E-Health Funding Requests in Budget Submissions – Are they Reasonable?

Last week the Australian reported on the E-Health wish list of some in the health sector

E-health funding urgent

Karen Dearne | January 22, 2008

FRUSTRATED health IT professionals hope the Rudd Government's first budget will kickstart several low-cost but urgent e-health programs.

The Australian General Practice Network (AGPN) wants $3.6 million for an immediate national rollout of the Argus secure clinical messaging system to link doctors, hospitals, laboratories and pharmacies.

"Work is under way to determine the requirements for an integrated e-health network, but it's still a long way off," network chief executive Kate Carnell said. "The use of secure electronic messaging provides an immediate solution. Argus is a licensed open-source product that is freely available, with intellectual property owned by the Government."

….

The Health Informatics Society of Australia (HISA) is seeking less than $1 million for an industry-led program that would fix IT inter-operability problems that hamper communications between existing systems.

…..

The Australian Healthcare and Hospitals Association is seeking an urgent deployment of a $200 million electronic medication management system in all public hospitals.

…..

Read the full article here:

http://www.australianit.news.com.au/story/0,24897,23087176-15306,00.html

Before reviewing the other two claims I need to point out that HISA not only suggest some modest spending on Integrating the Healthcare Enterprise (IHE) but also and crucially and first off recommended a Nation E-Health Plan be developed to put all these initiatives in context.

The AGPN has an e-Health request of $28.6 Million for the development of a Universal Secure Electronic Messaging Platform.

The details are as follows

“AGPN recommends that funding is allocated in the 2008-09 Federal Budget to:

1. Establish a small grants program to enable primary care professionals to purchase computers and clinical management software to increase connectivity and better integration within the sector; ($25m) = $1500 for 15,000 health professionals

2. Facilitate the national rollout of secure electronic messaging by providing the Argus open source product to all primary care professionals. The Divisions of General Practice network is well placed to support the national rollout by providing support to connect and integrate local primary health care professionals with the hospital sector at the local level. $3.6m ($30k per division)

3. Extend the existing commitment to rollout individual Personal Key Identifier (PKI) to GP’s, to include the rollout of PKI’s to specialists and allied health professionals.”

Bizarrely there is $3.6 Million for secure messaging and $25.0 Million for computer grants for primary care professionals who – as best I can tell – already have them.

The key point here is that the AGPN is recommending the Federal Government pick a winner with no review or evaluation of the already existing competitors to Argus. (HealthLink, Medical-Objects and e-Clinic to mention just 3). I very strongly agree with the need for secure messaging as the AGPN describes but not this sort of bull at a gate approach. Let’s have the Government do a proper plan for secure clinical messaging in Australia and then work out how it can be best delivered!

The request for $25 Million for computers is to me just a joke and reduces the credibility of the AGPN case about as dramatically as their approach the secure clinical message acquisition.

The details of the Australian Healthcare and Hospitals Association’s Electronic Medication Management proposal are as follows:

“Electronic medication management

The introduction of electronic medication management throughout the health system would reduce some of the most common mistakes in health care and would save lives, as well as dollars (estimated at $4-7,000 per bed per year).

Medication error has been estimated to result in 80,000 hospital admissions in Australia and costs around $350 million per year.

Medication errors often occur in handover situations (when people move from one form of care to another) for example, from hospital to an aged care institution or GP care in the community. A significant benefit of electronic medication records is enhancing continuity of care, enabling care providers with on-line records in real-time advising of any changes in their patients' medications, greatly reducing the risk of errors such as double-dosing or missing important prescriptions.

Major areas of savings are:

· reduced lost bed days due to decrease in adverse events (shorter stays > shorter waiting lists);

· reduced use of expensive drugs;

· increased use of generic drugs;

· increased standardization of treatment regimens/protocols (best practice);

· efficient nursing and other staff time utilisation;

· streamlined pharmacy process and improved supply chain management; and

· reduced medical indemnity costs.

The technology is now available and has been demonstrated to work in Australian public hospitals. Northern Territory is already partway through a Territory-wide rollout of an Australian made product that is also being used at St Vincent’s Hospital in Sydney

NSW and Victoria are already committed to State wide clinical projects but electronic medication management is still a long way off.

As the technology is proven in this case, the much greater challenge is to manage the impact of the change on the existing processes and the people involved. For this reason we would suggest an incremental approach commencing in one or two hospitals in perhaps two states in order to give people and systems time to adapt and minimise the risks. Qld, ACT and WA may be appropriate jurisdictions in which to initiate jointly funded projects in key hospitals.

The AHHA recommends funding to implement electronic medication management systems in hospitals.

Indicative Cost: (for implementation in every public hospital excluding NSW and VIC): $200m over 4 years ($50 million per annum ongoing) plus funding for change management. NB This cost includes hardware which can also be used for many other purposes (such as clinical guideline tools and pathology results (see below)).”

This really is a very sad submission. Yes medication management is a very good thing and yes it should be done – but as a stand-alone project lacking integration to and support from surrounding systems it can never reach anything near its full potential.

It is also not clear why there is discrimination against NSW and VIC.

Yet again trying to run before you can walk and having no roadmap to show where you should be walking will only lead to walking into a river or off a cliff. So sad!

On the other hand this suggestion is a really good one I believe.

“National clinical practice guidelines

The system-wide adoption of known best practice within health care would also significantly improve quality and reduce preventable errors. Clinical Practice Guidelines provide clinicians with the best available evidence on treatment for specific conditions.

Incorporating these guidelines into standard hospital and health service practices and making them available electronically will ensure that consistently high quality care is provided to all patients.

The AHHA recommends funding to establish a taskforce of clinicians, experts and consumers to assess existing electronic clinical practice guideline systems, including the UK’s Map of Medicine, for adaptation to the Australian healthcare environment with the view of implementing a system of localizable electronic clinical practice guidelines, in conjunction with states/territories, throughout the public health system.

Indicative cost:

1. $7m per annum [minimum five year term] for fully serviced Australianised web service; includes initial core service training (train the trainers model);

2. Additional costs to include local hosting and implementation requiring web-access and related hardware (clinical guidelines tools should not require extra hardware or network facilities if hardware has been installed for other clinical functions such as electronic medication management systems).

In summary, the Map of Medicine^®:

• is an evidence-based benchmark for clinical processes that supports the configuration of services, local commissioning and clinical practice across all care settings;
• addresses clinical governance by providing a national benchmark for clinical guidelines while allowing the development and sharing of local guidelines and care pathways;
• provides content which is a distillation of recognised international sources of clinical evidence, designed by clinicians;
• can be integrated with electronic medication management systems and other local healthcare IT applications; and
• includes software tools to facilitate localization of the content at a national and local level promoting usability and adoption.”

The issue of localising the content however is not a trivial one, and needs to be carefully thought through. It can be done and would be helped greatly if Australia had a National Institute for Health and Clinical Excellence (NICE) like entity as exists in the UK.

The great thing about this proposal is that it only needs basic IT infrastructure which is widely available and is able to be implemented essentially stand alone. Would be great to see it properly planned and done!

David.

Useful and Interesting Health IT Links from the Last Week – 27/01/2008

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

These include first:

Tech's all-time top 25 flops

These pivotal moments are the history you don't want to repeat

Neil McAllister (InfoWorld) 22/01/2008 11:20:32

Imagine how different the tech industry might have been had Gary Kildall accepted IBM's offer, back in 1980, to license his computer operating system for a top-secret project. CP/M would have been the OS that shipped with the original IBM PC, and the world might never have heard the name of Kildall's competitor, who eventually accepted the contract: a Mr. Bill Gates.

For all the amazing advances that the computing industry has brought us over the years, some of its most pivotal moments are memorable for all the wrong reasons. Not every idea can be a winner, and not even Microsoft can avoid every misstep. But as they say, those who forget history are doomed to repeat it -- and then again, others just keep screwing up. In the interest of schadenfreude, then, here is a look back at the last 20 years' worth of blunders, fumbles, also-rans, and downright disasters that you may have forgotten about -- or wish you could.

25. IBM PS/2. The original IBM PC hit the market like lightning in 1981. Unlike earlier IBM computers, it was built with off-the-shelf parts instead of proprietary components, making it the most affordable business machine yet. But by the late 1980s, IBM found itself edged out of the market by Compaq and the other PC clone makers. Its solution? Try again with proprietary components, of course!

The Personal System/2 series, introduced in 1987, was meant to be "software compatible" with the PC, but its Micro Channel Architecture made it incompatible with existing hardware. The clones had no such problem. Like the disastrous PCjr before it and the PS/1 series to follow, the PS/2 convinced customers that lightning would never strike twice in IBM's PC division.

24. Virtual reality. In 1982, the movie "Tron" imagined a man traveling the eerie internal landscapes of a computer. Fifteen years later, the technology arrived to make it happen -- sort of.

Building a spatial interface for the Internet was all the rage in the late 1990s, owing in part to VRML (Virtual Reality Markup Language). The problem was, it didn't make much sense. The Web put the world of information at your fingertips; leave it to software engineers to find a way to send it back down the street, across a bridge, and up two flights of stairs.

The concept lives on today in Second Life, which seems to think the problem is not enough advertising. But the truth is that mainstream users have never warmed to VR. Wake us up when we can ride real lightcycles to work and meet our clients on the Game Grid.

Continue reading the quite long article below for number 23-1 here:

http://www.computerworld.com.au/index.php?id=1752273155&eid=-6787

Sorry, I really could not resist this. All those amazing and expensive missteps in an industry that claims to be smart. Just shows how hard prediction is. Who or what do you reckon got number 1?. Well all I can say is that Windows Vista got number 2!

Second we have:

Royal Navy loses laptop with data on 600,000 people

A laptop containing personal data on about 600,000 people has been stolen from the Royal Navy, the UK Ministry of Defense said Friday.

James Niccolai (IDG News Service) 21/01/2008 12:26:36

A laptop containing personal information on about 600,000 people was stolen from an officer in the Royal Navy, the U.K.'s Ministry of Defense said on Friday.

The laptop contained information about new and potential recruits to the Royal Marines, the Royal Navy and the Royal Air Force, and was stolen in Birmingham last week, the ministry said.

The stolen data includes passport details, national insurance numbers, family details and doctors' addresses for people who submitted an application to the forces, the ministry said. The laptop also contained bank details for at least 3,500 people.

"The Ministry of Defence is treating the loss of this data with the utmost seriousness," it said in a statement.

It is writing to people whose bank details were on the laptop and has notified the Association for Payment Clearing Services to watch for unauthorized access, it said.

The ministry is investigating the theft with the West Midlands Police. The laptop was stolen Jan. 10, but the ministry said it didn't disclose the incident immediately for fear of compromising the investigation. It decided to go public with the loss after media reports surfaced about it on Friday, it said.

Continue reading here:

http://www.computerworld.com.au/index.php?id=21257380&eid=-6787

This is quite a bad information leak. What I struggle to understand is how organisations which have access to information on this scale do not have basic processes in place to prevent occurrences like this. Even basic approaches like ensuring encryption of all data that leaves an organisation’s physical control can make a huge difference. Anyone who allows any staff to wander off with unencrypted information of this depth and sensitivity on a personal lap top should just lose their job – all the way up the chain to the CEO or Minister. The time to make such breaches a criminal offense is fast approaching.

Third we have:

NSW dumps Tcard for good

Correspondents in Sydney | January 23, 2008

The NSW government has terminated its contract for the integrated public transport ticketing system, the Tcard, after the company behind the project repeatedly failed to meet targets.

Transport Minister John Watkins said the contract with Integrated Ticketing Solutions (ITSL) was cancelled at 1pm (AEDT) today.

The government will now pursue a damages claim to recover as much as possible of the $95 million taxpayers have spent on the Tcard.

The termination of the contact comes after the government in November last year issued ITSL with a notice of intention to terminate the Tcard contact on December 3.

The company responded with a proposal outlining a timetable that would have had the Tcard fully operational in 2009.

But, Mr Watkins said a review of the plan by the Public Transport Ticketing Corporation (PTTC) found it was unsatisfactory.

Continue reading here:

http://www.australianit.news.com.au/story/0,24897,23096346-16123,00.html

Further information on the cancellation is available here:

$95m down the drain, and transport card is years off

Alexandra Smith

January 24, 2008

SYDNEY'S long-suffering commuters will have to wait years, perhaps even a decade, for an integrated cashless ticketing system for buses, trains and ferries after the Iemma Government finally terminated the contract for the failed Tcard project yesterday.

In a bid to save face, the Transport Minister, John Watkins, immediately promised the Government would recoup the $95 million NSW taxpayers have forked out on the delayed project, starting yesterday with the seizure of a $10 million performance bond.

But Mr Watkins, who has repeatedly expressed frustration with the project, could not say when commuters would finally have the sort of smart transport card that other cities around the world have implemented.

Instead, he laid all blame for the chronically delayed project on the Perth contractor, ERG, which has implemented smart cards in cities including Hong Kong, Melbourne, Rome, San Francisco and Singapore.

Mr Watkins said the company's history was one of "missed deadlines and missed opportunities". He admitted Sydney's system was a complex job for ERG, but said it had gone into the contract "with their eyes open".

"Ongoing delays, failures and the company's appalling project management have left the Government no choice," he said.

Continue reading here:

http://www.smh.com.au/news/national/95m-down-the-drain-and-transport-card-is-years-off/2008/01/23/1201024992973.html

There are sure to be lessons here for all large public sector technology projects which I am sure will emerge over the next year or so.

This total project has run for over a decade – the original plan being to have the system in place for the 2000 Sydney Olympics – and, given the company has actually implemented similar system in other cities around the world one really wonders at the competence of the NSW Government in managing this. At first look it seems to me the contract (which was signed in February 2003) should have been cancelled by early in 2006 – allowing an extra year for success – rather than letting it drag on for another two years.

I suspect this is another occasion where NSW Government’s project management and not the company’s project management is at fault – despite the rather hollow claims of Minister Watkins.

It is a basic axiom that any technology project that runs for more than a few years has a very high chance of failure unless there are the most exceptional circumstances or complexity. An integrated ticketing system for Sydney hardly falls into that category given the number of cities around the world who have succeeded.

The following analysis seems to support my view

Pointing fingers towards the wrong direction

January 24, 2008

ANALYSIS

With the Iemma Government, there is always someone else to blame. In the case of the disastrous Tcard project, the one to blame is either the company ERG or the former transport minister, Carl Scully, for signing the contract.

The Government could have ended this contract a long time ago. But it went to the election still promising to deliver an integrated ticketing system for Sydney.

The Tcard is emblematic: if something so apparently simple cannot be delivered, what hope can we have in the Government's promises to deliver much more complex proposals, such as a metro rail system or the M4 East project?

Tcard is just another example of how other cities can achieve things that Sydney can't. Brisbane has one, Melbourne has one, Perth has one.

Continue reading here:

http://www.smh.com.au/news/national/pointing-fingers-towards-the-wrong-direction/2008/01/23/1201024992999.html

Fourthly we have:

The Internet is down -- now what?

If the Internet goes down, will you be ready?

Gary Anthes 22/01/2008 10:30:50

It's likely that the Internet will soon experience a catastrophic failure, a multi-­day outage that will cost the U.S. economy billions of dollars."

Or maybe it isn't likely.

In any case, companies are not prepared for such a possibility.

But then again, some are.

These mixed messages come from credible sources. The confusion stems in part from the fact that the Internet has never seen anything much worse than local outages and brief slowdowns. But could it? And if it did, how ready would your company be?

Indeed, the threat is "urgent and real," says The Business Roundtable, an association of CEOs of large U.S. companies. The Washington-based public policy advocacy group says there is a 10% to 20% chance of a "breakdown of the critical information infrastructure" in the next 10 years, brought on by "malicious code, coding error, natural disasters, [or] attacks by terrorists and other adversaries."

An Internet meltdown would result in reduced productivity and profits, falling stock prices, erosion of consumer spending and potentially a liquidity crisis, according to a recent Business Roundtable report, "Growing Business Dependence on the Internet -- New Risks Require CEO Action." The organization based its conclusions on earlier risk analyses done by the World Economic Forum in Geneva.

Continue reading here:

http://www.computerworld.com.au/index.php?id=1631655655&eid=-44

This is really discussing the unthinkable, but in the health sector it is vital that the basic manual systems be exercised often enough to remain a viable, if not as efficient, alternative.

The thinking of the various organisations as to how they would cope is well worth a browse.

Fifthly we have:

International standards group accepts its first member organizations

By Bernie Monegain, Editor 01/18/08

The interim board of IHE International has accepted 93 members from the first group of applications submitted.

The new member organizations include healthcare professional societies, healthcare IT vendors, provider organizations, universities, standards organizations, government agencies and other stakeholder groups interested in promoting the adoption of interoperable healthcare IT systems and electronic patient records.

Integrating the Healthcare Enterprise (IHE), now in its ninth year, is dedicated to improving patient care by promoting the adoption of standards-based and interoperable solutions for healthcare information systems.

To qualify for membership, organizations have to comply with IHE International's governance documents, which ensure transparency, equitable representation and the disclosure and fair use of intellectual property.

Representatives of the member organizations will be eligible to participate in the first election of IHE International board members in March. The current interim board comprises representatives of IHE's sponsoring organizations and each of its clinical/operational domains.

Continue reading here:

http://www.healthcareitnews.com/story.cms?id=8493

This is important news. We see from it that it is possible to make a difference to the quality and utility of Health IT around the world based on efforts of concerned individuals and organisations that aim to interoperate to make obtain overall improvement.

More power to their arm in these vital efforts – made that much more important by the strategic vacuum presently existing in Australia.

Lastly we have:

http://www.e-health-insider.com/news/3401/isoft_reaches_halfway_point_on_irish_pas_deal

iSoft reaches halfway point on Irish PAS deal

23 Jan 2008

iSoft has reached the halfway point on a £41.5m project to deliver integrated patient management system to hospitals across Ireland. iSoft is providing its iPM PAS system under the contract.

The company announced that it has delivered systems which are now live in 26 hospitals in Ireland, a mixture of acute community and mental health. In total 52 Irish hospitals are covered by the deal.

The implementation programme is being managed by Ireland’s Health Service Executive, which is responsible for providing Health and Personal Social Services for everyone living in Ireland. iSoft say that the remaining hospitals will go-live over the next two years in accordance with HSE timescales. Ultimately the system will be rolled-out to all hospitals in Ireland.

In a statement, iSoft’s parent company, IBA Health, said it had also resolved outstanding contractual issues with HSE: “In addition to these successful implementations, a number of outstanding contractual matters with the HSE have now been resolved, including settlement of outstanding payments due to iSoft.”

Continue reading here:

This is good to see – IBA Health / iSoft making some real progress in another market. It augurs well for the eventual success of this largest Australian –owned Health IT provider. ( Disclosure: I am sure readers all recall I have a few – presently looking rather sick – shares in IBA).

More in next week.

David.

Infection Control – An International Problem!

I thought it was interesting that the need for improved infection control in hospitals is getting a serious run both here and in the US.

From Australia we had:

Dirty name tags add to risk of superbug deaths

Kate Benson Medical Reporter

January 7, 2008

FIRST it was ties, then it was stethoscopes and keyboards. Now, a study has found that deadly superbug bacteria are crawling all over identity badges and lanyards worn by doctors and nurses.

The study, published in The Medical Journal of Australia, found that the superbug methicillin-resistant Staphylococcus aureus, or MRSA, which kills more than 700 patients a year, lives on about 10 per cent of name tags and lanyards, sparking concerns hygiene procedures in hospitals are inadequate.

An analysis of 71 clinical and infection-control staff at Monash Medical Centre in Melbourne showed that 27 lanyards and 18 badges carried pathogenic bacteria, including seven with MRSA and 29 with methicillin-sensitive Staphylococcus aureus, a more common but equally dangerous bug. Lanyards carried about 10 times the bacterial load of badges.

The author of the study, Rhonda Stuart, an infectious diseases physician, said yesterday the results had come as no surprise.

"Lanyards and identity badges are worn by both male and female clinical staff for long periods of time without cleaning … and their position at waist level and their pendulous nature increase the risk that they will become contaminated," Dr Stuart said.

"We believe hand hygiene is the most important defence against these bugs so we did this study to remind people to not only disinfect their badges regularly, and replace the lanyards, but wash their hands after touching them."

She said bacteria could survive on fabrics and plastic surfaces for up to 90 days and that doctors' badges were four times more likely to carry bugs than those belonging to nurses, consistent with previous studies indicating doctors were less likely than nurses to continually wash their hands.

Continue reading here:

http://www.smh.com.au/news/national/dirty-name-tags-add-to-risk-of-superbug-deaths/2008/01/06/1199554485373.html

And more relevantly to this blog from the US we had:

Dangerous Devices

By Steven J. Davidson, M.D., and Gregg Malkary

Mobile computers can bring both information and infection to the point of care.

Mobile computing devices represent a patient safety conundrum. While they bring decision support, bar-code and RFID-assisted medication administration, and the latest patient data to the point of care, they also can serve as vehicles for germs and increase the potential for hospital-acquired infections.

A recent market research study of the current state of physician computer adoption in the United States found that 65 percent of physicians interviewed believe mobile computing devices pose infection control risks at the point of care due to poor physician hand-washing habits, multi-tasking at the bedside (simultaneously using a device while examining patients’ ears and eyes or listening to their heart and lungs) and ignorance of the potential risk. This represents a 160 percent increase from a January 2005 study in which only 25 percent of physicians interviewed believed mobile devices posed any form of risk.

Spotlight on Nosocomial Infections

Hospitals are under increasing pressure to prevent hospital-acquired infections, and anything that could be a carrier—a physician’s necktie, white coat and stethoscope, or a device used at the point of care—is under scrutiny. Stethoscopes often are contaminated with Staphylococcus aureus and other dangerous bacteria because caregivers seldom take the time to clean them in between seeing patients. The Committee to Reduce Infection Deaths, a not-for-profit education campaign that suggests lower-cost interventions, recommends that patients ask their physicians to wipe the stethoscope’s diaphragm with alcohol before use.

Similarly, a new dress code banning neckties, long sleeves and jewelry for physicians takes effect in British hospitals this month. The dress code, which also bans the traditional white coat, is being implemented to stop the spread of deadly hospital-borne infections, including Methicillin-resistant Staphylococcus aureus (MRSA).

Continue reading here

http://www.hhnmostwired.com/hhnmostwired_app/jsp/articledisplay.jsp?dcrpath=HHNMOSTWIRED/Article/data/Fall2007/080109MW_Online_Davidson&domain=HHNMOSTWIRED

The lessons from all this seem to be very clear.

Those germs are clever and will travel on whatever they can.

The obligation clinicians have is to alert to the cleverness and use the basics of handwashing and alcohol hand rinses religiously to make it tough for the bugs!

Device designers also need to make sure their stuff is easily and properly cleanable and that it is easy to do!

More can also be learnt on the topic here:

Basic Microbiologic and Infection Control Information to Reduce the Potential Transmission of Pathogens to Patients via Computer Hardware

What a can of worms and germs (figuratively)!

David.

Too Much Information – A Risk in More Ways than One!

A recent study from the Annals of Internal Medicine is fascinating

The study, titled "Systematic Review: The Evidence That Publishing Patient Care Performance Data Improves Quality of Care," found that there is scant evidence to determine if public reporting of hospital data impacts patients' decisions.

Here is the abstract:

Systematic Review: The Evidence That Publishing Patient Care Performance Data Improves Quality of Care

Constance H. Fung, MD, MSHS; Yee-Wei Lim, MD, PhD; Soeren Mattke, MD, DSc; Cheryl Damberg, PhD; and Paul G. Shekelle, MD, PhD

15 January 2008 | Volume 148 Issue 2 | Pages 111-123

Background: Previous reviews have shown inconsistent effects of publicly reported performance data on quality of care, but many new studies have become available in the 7 years since the last systematic review.

Purpose: To synthesize the evidence for using publicly reported performance data to improve quality.

Data Sources: Web of Science, MEDLINE, EconLit, and Wilson Business Periodicals (1999–2006) and independent review of articles (1986–1999) identified in a previous systematic review. Only sources published in English were included.

Study Selection: Peer-reviewed articles assessing the effects of public release of performance data on selection of providers, quality improvement activity, clinical outcomes (effectiveness, patient safety, and patient-centeredness), and unintended consequences.

Data Extraction: Data on study participants, reporting system or level, study design, selection of providers, quality improvement activity, outcomes, and unintended consequences were extracted.

Data Synthesis: Forty-five articles published since 1986 (27 of which were published since 1999) evaluated the impact of public reporting on quality. Many focus on a select few reporting systems. Synthesis of data from 8 health plan–level studies suggests modest association between public reporting and plan selection. Synthesis of 11 studies, all hospital-level, suggests stimulation of quality improvement activity. Review of 9 hospital-level and 7 individual provider–level studies shows inconsistent association between public reporting and selection of hospitals and individual providers. Synthesis of 11 studies, primarily hospital-level, indicates inconsistent association between public reporting and improved effectiveness. Evidence on the impact of public reporting on patient safety and patient-centeredness is scant.

Limitations: Heterogeneity made comparisons across studies challenging. Only peer-reviewed, English-language articles were included.

Conclusion: Evidence is scant, particularly about individual providers and practices. Rigorous evaluation of many major public reporting systems is lacking. Evidence suggests that publicly releasing performance data stimulates quality improvement activity at the hospital level. The effect of public reporting on effectiveness, safety, and patient-centeredness remains uncertain.

Further access options are available at the following URL

http://www.annals.org/cgi/content/abstract/148/2/111

This is a really important negative finding – and suggests to me that there are almost certainly better ways to improve the quality and safety of our hospitals and doctors than publishing vast amounts of largely incomprehensible information for patients to wonder at on the World Wide Web.

It would be my take that these authors have done us all a favour in hopefully directing efforts to improve quality and safety to activities that that can be shown to work rather than waste money doing things that don’t.

David.

The Good Guys At the California HealthCare Foundation Do it Again!

Last week we had three useful and interesting document release by the California HealthCare Foundation (CHCF)

They were announced in a single press release.

Health Information Technology: California Leads the Nation But Still Has Far To Go

CHCF releases three reports on HIT adoption and use in California; national HIT perspectives; and open source systems

January 17, 2008

Despite efforts to increase the use of information technology in health care by the federal and state governments, the potential to improve care through electronically stored and shared clinical information remains largely a promise, with nearly three-quarters of medical groups in California still relying on paper records, according to a new study published by the California HealthCare Foundation.

The State of Health Information Technology in California -- the first comprehensive look at HIT adoption in the state -- reveals that large majorities of physician practices, hospitals, clinics, and long-term care facilities, as well as patients, are still far from realizing the benefits of HIT. Reasons for the slow pace of adoption range from implementation costs to concerns about security and confidentiality.

"HIT can play a significant role in preventing medical errors, giving patients the appropriate level of care, and making health care more efficient," said Jonah Frohlich, CHCF senior program officer. "HIT is not a cure-all for what ails our health care system, but where it is used, it has helped support better care."

The Larger the Medical Group, the More Likely It Uses HIT

California leads the nation in physicians using electronic health records (EHRs), with 37% of physicians reporting use of EHRs, compared with 28% nationally, according to the snapshot. In California, the larger the medical practice, the more likely it uses EHRs. Some 79% of Kaiser Permanente physicians reported using EHRs, followed by 57% of patients in large practices of ten or more physicians. But EHR usage dropped considerably among small/medium practices (25%) and solo practitioners (13%).

This trend surfaces in another new CHCF report, Gauging the Progress of the National Health Information Technology Initiative: Perspectives from the Field. Author Bruce Merlin Fried writes that, despite President Bush's 2004 plan to ensure that most Americans have interoperable electronic health records by 2014, "the vast majority of practicing physicians, those who practice alone or in small groups, are no closer to using HIT now than they were three years ago."

Yet even when physicians have EHRs, they often fail to take advantage of the full capability these powerful systems can offer. The snapshot reveals that only 12% of California physicians use alerts to warn them about potential adverse drug events, receive electronic warnings about abnormal lab results, and send reminder notices to patients about regular or preventive follow-up care.

Manual Medication Orders Persist

Most California physicians still prescribe medications using handwritten orders. This puts patients at greater risk of receiving prescriptions that they are allergic to, that adversely interact with medication they are already taking, or that are simply incorrect. While electronic prescribing systems can prevent many such adverse events, only about one-quarter of California physicians routinely use electronic prescribing.

Few Hospitals Embrace HIT

Only 13% of hospitals have fully implemented EHRs and only 11% are fully using bar-coding technology for the administration of drugs. "Institutions that lag behind on HIT are likely to continue seeing avoidable treatment errors," said Frohlich.

Community Clinics Need to Use Disease Registries

Disease registries are powerful tools for ensuring that patients most at risk are getting appropriate treatment. While many California community clinics have disease registries in place to track their patients with diabetes, few clinics use registries for other conditions, such as asthma, cancer screening of women, or immunizations. Even when clinics have disease registries in place, however, their medical directors report relatively low use of the registries by individual providers.

Consumer Concerns about HIT

According to the snapshot, nearly half of adults reported that they had used the Internet to obtain medical or health information within the past year. And while more than half of adults said they were very or somewhat interested in the ability to schedule medical appointments online, 29% said security and confidentiality issues made them "not at all interested" in receiving email from their doctor's office and 39% said they were "not at all interested" in accessing personal health records online for the same reasons.

Provider Concerns about HIT

The major barrier for EHR adoption by medical groups was cost (59%), followed by the difficulty and expense of implementation (42%), uncertainty about how to select the right product (31%), and resistance to changes in practice style (30%). Among long term care facilities, the lack of integration with other systems was the most commonly cited barrier to HIT adoption.

Open Source EHRs: Opportunities and Challenges

A third new CHCF report, Open Source EHR Systems for Ambulatory Care: A Market Assessment, looks at free and open source software (FOSS) and whether FOSS systems are suitable for widespread adoption and effective use as EHRs in physician offices. The report provides detailed assessments of a number of FOSS EHR systems and describes both the advantages and limitations to the software. The FOSS approach offers advantages such as lower acquisition and maintenance costs, greater opportunity for customization and enhancement, decreased barriers to interoperability, and less vulnerability to vendor failure or product termination. Limitations cited include a general lack of decision-support capabilities, greater reliance on free text relative to coded clinical data, and less support for electronic prescribing and lab-test ordering, although this varies by specific system.

Role of the Federal Government

Many of the two-dozen HIT thought leaders (provider, payer, physician, health information exchange, consumer, vendor, philanthropy, and association representatives) interviewed for the perspectives report called on both the U.S. Congress and the federal government to accelerate HIT adoption through the creation of incentives and regulations, and the leveraging of government purchasing power.

"These three reports," said Frohlich, "underscore the significant gaps in HIT use across California and the nation. They point to the need for a strategy to help providers and institutions adopt these technologies to improve health care delivery and efficiency and to reduce medical errors throughout our health care system."

The three CHCF reports and an HIT glossary of terms are available through the links below.

Contact Information

Marcy Kates
California HealthCare Foundation
510.587.3162

Related CHCF Pages

Snapshot: The State of Health Information Technology in California, 2008

Gauging the Progress of the National Health Information Technology Initiative: Perspectives from the Field

Open-Source EHR Systems for Ambulatory Care: A Market Assessment

----- End release

These are really each important reports although I would rate their individual importance, for me, in the reverse order to the CHCF announcement.

Visiting the sites and reading the reports strongly recommended even if you are only slightly interested in what is happening in the US!

David.

How the Lack of a Plan Will Hurt E-Health in Australia.

Last week a useful summary of the state of E-Health in Australia appeared in the Australian – reporting on the submission prepared by the Health Informatics Society of Australia for our new Treasurer’s May 2008 budget round.

Australia's e-health in dire straits

Karen Dearne | January 18, 2008

THE Rudd Government should bypass the National E-Health Transition Authority and fund a key health stakeholder group to develop an "agreed vision and plan for e-health", the Health Informatics Society of Australia says.

"Despite recognition in most other advanced countries of the need for investment in and the use of IT in the health sector, Australia sits without a plan for how it will deliver its e-health future," HISA said in a pre-Budget submission prepared for the federal Treasurer, Wayne Swan.

"There is not even a clearly articulated and shared vision of what we expect our investments in e-health to deliver."

In the past two years, NEHTA has suffered from a lack of direction and has been criticised for its inability to engage with doctors and health IT providers, and its failure to deliver on work plans, HISA said.

"There is no doubt that the standards and infrastructure elements which NEHTA has been charged with delivering are important, but it's more important to ensure those elements will fit the requirements of patients, providers and the Government, and that they can be delivered by industry," it said.

The new group should be independent of NEHTA and the Australian Health Information Council, and focus on the "enormously complex task" of building a fully interoperable health system across state borders, which supports both private and public sectors, and is accessible by a diverse range of medical providers.

Continue reading here:

http://www.australianit.news.com.au/story/0,24897,23071592-16123,00.html

Last week I was also sent a copy of the following e-mail which was sent to ‘Undisclosed Recipients’ on January 2, 2008 by the Commonwealth Department of Health and Ageing (DoHA)

------

Hello

Thank you for your Registration of Interest regarding the development of a Health Information Exchange.

The concept of a Health Information Exchange is to explore the potential of, and benefits from, the sharing of health information. It would see GPs, aged care providers, hospitals, pathology and imaging companies and other health workers communicating electronically and sharing information securely.

As previously advised the call for Registrations of Interest will be followed by an Industry Forum. At this forum, interested parties will have an opportunity to hear more about the program, and to seek further information. As you have registered interest an invitation will be sent to your nominated contact advising you of the date and venue in the near future.

Regards

Details Omitted

e-Health Branch

Primary and Ambulatory Care Division

Department of Health and Ageing

-----

The e-mail was also accompanied by the usual threats of dire consequences flowing if the public got to know what the Government was doing!

So what do we have here? We have NEHTA planning to have COAG fund the development of a Shared Electronic Health Record (Shared EHR) while we have DoHA seeking registrations of interest in developing Health Information Exchanges around the country.

Information and commentary on the apparent official NEHTA vision is laid out here:

http://aushealthit.blogspot.com/2007/12/nehta-is-planning-ill-conceived-e.html

and here

http://aushealthit.blogspot.com/2007/12/i-wonder-if-nehta-has-plan-b-or-should.html

(Note I say ‘apparent’ as our E-Health future is so important that we are not allowed to know what it is until the Council Of Australian Governments (COAG) – a collection of E-Health luminaries NOT! – have approved it. If they don’t approve it we will never know what might have been I guess).

The only thing that is certain out of all of this is that, unless because of the shrouds of secrecy surrounding all this I have missed something, both of these apparent approaches can’t proceed as they seem to be planned as they reflect strategically different approaches to making critical health information available where and when it is needed.

A key part of any National E-Health Strategic Plan needs to be some form of business, information and enterprise IT architectures that show how the business of health service delivery is supported by information and technology. To date I have yet to see such a document (current) from either NEHTA or DoHA. Has anyone else – it’s pretty important to have it to avoid waste, duplication and simple project obsolescence!

Despite NEHTA working for over a year to update their Interoperability Framework from Version 1.0 to Version 2.0 the actual shape of their suggested Enterprise Architecture (if it exists other than restatements of TOGAF and the like) remains shrouded in mystery.

Another classic in the right and left hands not knowing what the other is doing! It will cost us all – big time – unless sorted pronto.

David.

Useful and Interesting Health IT Links from the Last Week – 20/01/2008

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

These include first:

Semantic Web takes big step forward

World Wide Web Consortium's SPARQL query technology published; Semantic Web could impact Google, Internet ad models, analyst says

Paul Krill (InfoWorld) 16/01/2008 08:12:19

The Semantic Web, a concept tossed around for years as a Web extension to make it easier to find and group information, is getting a critical boost Tuesday from the World Wide Web Consortium (W3C).

W3C will announce publication of SPARQL (pronounced "sparkle") query technology, a Semantic Web component enabling people to focus on what they want to know rather than on the database technology or data format used to store data, W3C said.

The potential of the Semantic Web cannot be underestimated. By scanning the Web on behalf of users, even Google's ad-based business model could be impacted, an analyst said.

SPARQL queries express high-levels goals and are easier to extend to unanticipated data sources. The technology overcomes limitations of local searches and single formats, according to W3C.

"[SPARQL is] the query language and protocol for the Semantic Web," said Lee Feigenbaum, chair of the RDF (Resource Description Framework) Data Access Working Group at W3C, which is responsible for SPARQL.

Already available in 14 known implementations, SPARQL is designed to be used at the scale of the Web to allow queries over distributed data sources independent of format. It also can be used for mashing up Web 2.0 data.

The Semantic Web, the W3C said, is intended to enable sharing, merging, and reusing of data globally. "The basic idea of the Semantic Web is take the idea of the Web, which is effectively a linked set of documents around the world, and apply it to data," Feigenbaum said.

Continue reading the quite long article below

http://www.computerworld.com.au/index.php?id=1545590871&eid=-180

This is an important announcement from the World Wide Web Consortium as it flags progress towards making all sorts of disparate information sources more easily searchable and accessible. The range of possible applications to the e-Health sector information silos are obvious!

Second we have:

Fast data link for researchers

Paul Ramadge, San Diego
January 16, 2008 - 11:09AM

World-best collaborative research between Australian and United States universities has taken a giant leap forward with the successful launch today of a 1Gigabit per second data connection between the two countries.

The ultrabroadband optical-fibre link - roughly 250 times faster than the standard broadband connection offered in metropolitan Melbourne - was demonstrated at the University of California San Diego and at the University of Melbourne today.

Using large visual-display walls of high-definition screens in both cities, still images, audio, animations and video from Australian research conducted by neuroscientist Professor Graeme Jackson and water researcher Professor John Langford were presented in both cities at the same time.

Participants in San Diego were able to question Professor Langford and Professor Jackson in real time - as if they were in the same room.

The potential applications that will flow from the new technology are immense - from research into the brain using scans that can be shown at the cellular level through to drug discoveries and collaboration on high-end climate change research.

Excited researchers are already talking about sharing data from MRIs, synchrotrons, supercomputers and telescopes to interpret a range of complex data - previously beyond the reach of those in Australia.

The high-speed connection - the power of which will not be lost on those in the Australian community begging for next-generation broadband services - is a joint initiative of the Australian American Leadership Dialogue, the University of Melbourne, the California Institute for Telecommunications and Information Technology at UCSD and the University of California Irvine, the Victorian Government and Australia's Research and Education Network (AARNet).

Continue reading here:

http://www.smh.com.au/news/technology/fast-data-link-for-researchers/2008/01/16/1200419846497.html?page=fullpage#contentSwap1

This is an interesting report showing just part of the potential of really fast Internet connectivity. Clearly in the future this sort of connectivity will mean the need to travel around the world for expert clinical advice will slowly become a thing of the past – among a zillion other possible applications.

Third we have:

Patient tracking system unveiled to solve drug errors

Liam Tung, ZDNet Australia

15 January 2008 04:12 PM

Australian citizens will be assigned a unique identifying number to help healthcare providers protect their patients from accidentally being given the wrong treatment.

Australians' Medicare records will be accessed to create the "Unique Health Identifiers" (UHI), under an initiative announced by minister for Health, Joe Ludwig.

While Medicare will be responsible for the design, building and testing of the UHI system, Australia's National E-Health Transition Authority (NEHTA) will coordinate the project to collect information needed to develop the identifiers, as well as develop requirements for an identity management system.

The system is meant to resolve the limitations of current identifiers -- name, sex, address and date of birth -- which has led in some instances to the wrong test results being applied to a patient, according to an earlier NEHTA report.

At present, medical service providers such as community GP clinics, pharmacies, private and public hospitals have diverse methods and systems to identify individuals, which can potentially lead to the mis-allocation of tests and treatment. Likewise, medical provider information is often stored on disparate systems.

Continue reading here:

http://www.zdnet.com.au/news/business/soa/Patient-tracking-system-unveiled-to-solve-drug-errors/0,139023166,339285138,00.htm

and we also have this

AMA Qld backs electronic healthcare ID

Posted 1 hour 33 minutes ago

The Queensland Branch of the Australian Medical Association (AMA) says a new electronic healthcare identification service could save doctors hundreds of hours which are normally wasted writing prescriptions.

The Federal Government has signed a contract to develop and test the national scheme, which would electronically identify a person's name, date of birth, address and the names of their healthcare providers.

AMA Queensland spokesman Dr Wayne Herdy says the system would improve efficiency and guarantee correct information is transferred between private practice and hospitals.

"We spend a lot of time writing prescriptions and sending prescriptions to pharmacies and writing them out by hand, or having to sign pieces of paper," he said.

Continue reading here:

http://www.abc.net.au/news/stories/2008/01/13/2137293.htm?section=justin

I have no idea just what those who are briefing these journalists are smoking but to attribute reduced prescription error rates and saved time in prescribing to having a patient identifier is really stretching it. It is the applications – yet to be developed and deployed – that will use the identifier that may help..not the fact of the identifier. More lives would be saved by having quality GP system with good up-to-date decision support than are likely to be saved by the identifier alone. It is simply a piece of IT infrastructure which should have been in place a decade ago.

Fourthly we have:

EU health sector lags behind in IT

Standardisation of systems needed to cut costs, says Commission

Matt Chapman, vnunet.com 10 Jan 2008

The European Commission has criticised the European health sector for lagging behind when it comes to technology.

The Commission's Lead Market Initiative report said that a gap had been created because investment had been ploughed into other areas and not into e-health.

"Healthcare has fallen progressively behind other service sectors over the past 25 years in terms of relative levels of ICT investment," the report said.

…..

"European citizens would greatly benefit from cost reductions, coupled with better efficiency of the healthcare systems through the wider development of e-health," the report said.

The study also claimed that improvements to health technology would see systems used as "tools" for health authorities and "personalised health systems " for patients.

Health costs in the EU currently run at nine per cent of gross domestic product, but the report expects this to rise to 16 per cent by 2020 thanks to ageing populations.

Read the full article here.

www.vnunet.com/2206964

The expected rise in healthcare costs in the EU by 2020 is a little alarming!

Fifthly we have:

Report lauds VA's focus on quality care, health IT

By Mary Mosquera
Published on January 11, 2008

The Veterans Affairs Department has improved its quality of health care through management initiatives and use of health information technology, the Congressional Budget Office said in an interim report. VA's accomplishments come during a period of increased demand for its services from soldiers returning from Afghanistan and Iraq.

VA has restructured efforts to permit more shared decision-making among its central office, regional managers and facility directors; measure performance, process and outcomes; and use health IT systemwide.

The department's integrated structure and appropriated funding may have helped it focus on providing the best quality care for a given amount of money compared with fee-for-service incentives toward billable services and procedures, CBO said in the Jan. 9 report.

The improvement in VA's health care quality has been documented in a number of independent studies, including by the Institute of Medicine. VA will provide care to more than 5.8 million veterans this year in its 153 hospitals and nearly 900 clinics.

VA tracks the quality of its care using indicators such as adherence to clinical guidelines and standards that have been shown to improve outcomes, waiting times for access to services and customer satisfaction. This year, VA plans to adopt more industrywide quality measures, such as those in the Healthcare Effectiveness Data and Information Set, to boost comparability with other providers, CBO said.

Continue reading here:

http://www.govhealthit.com/online/news/350168-1.html

The report can be found by clicking the following link

The Health Care System for Veterans: An Interim Report

Confirming this finding is research undertaken for the Welsh Health Department when reviewing the progress of the Welsh Health IT Strategy. To quote

“The proven experiences from Veterans Administration and Kaiser Permanente as well as others such Andalucia in southern Spain, clearly demonstrates that the Electronic Health Record is not only very useful, it is a necessity if improved clinical outcomes and patient safety is to be achieved. We should sit up and take notice when an organization as large as the VA is able to show that: a) their cost of care per patient day has stayed the same for over 10 year while it has risen by 40% for everyone else and, b) that they are the top of table for all the quality health indicators currently being used.

In the past 10 years, the VA has increased the number of patients treated by 34%, decreased staffing by 15%, and opened over 300 community based patient-centred primary health care clinics -- with no increase in budget! But, it came at a price; the benefits that information technology generated for the VA only came when clinical workflows and processes were changed and optimised. This often meant bringing down boundary barriers and changing rules and regulations. The Dutch approach to this phenomenon is intriguing: stimulate – facilitate – obligate.”

Source: “An assessment of Informing Healthcare in Wales – International Advisory Group -September 2007”

This is an important! If ever there was proof of Health IT and decent management making a difference in the real world for the better this is it. Pity our politicians are yet to get it.

Lastly we have:

Making the Rounds With Robo Doc

Tuesday, January 15, 2008; HE02

A white-coated mobile robot may seem like something out of a sci-fi movie, but one of these gizmos may one day ask how you're feeling and listen to your reply. Some physicians -- like Joseph Patelin, of Shawnee Mission, Kan., whose face is shown above -- are using monitor-mounted robots to check on patients.

A study in last month's Archives of Surgery found that robo docs "matched the performance" of the flesh-and-blood variety with 270 urology patients. Compared to traditional bedside checkups, robot rounds didn't increase complications after surgery, lengthen hospital stays or prompt more patient complaints.

Continue reading here:

http://www.washingtonpost.com/wp-dyn/content/article/2008/01/14/AR2008011402011.html

Interesting study – similar results have been found with remote supervision of ICU patients – and I love the robot dressed up in a white coat as shown in the picture.

More in next week.

David.