e-Prescribing – A Strong Case Put for Adoption.

The following article appeared a few days ago.

ePrescribing and its Impact on Care Management

Marybeth Regan, PhD, for HealthLeaders Media, January 28, 2008

New technology is being introduced every day in the healthcare industry, which impacts the manner in which providers deliver care. Impacts may be positive or negative, depending on the technology and the way in which it is implemented and supported. The goal is to implement the right technology at the right time, in the right way, so patients are receiving higher quality care, delivered in a safer environment and in a more efficient manner.

In the ideal scenario, prescriptions would be checked against a patient's current medications, allergies, diagnoses, body weight, and age for possible interactions, appropriateness, and dosage. Prescriptions would be legible and patient information about their medications, including indications, properties, side effects and instructions for administration, would be dispensed with the medication. A permanent record would be created that included all of the patient's medication history over time. Not only would prescription data be available on orders, but also that the prescription was refilled. Patient adherence to medication regimens can be improved through a closed-loop communication of refill data to both payers and physicians.

ePrescribing is an interactive data transaction that allows the prescriber to see a complete profile of the patient's medication with software inputs allowing the physician to check formulary status, any administrative limits (Rx limits per month, days supply limits, etc) and clinical edits (drug/drug interactions, disease drug interactions, dose checks, etc.)

ePrescribing is greater than just process improvement. ePrescribing has the possibility of impacting clinical outcomes for the positive. Prescribing medication is the physician's most frequently used, efficacious, and potentially dangerous therapeutic tool, outside of surgical interventions. The proper or improper use of prescription drugs has a profound effect on patient outcomes. And, because prescription drugs are expensive, the physician's selection of drugs has a major impact on the cost for payers and employers. The management of prescription medications directly or indirectly affects every stakeholder in healthcare.

The bulk of the over 3.27 billion prescriptions issued in United States last year were still written manually, generating the need for an estimated 150 million phone calls from pharmacists to physicians' offices for clarification of handwriting, dosing, and other issues. Up to 40 percent of prescriptions require reworking at the retail pharmacy before they are dispensed to the patient. Medication errors are currently responsible for an estimated 7,000 deaths per year, and approximately $77 billion is spent annually on treatment of adverse drug events.

ePrescribing can benefit patients, physicians and pharmacists by significantly decreasing medication errors, reducing the incidence of adverse drug reactions, saving physicians and pharmacists valuable time now spent on non-clinical administrative tasks, and enabling payers to improve formulary program compliance--collectively saving millions of dollars while potentially increasing patient and physician satisfaction.

Doctors' hieroglyphic handwriting and prescription pads could soon be a thing of the past. Electronic drug prescriptions can now be delivered to pharmacies in all 50 states.

It is no longer appropriate to manage pharmaceutical therapies and costs independent of overall medical care, as prescription drugs have become an indispensable part of modern treatment regimens. By 2010, prescription drugs will account for about 16 percent of overall healthcare costs, according to Hewitt Associates, but this underestimates their impact on costliness, because pharmaceutical care also influences the use of inpatient, outpatient and emergency room services.

ePrescribing takes a process laden with numerous workaround steps and streamlines it to offer significant clinical improvements. Experience teaches us that the greatest problems do not involve technology, but rather are due to organizational issues and human factors. At the end of the day, it is human will--political, professional, and personal--that must drive the technology if it is to serve the users.

Continue reading this excellent article here:

http://www.healthleadersmedia.com/content/204626/topic/WS_HLM2_TEC/ePrescribing-and-its-Impact-on-Care-Management.html

A very useful part of the analysis presented is the following assessment of benefits:

“All of the stakeholders benefit from ePrescribing; listed below are the stakeholder benefits;

Patients

• Improved patient safety and accuracy
• Better formulary adherence
• Streamlined communication of prescriptions to pharmacies
• Improved patient satisfaction, through rapid prescription fulfillment, less visits to the pharmacy and fewer errors

Physicians

• Increased safety and accuracy
• Improved access to data--Rx History
• Improved decision support
• Increased patient satisfaction and peace of mind
• Potential decreased premiums for malpractice insurance.
• Enhanced efficiencies through decreased callbacks to pharmacies through illegible prescriptions, non-formulary medications, potential drug interactions, incorrect dosages, renewal requests and others

Pharmacies

• Reduced errors due to misinterpretations or data entry mistakes
• Avoided unnecessary phone calls
• Increased processing efficiencies
• Improved customer relationships

Health Plan/Employers

• Control increasing pharmacy cost
• Improved formulary adherence and generic drug utilization
• Future opportunities for disease management and patient compliance
• Reduction in costs associated with adverse drug events
• Improved access to data on physicians prescribing patterns and patient medication profiles
• Improved patient adherence to therapeutic regimens
• Reduced healthcare costs
• Healthier, more satisfied workers
• Potential reduced claim losses”

While some of the suggested benefits are a little US centric a lot of this list is on the money (sorry!).

It is really amazing that such useful and proven technology is taking so long to be deployed in Australia.

With NEHTA’s currently announced time frames (mid 2009 for the IHI etc.) it seems it will be a good while yet. The opportunity costs in all this are just enormous!

Dr Regan makes a very compelling case that Australian policy makers should be taking notice of.

David.

The Institute of Medicine and Clinical Effectiveness – Relevant to OZ?

The following press release came from the US Institute of Medicine (IOM) a few days ago.

http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=12038

IOM Recommends New National Program To Evaluate Effectiveness Of Health Care Products And Services And End Confusion About Which Work Best

WASHINGTON — Solutions to some of the nation's most pressing health problems hinge on the ability to identify which diagnostic, treatment, and prevention services work best for various patients and circumstances. Spending on ineffective care contributes to rising health costs and insurance premiums. Variations in how health care providers treat the same conditions reflect uncertainty and disagreement about what the standards for clinical practice should be. Patients and insurers cannot always be confident that health professionals are delivering the most effective care.

A new report from the Institute of Medicine offers a blueprint for a national program to assess the effectiveness of clinical services and to provide credible, unbiased information about what really works in health care. The report recommends that Congress direct the U.S. Department of Health and Human Services to establish a program with the authority, expertise, and resources necessary to set priorities for evaluating clinical services and to conduct systematic reviews of the evidence. This program would also be responsible for developing and promoting rigorous standards for clinical practice guidelines, which could help minimize the use of questionable services and target services to the patients most likely to benefit, said the committee that wrote the report.

"We need a way to synthesize data about the effectiveness of health care products and services in a standardized, objective fashion that will be considered reliable and trustworthy by all decision makers," said committee chair Barbara J. McNeil, Ridley Watts Professor and head, department of health care policy, Harvard School of Medicine, and professor of radiology, Brigham and Women's Hospital, Boston. "A system coordinated by a single, national entity that can prioritize and coordinate these evaluations would enable us to sort the wheat from the chaff and make sense of it all."

Although several organizations conduct evidence reviews and develop clinical practice guidelines, a single entity with the authority and resources is needed to determine what works and end confusion, the report says. Lack of coordination has led to duplication of effort, dozens — and in some cases hundreds — of competing practice guidelines, and uncertainty about which study results and guidelines are the most reliable and objective. This situation complicates the push to empower individuals to become more engaged in choosing and managing their care, the committee said.

If established in a way that ensures transparency, scientific rigor, and high standards for accountability and objectivity, the proposed national program would be a trusted resource for reliable information on the effectiveness of health services, the report says. With thousands of new clinical studies published every year, the amount of medical data has become so vast that it is essentially unmanageable for providers, patients, health plans, and others. Most people, including many health professionals, lack the scientific training necessary to evaluate and interpret such clinical findings by themselves. Moreover, research has shown that when evidence reviews are financed by manufacturers or vendors — as a significant proportion are — they are more likely to show effectiveness, which leads some to question whether, or to what extent, the cumulative body of evidence for any given health care product or service is biased.

The committee noted the relevance of cost and cost-effectiveness analysis to this issue, but did not make cost-related recommendations. Many policymakers believe cost-effectiveness information could guide more efficient use of health care resources, but the committee was asked to focus on other issues in its study. The report notes that reliable cost-effectiveness analysis depends on having high-quality evidence on the effectiveness of products and services.

The study was sponsored by the Robert Wood Johnson Foundation. Established in 1970 under the charter of the National Academy of Sciences, the Institute of Medicine provides independent, objective, evidence-based advice to policymakers, health professionals, the private sector, and the public. The National Academy of Sciences, National Academy of Engineering, Institute of Medicine, and National Research Council make up the National Academies. A committee roster follows.

End Release.

Copies of Knowing What Works in Health Care: A Roadmap for the Nation are available for browsing or purchase from the National Academies Press.

There is a download summary available here.

This is a really important report and it has huge relevance for Australia. Just as in the US we have a legion of different entities all developing recommendations, guidelines and so on (think Cochrane Collaboration, Therapeutic Guidelines, The learned clinical Colleges, the TGA, the Pharmaceutical Benefits Advisory Council (PBAC), the various Departments of Health advisory committees, GP magazines and so it goes on) and the informed layman – as well as Government – have no real idea as to the quality and reliability of what is produced – let alone what hidden vested interests may be operating.

With a scope of diagnostic, treatment, and prevention services this is a huge job but it has to be worthwhile just so we can all know the answer to one key question – what really works and what doesn’t.

The secondary issue is, if it works is it sensibly affordable – and that is clearly a political and economic decision.

One could sensibly hope the scope could also be extending to Health IT to develop evidence in this domain as to what works and what doesn’t – but I fear that is a way off yet.

It does need to be noted that an idea like this is not new.

See http://www.nice.org.uk/

The UK National Institute for Health and Clinical Excellence certainly has a very similar mandate, and while occasionally causing controversy for making some hard decisions is clearly a success.

The role is succinctly put:

Who we are

The National Institute for Health and Clinical Excellence (NICE) is the independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health.

What we do

NICE produces guidance in three areas of health:

• public health - guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector
• health technologies - guidance on the use of new and existing medicines, treatments and procedures within the NHS
• clinical practice - guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS.

Time for Australia to follow our two “Great and Powerful Friends” I believe!

David.

Could a Major E-Health Opportunity is Passing Us By?

The European Union has been researching where the ‘main chances’ lie for market innovation and profit over the next five years.

The Lead Market Initiative Program is described as follows:

“The Lead Market Initiative for Europe will foster the emergence of lead markets high economic and societal value. On the basis of intense stakeholder consultations, six markets have been identified against a set of objective criteria; eHealth, protective textiles, sustainable construction, recycling, bio-based products and renewable energies. These markets are highly innovative, respond to customers’ needs, have a strong technological and industrial base in Europe and depend more than other markets on the creation of favourable framework conditions through public policy measures. For each market, a plan of actions for the next 3-5 years has been formulated. The European citizens will benefit both from the positive impact on growth and employment (the identified areas could represent three million jobs and 300 billion EUR by 2020) and from the access to enhanced goods and services of high societal value.”

And what do we find at the top of the list? Good heavens its e-Health!

The following provides some more details

Building Europe’s e-health market

30 Jan 2008

E-Health Europe: How does the new Lead Market Initiative (LMI) on e-health differ from the initiatives previously undertaken by the Commission in this area?

Information Society and Media Directorate-General ICT for Health: “The European Commission has been mainly supporting research and innovation in e-health for the last 20 years. In 2004, it has officially unveiled its support to deployment and policy activities with the e-health action plan. The LMI is a continuation of the e-health action plan and the first initiative to focus on specific policy activities targeting sustainability, growth and transparency of the e-health market.”

EHE: What will be the key milestones by which success of the strategy will be measured?

ICT4H: “The overall Lead Market Initiative calls for urgent and coordinated action in six different market areas - e-health, protective textiles, sustainable construction, recycling, bio-based products and renewable energies - with a timeline of three to five years. The six identified markets cover domains of high economic and societal interest and are expected to grow to €300bn per year in 2020 (in Europe only), from their current estimated €120bn value.

“In the area of e-health we forecast an increase of 43% by 2020, bringing the total volume of the market to €30bn from the current estimate of €21bn in 2006 within the EU. If this materialises, there would be an estimated 360,000 more jobs in Europe in this sector.

“As well as market growth, another key indicator for success will be a scoreboard of member state procurement of innovative ICT solutions in healthcare.

“Ultimately, what matters is that through e-health people will receive better quality care, will have access to care and health information when and where needed and health delivery systems will be more efficient.”

EHE: What period does the strategy cover?

ICT4H: “Action plans focus on a time period of three to five years.”

EHE: What funding does the Commission plan to back the strategy with over its lifetime?

ICT4H: “The Commission has already invested in projects worth over €1bn over the past 20 years through its research framework programmes, for example in the areas of electronic health records, regional health information networks, personal health systems and other tools for patients, as well as ICT tools for professionals including those that support the improvement of patient safety.

“Regarding the LMI, there will be opportunities to fund networking activities of stakeholders (policy makers, finance, standards, clusters and industry) in the themes of the emerging markets, building on ongoing Europe INNOVA activities. Also very targeted events and projects/studies will be called for on business models, on securing and protecting investment and financing of e-health deployment, support to innovation friendly procurements etc. Engaging all relevant services of the Commission will be an important aspect of this initiative.”

EHE: How would you characterise the state of the current European e-health market?

ICT4H: “The health sector as a whole currently involves 9.3% of the EU workforce, more than 15m people. Health expenditure represents more than 8.5% of GDP, growing 4% a year (faster than EU economic growth), and can reach 16% of GDP by 2020 (Healthcast 2020 PricewaterhouseCoopers).

“The e-health industry in the EU was estimated to be worth close to €21bn in 2006. Market players and observers agree that e-health in Europe is set for explosive growth, driven by the need to face the health-related challenges and to take advantage of burgeoning new medical information and communication technologies.

“By 2010, a double digit growth rate of up to 11% is foreseen as driven by a search for more productivity and performance. The prospects are even rosier for the specific sector of telemedicine services in which annual growth of 19% is foreseen.”

Continue reading here:

http://ehealtheurope.net/comment_and_analysis/291/building_europe%E2%80%99s_e-health_market

It seems clear to me Australia needs part of this action!

We are already reasonably positioned with IBA / iSoft having a reasonable and growing presence in the EU.

It seems there are two opportunities here. First the possibility of export of our innovative products to the EU and second the use of this growing market to foster innovation and growth back in Australia to the benefit of all.

First of all we need to get rather better organised or this opportunity will sail on past!

Ms Roxon and Senator Carr – please note!

David.

Useful and Interesting Health IT Links from the Last Week – 03/02/2008

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

These include first:

Gartner's top 10 IT predictions for 2008 and beyond

Open source, Apple, green technology and 3-D printing highlighted

Jon Brodkin (Network World) 01/02/2008 08:41:41

Open source, Apple computers, green technology, the rise of users and the proliferation of three-dimensional printing are among the hot trends IT shops should look out for in the next few years, according to Gartner.

The analyst firm on Thursday highlighted 10 key predictions of developments that will affect IT and business users in 2008 and beyond. Here's a detailed look at the list, culled from more than 100 predictions Gartner has made based on its research:

• Apple will double its market share for computers in the United States and Western Europe by 2011. "Apple's gains in computer market share reflect as much on the failures of the rest of the industry as on Apple's success," Gartner says. A focus on interoperability between the iPod, iMac and other devices is one of the keys for Apple.
• By 2012, half of all workers will use devices other than their laptops when they travel. "Even though notebooks continue to shrink in size and weight, traveling workers lament the weight and inconvenience of carrying them on their trips," Gartner states. "Vendors are developing solutions to address these concerns: new classes of Internet-centric pocketable devices at the sub-US$400 level; and server and Web-based applications that can be accessed from anywhere."
• 80% of commercial software will contain open source code by 2012, providing "significant opportunities for vendors and users to lower their total cost of ownership and increase returns on investment."
• Software-as-a-service will account for at least one-third of business application spending by 2012. "Endorsed and promoted by all leading business applications vendors (Oracle, SAP, Microsoft) and many Web technology leaders (Google, Amazon), the SaaS model of deployment and distribution of software services will enjoy steady growth in mainstream use during the next five years," Gartner writes.

Continue reading here:

http://www.computerworld.com.au/index.php?id=818517154&eid=-255

This is an interesting list of the technology trends Gartner thinks will be important in 2008. Well worth the browse.

Second we have:

Age does not weary Medicare system

Karen Dearne | January 29, 2008

MEDICARE's claim processing systems are largely accurate despite being handled by an outdated IBM mainframe computer and a 35-year-old flat file format, the Australian National Audit Office says.

New claim and payment methods, such as Medicare Online, have forced the retrofitting of legacy systems to allow connection with the internet.

Medclaims, the bulk-billing system based on electronic data interchange technology, is being phased out in favour of Medicare Online.

In 2006-07, 25 per cent of claims were submitted via Medicare Online, up from 19 per cent the previous year. During the year, $11.8 billion in benefits were paid for almost 258 million Medicare services.

Overall processing accuracy was 98 per cent. Almost 99 per cent of scanned or electronically lodged claims were handled without human intervention.

Continue reading here:

http://www.theaustralian.news.com.au/story/0,25197,23122867-23289,00.html

This comment on page 14 of the report is of some concern.

“The focus was on the mainframe based common assessing processing system, and the supporting processes, that are used to assess all Medicare claims irrespective of what method was used to submit or pay the claim. The validity of the Medicare Consumer Database, which is used to determine whether a patient is a ‘valid Medicare’ patient, was not tested by this audit.”

If the audit has not checked the validity and accuracy of the Consumer Database how can they know anything about the levels of fraud etc. Accurately processing payments for an invalid client is hardly an achievement.

Of course, it is this database NEHTA plans to download as the starting point for their Individual Health Identifier. Knowing reliably its accuracy seems to me to be vital. A missed opportunity I would suggest.

Third we have:

http://www.theaustralian.news.com.au/story/0,25197,23141570-23289,00.html

Roxon rules out league tables for hospitals

Milanda Rout and Patricia Karvelas | February 01, 2008

FEDERAL Health Minister Nicola Roxon has ruled out using league tables to form a national reporting system for public and private hospitals.

Ms Roxon yesterday encountered fierce opposition from the states for a national hospital league table during negotiations on how a reporting system might work at the meeting of health ministers in Melbourne.

NSW was one of the most vocal opponents to the federal government initiative, saying league tables would have a negative rather than positive impact on hospitals.

"We do have reservations about the concepts of league tables for hospitals, and in fact it could provide quite a disincentive to providing good quality care," NSW Health Minister Reba Meagher said.

"All the clinicians tell us that league tables aren't an accurate reflection of what kind of care and quality of care (are) being delivered in a hospital setting."

Ms Meagher said she was pleased Ms Roxon had ruled out league tables as part of the national reporting system.

Continue reading here:

This outcome is really condemns the quality of the health care policy debate in Australia. Research in the US and elsewhere has identified reliable non-discriminatory indicators of quality, safety and efficiency and implementing these in Australia is not a technical issue – it is a matter of will and of ensuring the medical lobby and jurisdictional pride do not block developing a clear view of how our health systems are performing.

A few good places for Ms Roxon to visit to understand what is possible include:

http://www.jointcommission.org/

and

http://www.ahrq.gov/

Fourthly we have:

Cable break downs web services

Matthew Rosenberg in New Delhi | February 01, 2008

AT least for a while, the world wide web wasn't so worldwide.

Two cables that carry internet traffic deep under the Mediterranean Sea snapped, disrupting service Thursday across a swath of Asia and the Middle East.

India took one of the biggest hits, and the damage from its slowdowns and outages rippled to some US and European companies that rely on its lucrative outsourcing industry to handle customer service calls and other operations.

"There's definitely been a slowdown," said Anurag Kuthiala, a system engineer at the New Delhi office of Symantec, a security software maker based in California. "We're able to work, but the system is very slow."

While the cause of the damage was not yet known, the scope was wide: Traffic slowed on the Dubai stock exchange, and there was concern that workers who labour for the well-off in the Mideast might not be able to send money home to poor relatives.

Although disruptions to larger US firms were not widespread, the outage raised questions about the vulnerability of the infrastructure of the internet. One analyst called it a "wake-up call," and another cautioned that no one was immune.

The cables, which lie undersea north of the Egyptian port of Alexandria, were snapped Wednesday just as the working day was ending in India, so the full impact was not apparent until Thursday.

Continue reading here:

http://www.australianit.news.com.au/story/0,24897,23143232-15306,00.html

Funny that a news item last week explored what one would do without the Internet and a good fraction of the Middle-East experienced just that this week. The lesson is clear – we need multiple redundancies in our network services as we become increasingly dependent for much of our daily work and productivity on these services.

I must say some of the consequences of the service interruption were unexpected initially to me and shows the depth of transformation and dependency the Internet has achieved.

Fifthly we have:

HIMSS Analytics Releases ‘Health IT Sanity Check’

January 22, 2008 | Despite all the perceived progress toward the wiring of America’s hospitals, a new study suggests there remain some serious misunderstandings between provider-side health-IT executives — chief information officers — and top marketing officials at technology vendors.

In the first “Healthcare IT Sanity Check,” released Tuesday by the HIMSS Analytics division of the Chicago-based Healthcare Information and Management Systems Society (HIMSS) and marketing firm O’Keeffe & Co. (Falls Church, Va.), only 2 percent of health-IT executives gave an A to marketing executives, while the marketing people were heavily self-critical, with only 7 percent giving themselves the top mark.

The survey, which includes 100 IT professionals and 100 vendor representatives, has a margin of error of roughly eight percent.

“What this survey was for was to put some numbers behind the anecdotes,” HIMSS Analytics executive vice president Michael Davis told Digital HealthCare & Productivity. “We found some disconnects,” he adds.

A majority of vendors still believe price is among the top factors in a purchasing decision, but only 44 percent of CIOs agree. Far and away the most important criterion for CIOs was functionality, named by 77 percent of IT professionals. For vendors, functionality tied with price, at 57 percent each.

An unnamed IT professional quoted in the report advised, “Tone down the sales pitch and focus on functionality.” “Take the time to understand our specific organizational culture, requirements, and expectations,” said another.

“I think enough people have been burned by picking the lowest bidder,” Davis says. As Exhibit A, he points to the British National Health Service, which largely chose its vendors by negotiating for rock-bottom prices, and now is struggling to implement a massive health-IT network to serve the 52 million people in England. However, Davis adds, “I think the market is learning.”

Continue reading here:

http://www.health-itworld.com/newsletters/2008/01/22/healthcare-it-sanity-check

This is an absolutely fascinating report showing just how large the disconnect seems to be between Health System CIOs and Health IT Vendors. This must be a wakeup call to all those involved to improve their communication between each other.

The success of Health IT initiatives is surely dependent on the vendors delivering software that satisfies the needs of the clinical users. The vendors ignore this fact at their long term commercial peril!

Lastly we have:

National media attention for anti-smartcard group

30 Jan 2008

In Germany this week doctors and civil rights activists joined forces to organise a boycott of the German smartcard programme, attracting huge media interest, including national TV.

The new alliance went public last Friday with a joint press conference at which it proclaimed the explicit goal of halting the smartcard health programme and move to centralised systems, citing privacy worries.

The alliance’s opposition extends to all efforts to digitally communicate in the German healthcare system on a supra-regional level.

“We do not need a national communication infrastructure for the healthcare system”, said Silke Lüder, a Hamburg-based GP and one of the speakers of the alliance.

“We are fed up with feeding industry with money just for prestige projects of politicians without any benefit for the patient”, added Martin Grauduszus, head of the doctor’s body ‘Freie Ärzte’ (Free Doctors).

The event made its way through German media on Saturday, Monday and Tuesday. The national news agencies dpa and Reuters reported, as did one of the two main channels of national public television, at least two private channels, a number of national and regional newspapers and a broad spectrum of special interest magazines, including ‘Computerwoche’ (Computer Week), a leading weekly IT title.

The two main issues of criticism are concerns about privacy and about costs. The new alliance claims that smartcards in healthcare are the first step towards a system of national “mega-servers” which contain aggregated patient data in centrally stored shared electronic patient records.

Continue reading here:

http://ehealtheurope.net/news/3426/national_media_attention_for_anti-smartcard_group

Does all this remind anyone of the recent Access Card debate in Australia?

More next week.

David.

Sorry – This Really Makes Me Grumpy!

Today this came across my desk.

Bush presses healthcare IT in State of the Union speech

In his final State of the Union address loaded with tough topics such as troop withdrawal from Iraq and emergency measures to boost a weakened economy, President Bush again highlighted information technology as critical to transforming healthcare.

"To build a future of quality healthcare, we must trust patients and doctors to make medical decisions and empower them with better information and better options," Bush said.

"We share a common goal of making healthcare more affordable and accessible for all Americans."

The president listed healthcare IT among several key aspects of healthcare reform, including the expansion of health savings accounts, the creation of association health plans for small businesses and the elimination of junk medical lawsuits. He also called for a change in the tax code to put coverage within reach of millions of Americans who do not get health insurance through their employers, and thus can't pay premiums with tax- free dollars.

He received rousing applause from Republicans when he said expansion of consumer choice, not government control, is the best way to achieve healthcare reform.

Consumer choice has been a cornerstone of Bush's policy to bring value to U.S. healthcare. His value-driven healthcare plan calls for electronic health records and the reporting of quality measures as a way to drive down costs and bring transparency to an ailing healthcare system.

Continue reading here:

http://www.healthcareitnews.com/story.cms?id=8519

Where the hell is the e-Health leadership in Australia?

All I can say is that if the most awful and incompetent leader in the Western World – and all his smarter international mates ‘get-it’- what about the current Rudd Government? Thus far not a ‘dickie bird’ – except rubbish about the Government apparently following some secret NEHTA / Medicare Plan for Australian e-Health domination. What a policy farce! Ms Roxon and her advisors need to lift their game – and promptly!

The lack of Commonwealth co-ordination, planning and care in e-Health is moving from a serious problem to a serious policy failure at an amazing pace. Ms Halton, Mr Reid and mates – get onto this and fast!

This is simply not good enough.

David.

Really Successful use of Health IT in the US Veteran’s Affairs Department.

Good news for the effectiveness of properly implemented health IT this week.

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 system wide.

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 industry wide quality measures, such as those in the Healthcare Effectiveness Data and Information Set, to boost comparability with other providers, CBO said.

VA's structure as an integrated health care system makes it easier for the department to use two effective tools: incentives for managers and providers to meet quality of care and practice guideline targets, and health IT systems that provide reminders about tests and treatments recommended by the practice guidelines, CBO said. It also found that the low cost of care for veterans was an incentive for seeking care.

….

VA has an electronic health record for every patient, which provides up-to-date information about a patient at the point of care, including medical history, allergies and medications. It also contains relevant diagnoses and laboratory tests, which lets providers avoid duplicate tests and adverse drug interactions. Research indicates that computer reminders and prompts can significantly improve adherence to clinical guidelines, particularly for preventive care.

VA could serve as a model for improving other health care systems through sustained efforts to monitor indicators of quality, access and satisfaction. CBO’s final report, expected early this year, will consider how other health care systems can apply similar approaches and lessons from using health IT.

…..

Read the full article here:

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

Read the full report here:

http://www.cbo.gov/ftpdocs/88xx/doc8892/12-21-VA_Healthcare.pdf

What is shown in this report – and what will be more fully developed report due later in 2008 – is that is a single payer environment like the VA Department there can be substantial quality and efficiency improvements through the use of appropriate Health IT.

Given the successes already seen in Scandinavia and at Kaiser Permanente it seems to me we have reached a tipping point in the strength of the evidence about the utility of Health IT. This all has a climate change style denial feeling about it to me.

The question is not anymore whether Health IT is a good thing or not – the question is how can it be most efficiently and effectively introduced to meet the needs of my health sector!

David.

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.