do the jobs they came into the NHS to do and to do them better.

Using rapidly developing information technology clinicians will be able to draw on the expertise of others, sometimes over great distances. Test results will be dispatched in a fraction of the time it has taken up to now. Patient’s details will be transmitted between primary care and hospitals rapidly and accurately.

It will be possible to book hospital admissions over the phone at times which suit patients. Analysis of the data will show up any variations in the cost and effectiveness of treatments. Area studies will reveal sources of ill health or inequalities in healthcare.

All this won’t happen overnight. It will involve a lot of work. As with all our proposals for modernising the NHS, it will also involve detailed discussions with staff about what they want the system to provide and how best to provide it. But it has got to be done. A lot of people will have to change the way they work. The NHS can only face the challenges of the new century if it has the most modern information technology and systems in place. Nothing less will do for a service which looks after the health of the nation.

In the immediate future the most important non-clinical priority for the NHS must be to complete the work necessary to cope with the Year 2000 problem and make sure the NHS continues to function and function safely.

The details of this strategy are complex but the overall position is simple. We must grasp the opportunity which new information technology offers to improve both healthcare and health. All NHS organisations will have to play their part in delivering this key component in our programme to modernise and improve the NHS. Senior clinicians and managers throughout the NHS and senior members of professional bodies will have to show leadership and commitment. There are formidable educational, cultural and management challenges to overcome. But they are more than matched by the scale of the benefits the success of this strategy will bring for patients, professionals and the public.

Frank Dobson
Secretary of State for Health

I must say such an introduction to a national e-Health Strategy could almost be written by a new Federal Health Minster in OZ with just the dates changed!

I would guess there is another five years of hard slog before the work started by this initial UK strategy is getting close to being complete – although it should be noted some areas are (e.g. PACS rollout to all English Hospitals) – and it is only then will we really be able to finally evaluate what has been achieved. There are doubtless a huge number of lessons to be learnt at all levels as the major systems are more fully rolled out.

Being an optimist I think a decade from now we will all look back and wonder what all the fuss, pessimism and clinical resistance to change was all about and we will all be wondering what is the best way to get the benefits the UK will be achieving.

These are long journeys. We really need the leadership to start down a path that suits our health system sooner rather than later. I really like the idea of Australia having “A national strategy for local implementation”

David.

Useful and Interesting Health IT Links from the Last Week – 28/10/2007

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

These include first:

Online tool to help women calculate the risk

Natasha Wallace Health Reporter
October 22, 2007

WOMEN aged over 20 will for the first time be able to assess their risk of developing breast cancer with an online calculator designed to also debunk the myths surrounding the disease.

The interactive tool launched in Sydney today by the federal Health Minister, Tony Abbott, asks questions about age, family history of breast and ovarian cancer, genetic factors, height, weight, alcohol intake, menstrual and reproductive history. .

The calculator, developed by the National Breast Cancer Centre, tells women if they are at "low or average risk", "moderately increased risk" or "potentially high risk" of developing breast cancer. It also suggests what might have contributed to that risk.

Women were generally confused about the causes of breast cancer, and one in three wrongly thought alcohol was not a risk factor but a knock to the breast was, Dr Helen Zorbas, the director of the National Breast Cancer Centre, said yesterday.

Dr Zorbas, a breast physician at Royal Prince Alfred Hospital, said the tool would also be useful for GPs but stressed it was not a guarantee against developing breast cancer even if women actively reduced their risks.

"We had some very high-level epidemiologists working on developing algorithms which actually sit behind the workings of this tool, so there's some very high-level science which supports it," Dr Zorbas said.

Continue reading here:

http://www.smh.com.au/news/national/online-tool-to-help-women-calculate-the-risk/2007/10/21/1192940905034.html

The web site can be found at the following URL:

nbcc.org.au

Given that one in eight women will develop this awful disease in their lifetime – knowing where you stand from a properly researched calculator seems like a useful e-Health initiative to me.

Second we have:

Patents bid quietly laid to rest

Karen Dearne | October 23, 2007

THE federal Health Department has quietly halted a controversial Pharmacy Guild bid to patent key aspects of a national medical record sharing network.

In July, the guild assigned its interest to the commonwealth and, in August, the department withdrew the application ahead of a formal determination by the patents body, IP Australia.

A spokesman for the department said a dispute with the guild over a contract for the Better e-Dispensing and e-Claiming project had been resolved through mediation, "in a manner satisfactory to the parties".

The project was established to develop a draft data standard for communications between pharmacies, consumers and government agencies.

The project, which blew out to $4.5 million from the original $3 million, was funded by the Department of Health. The guild-engaged consultancy CR Group for the development work.

Then, in 2002, the guild and CR Group jointly applied for worldwide patents for a "method and system for sharing personal health data".

The patent bid sparked outrage from doctor, consumer and industry groups also collaborating on local e-health initiatives.

If successful, the guild could have charged royalties on government IT systems such as the proposed MediConnect and its replacement, the now-languishing HealthConnect.

Continue reading here:

http://www.australianit.news.com.au/story/0,24897,22630718-5013040,00.html

This really is good news – but frankly it should not have ever got this far. There exists what is termed ‘prior art’ talking about these sort of approaches going back at least a decade before that.

What these people were thinking is very hard to determine – good this silliness has gone forever.

Third we have:

IBA Health closer to $411m UK takeover

October 26, 2007 - 2:15PM

IBA Health Ltd has cleared one of the final hurdles for its $411 million takeover of ailing UK counterpart iSOFT plc, after receiving approval from a British court.

The million-dollar acquisition, making IBA the world's fourth largest e-health group, is now expected to be completed on October 30 when iSOFT is delisted from the London Stock Exchange.

The High Court of Justice for England and Wales still needs to confirm capital reduction before the takeover, but this was expected to take place, IBA said.

Continue reading here:

http://www.smh.com.au/news/breaking-news/iba-health-closer-to-411m-uk-takeover/2007/10/26/1192941311753.html

Given the sudden jump of a little over 8.5% on Friday 26^th October in Australia one has to assume the market has decided this is really over (at last)!

The following provides a useful perspective on the iSoft saga from an iSoft perspective.

Chairman reveals his iSoft low point

23 Oct 2007

iSoft chairman, John Weston, has revealed he reached the lowest point in his tenure at the healthcare software company when apparent accounting irregularities came to light.

In an interview with the Financial Times, Weston recalls his personal nadir in the iSoft saga. In July 2006 he was just six weeks into the job when newly-appointed auditors, Deloitte, discovered what appeared to be accounting irregularities in previous years’ figures.

He jokes with the FT that he will not be joining companies that have just appointed a new finance director, a new set of auditors and a new chairman of audit all at the same time.

Weston reveals that in early board meetings he chaired there were some tensions between executives and non-executives over Lorenzo, the software being developed for the National Programme for IT. In particular, he recalls: “I had some uneasy feelings about the lack of information available about the cost to complete development”.

He quickly learned that delays in the development of iSoft’s Lorenzo system covering three regions of England’s NHS were at the heart of the problems.

Continue reading here.

http://www.e-health-insider.com/news/3142/chairman_reveals_his_isoft_low_point

Fourth we have:

White House order puts HHS in charge of biosurveillance efforts

By Nancy Ferris

A new White House directive orders the Department of Health and Human Services to establish a national biosurveillance system to detect threats to human health and says the system should rely, where possible, on e-health records.

The directive, Homeland Security Presidential Directive 21, covers many aspects of public health and medical preparedness for a naturally occurring or deliberately induced health emergency on a large scale. The directive states that it “will transform our national approach to protecting the health of the American people against all disasters. “

For the most part, the directive gives HHS authority over the response to health emergencies. It appears to come down on the side of HHS in a number of areas where there has been uncertainty over whether HHS or the Department of Homeland Security was in charge. Both DHS and HHS have biosurveillance programs, for example.

Continue reading here:

http://www.govhealthit.com/online/news/350075-1.html

This is an important move and reminds us that in Australia we have the Australian Sentinel Practices Research Network (ASPREN). This system has about a hundred general practices around the county who report weekly the cases of influenza like illnesses, gastroenteritis, shingles and chickenpox. The reporting is done electronically using a web site at the University of Adelaide. It seems to me that while this is a very small start – Australia could be doing a great deal more in this area!

Lastly we have:

Ask and ye shall receive: study

By: Joseph Conn / HITS staff writer

Story posted: October 19, 2007 - 5:59 am EDT

Part one of a two-part series

Many Americans will do their part when asked to allow their heath records to be used for medical research, but the operative phrase is "when asked."

And, for a plurality of those who do volunteer, that means being asked each and ever time their records are to be used, according to a recent study whose author said that it may be the first of its kind, specifically focusing on patient attitudes about healthcare privacy in the area of clinical research.

A pair of preliminary reports and two PowerPoint presentations about the study conducted by veteran privacy researcher Alan Westin, emeritus professor of public law and government with the Department of Political Science at Columbia University, were presented during two days of meetings earlier this month in Washington before the Committee on Health Research and the Privacy of Health Information: The HIPAA Privacy Rule. The committee operates under the Board on Health Sciences Policy of the Institute of Medicine at the National Academies of Science.

Among its goals, the committee is to "consider the needs for privacy of identifiable personal health information and the value of such privacy to patients and the public," according to explanatory material about it on the IOM Web site. The committee is to make recommendations about retaining or changing the status quo and seeking to balance "the needs and benefits of patient privacy ... against the needs, risks and benefits of identifiable health information for various kinds of health research."

Continue reading here:

http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20071019/FREE/310190004/1029/FREE

Part 2 of the Article is here:

http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20071022/FREE/310220003/1029/FREE

Striking a balance between privacy and health

This is a useful review of public attitudes to the use of health information for research. Reading the two articles and visiting the IOM web site are very worthwhile for those interested in the area.

All in all not a bad start to the week!

More next week.

David.

The ABC’s Ockham’s Razor Does Health!

The last two weeks aspects of health have been the topic in Ockham’s Razor – the quarter hour chat on matters needing some clarity – on Sundays at 8.45am on ABC Radio National.

Both left me gasping and really should be read (or listened to for the next week or two) by all those wanting some background to the more perfidious side of the ‘Health Industry’.

Sunday 14 October 2007

Listen Now - 14102007 | Download Audio - 14102007

The pharmaceutical industry and doctors' prescribing habits

Professor Christopher Nordin, AO, who is Visiting Professor at the University of Adelaide and a consultant physician at the Royal Adelaide Hospital, discusses the influence the pharmaceutical industry has on doctors' prescribing habits. Read Transcript

Professor Nordin did not address a topic we did not know about – but his last paragraph makes a telling point as does much that precedes it.

I quote

“In this talk I have tended to blame the pharmaceutical companies for their undue influence on prescribing. It could be argued, however, that they are only doing their duty to their shareholders by maximising their profits; it is as much the fault of the medical profession, some say, in allowing itself to be manipulated. I asked a lawyer whether it is the briber or the bribed who commits the offence of bribery. 'Both', he replied. Perhaps that sums it up.”

Well worth a read or listen. The week before we had:

Sunday 07 October 2007

Listen Now - 07102007 | Download Audio - 07102007

Overseas trained doctors

Emeritus Professor of General Practice at the University of Western Australia, Max Kamien, looks at the history of overseas trained doctors (OTD) in Australia and the difficulties they faced, and still face to some extent, to be able to practice medicine in this country. Read Transcript

All I can say is that hearing what was presented I am glad I am not, nor never was, a member of the AMA!

A few selected paragraphs will whet the appetite!

“This anti-German feeling was rekindled in the 1930s when several thousand Jewish doctors fled Nazi Europe. Most went to the United Kingdom and the USA where they were able to practice. A small number came to Australia.

They had a hard time obtaining medical registration.

They arrived on German passports and were classified as 'enemy aliens'.

Although most spoke three or more European languages, English was not one of them.

They were broke.

Anti-Semitism was rife and overtly expressed. The then Director-General of Health and Medical Services in Queensland, Sir Raphael Cilento wrote: 'The Britisher is an individualist ... the Jew has 2000 years of servility behind him. If refugee doctors were permitted to go taking jobs along the Queensland coast, they would create the same situation that caused them to be thrown out of Germany and Austria.'

These doctors could seek requalification at one of the four university medical schools.

Melbourne University demanded they repeat the whole medical course. Gaining admission to University of Queensland was close to impossible. Adelaide and Sydney Universities required at OTD to repeat the last three clinical years.”

And

“Were some of the 1939 'letters to the editor' of the Medical Journal of Australia to be published today, the authors would certainly be prosecuted under the Race Relations Act. This example from a Macquarie Street specialist, Dr Maxwell, illustrates my point.

'Are these refugee aliens trained to our standards? Will they stay in unattractive outback centres? These newcomers will deliberately circumvent the restrictions in some surreptitious un-British way. Impudence implies dishonesty. Can their identity and the authenticity of their diplomas be established? I am sure not.

'I know the technique of these alien people. They will use their un-British European standard of ethics to insinuate themselves in our people's confidence. Our profession will not benefit, nor the public. All will suffer.'

That is an example of the sort of letter that was written.

Even doctors sympathetic to the plight of the Jewish refugee doctors were more than a little condescending. Dr Barrett of Adelaide wrote:

'They should be treated with consideration and courtesy. I, myself, placed one MD (Vienna) as a waiter in a seaside resort and have helped others become partially trained nurses.'

The treatment of the pre- and post-war medical practitioners was not the AMA's finest hour. For those two decades the Australian Medical Association became part of that xenophobic dark heart which periodically rises to the surface of our Australian politic. In 1957 this was obvious to the Minister of Health, Bill Sheahan, when he asked the New South Wales Legislative Assembly:

'What is the use of having a brotherhood of man as an ideal if we are not prepared to consider foreign doctors as human beings?'”

It seems little changes as the reader discovers as more modern times are reviewed and the just appalling self seeking behaviour of the AMA is catalogued.

Of course now – it is all sweetness and light – given that most of the regions and much of the city now relies on the OTD medical workforce

I can confidently predict once all the medical students now being trained become graduates the medico-political powers that be will yet again turn on the OTDs. History provides a racing certainty on that bet.

I wish it were not so – but the way Dr Haneef was treated suggests otherwise.

It is hard not to be deeply ashamed about all this, even though not directly, or even indirectly, involved.

David.

At Least Some-one Having a Serious Go at Doing it Right!

The following release appeared a day or so on my e-health alert system:

High-tech hospital a model of move towards electronic health-care delivery

BRAMPTON, Ont. - When the first patients walk through the doors of the new Brampton Civic Hospital in a couple of weeks, they will be entering a centre like no other in Canada - but one that will increasingly become the standard for health-care delivery across the country.

From check-in and lab tests to bedside care and drug dispensing, the $550-million institution that makes up one part of the three-hospital William Osler Health Centre northwest of Toronto is a model of electronic health - or e-health, as it's been dubbed.

Checking in or coming for a test? Electronic kiosks will allow patients to register with a swipe of their health cards, get a map directing them to the correct department and provide the service in eight languages, from English and French to Italian and Hindi. At a nearby "fast-lane" desk, a clerk will check photo identification and issue a hospital bracelet that next year will include a scannable bar code.

Going the way of the dust bin are paper records: all patient information will be logged onto computer, including blood test results and digitized X-rays and other images, which can be called up by authorized clerks, nurses and physicians anywhere in the hospital with the click of a mouse.

The hospital is completely wireless. Computerized monitors at the bedside record a patient's vital signs and allow treatment information to be added by nurses on the spot. And those real-time recordings will be accessible through hand-held devices carried by health providers that permit them to monitor changes, respond to emergency codes or just answer a patient's call for assistance.

"Innovative technology supports our health centre's objectives to increase efficiency, realize savings and focus on patient care," says Judy Middleton, chief information officer for the 479-bed hospital. "It is transforming the future of health-care provision and management."

Even drug dispensing will be computer-controlled. In the basement of the sprawling complex, a monster "drug robot" called PillPick electronically packages prescriptions in sealed baggies, which are then delivered to nursing stations and mobile medication cabinets, called MedCOWS. Each bag is specially ordered for an individual patient for a 24-hour period.

Carol Dueck, a nurse and consultant on the project, says PillPick does not dispense controlled substances such as narcotics, which are kept and packaged elsewhere in the building under strict security measures to ensure they don't go astray.

What PillPick does offer "is 99.9 per cent accuracy in delivery" of prescriptions, says Dueck, noting that the system was chosen because of its high patient safety profile. "It will ensure the right patient is getting the right pill at the right time."

Richard Alvarez, president and CEO of Canada Health Infoway Inc., says Brampton Civic represents the latest addition in a movement towards making e-health a reality across the Canadian medical system.

It's an evolution in Canadian health care that is long overdue, says Alvarez, whose federally funded, non-profit organization is working with provinces and territories to invest in electronic health projects.

"The one big issue is that while technology has really touched all our lives and very many aspects of our lives for the better . . . it's been absolutely absent in health care and it is really time to play catch-up."

Alvarez says Canadians can go to automated teller machines almost anywhere in the world - including "a little village in India" - and access their bank accounts. By contrast, Canadian health-care delivery is stuck in the medical Dark Ages.

Do continue reading here (there is a good deal more):

http://canadianpress.google.com/article/ALeqM5jT-CEMXgRqjCqL2BwKCPzMq_1pAA

This is really great to see. Here we have a brand new hospital being commissioned with technology to make it both safe and efficient right from the beginning. Clearly the process to get all this up and running – given the range and scope of what is being done will be a challenge! The good thing will be that the need for change management will be minimised as the staff will start – from day one - with new systems and new ways of working.

Wouldn’t it be good to see the struggling Royal North Shore Hospital (RNSH) – in Sydney – be offered a clean start in its new facilities (which are being planned right now) of this sort. I am sure that would be one sign that the hospital was not being discriminated against because of the apparent wealth of its potential patient base.

As someone who spent over a decade of my working life at RNSH I am deeply saddened by all that has gone on there in recent times. I know for certain because I worked with many of them and even partially trained some of them) there are many dedicated and caring clinicians working there – and that they have been badly let down by a really deeply flawed and profoundly neglected system.

A pox on both Reba’s and Tony’s houses for letting it get to this!

David.

Well, Now What is Needed in Australian e-Health is Confirmed - Let's Roll!

I must say it is always gratifying when something useful falls off the back of a truck!

This arrived this morning and has made my day from one of my favourite deep throats (no names – no pack drill)!

----- Begin Message -----

A copy of the AHIC eHealth Future Directions final briefing paper arrived last week.

The recommendations of the report, which went to the October 4 AHMAC meeting (that is the Australian Health Minister’s Advisory Council (AHMAC)– the peak e-Health body in the country) , are:

1. To develop a comprehensive national eHealth strategy in consultation with the Jurisdictions, industry, community and health services

2. That AHMAC recognises that eHealth is the cost of doing business in the 21st century, hence requiring continued investment

3. That AHMAC recognise that the Jurisdictions already have many of the necessary eHealth components already, and that what is needed is a system of knowledge exchange

4. That a ‘time limited’ implementation function / body be established and funded by AHMAC to integrate eHealth nationally

5. That the core set of components for a Shared Electronic Health Record be operating across Australia by 2012

6. That an implementation plan and resources schedule be developed to deliver the AHMAC eHealth strategy

----- End Message -----

The pain in all this is:

1. Why is the AHIC eHealth Future Directions briefing paper not public already?

2. With a Federal Election called what is the chance of any action?

3. Neither party has an e-health policy election announcement so far – maybe the HISA survey results – when published – can change that!

These recommendations, if implemented properly, will allow me to stop typing about the lack of an e-Health Strategy, Business Case and Implementation Plan, and get on with the blog being a tool to share information on the bleeding edge of Health IT!

I hope this is all true! It is not before time!

David.

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.