Useful and Interesting Health IT Links from the Last Week – 30/03/2008

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

These include first:

HIT Terms Project Calls For Final Comments On Proposed Definitions

To enable widespread participation in this project for U.S. Department of Health and Human Services’ Office of the National Coordinator, the Alliance is holding a second public comment period from March 24th to April 9th on the work completed so far in defining the five terms: electronic medical record (EMR), electronic health record (EHR), personal health record (PHR), health information exchange (HIE) and regional health information organization (RHIO).

The deadline for finalizing the definitions is approaching and now is the time to be heard and to provide input on the definitions. The final definitions will provide an important reference point for policy evaluation and standards development activities and they will help explain health IT concepts in language that consumers can readily understand. As an industry we need to quickly reach clarity and certainty about these terms so we can move forward with the important business of improving health care through health IT.

Committed to creating consensus-based definitions, the project’s Records Work Group and Network Work Group have already weighed and incorporated feedback received during two public forums and the first public comment period.

To review the updated version of the draft definition and provide please click here or browse to the Comments section of this web site.

Continue reading here:

http://definitions.nahit.org/

This interesting project is still underway and seeking further input.

The working document – some 33 pages is well worth a download and read.

http://definitions.nahit.org/doc/HITTerms_DraftReport_032408_Final.pdf

Comments are welcome until April 9, 2008.

Second we have:

Can you keep a medical secret?

Move to online records pits your privacy against a doctor's need to know

By Daniel Lee

daniel.lee@indystar.com

Does a doctor treating you for a broken leg need to know you had an abortion 20 years ago?

Should your dentist have access to information about your visit to a psychiatrist?

Such questions are moving center stage as patients' medical records increasingly are transferred from manila folders to the Internet, allowing easier access to medical history that the patient may not want known.

In one of the latest examples of the debate over how much patient history doctors should have access to, Dr. Marc Overhage, chief executive of Indiana Health Information Exchange, cast the lone dissenting vote as a 17-member federal panel recommended that patients get more control over electronic health records.

Overhage is a member of the National Committee on Vital and Health Statistics, which sent its recommendations to the U.S. Department of Health and Human Services last month. The panel encouraged HHS to give patients the power to sequester from their online medical records certain sensitive information such as domestic violence-related treatment, reproductive health and genetic information.

"I certainly believe it's a patient's right to protect and control their information," said Overhage, a professor at the Indiana University School of Medicine.

However, he said physicians, in order to provide the best care possible, also need access to information -- sometimes including information that is more personal in nature. The fact that a woman takes birth control pills, he said, could have an effect on how a doctor would prescribe other medications.

He also said the recommendations he voted against leave too many unanswered questions and contain initiatives that could cost hundreds of millions of dollars to implement.

Continue reading here:

http://www.indystar.com/apps/pbcs.dll/article?AID=/20080323/BUSINESS/803230394/1175/LOCAL0102

This is an excellent summary of the differing view that exist in the US (and here) as to how the privacy of electronic health records should be best addressed.

More discussion is also found here:

http://www.healthleadersmedia.com/content/208205/topic/WS_HLM2_TEC/Privacy-Where-Are-We-Headed.html

Privacy: Where Are We Headed?

Gary Baldwin, for HealthLeaders Media, March 25, 2008

Let it be said that I am no big fan of legislating healthcare privacy. After all, many people among us willingly blab about the very health conditions that privacy advocates insist are sacrosanct. And the laws that attempt to regulate access to privacy can quickly become confusing and burdensome--just look at the massive industry attempt to comply with HIPAA and its disclosure requirements for personally identifiable health information. But I understand that the burdens of legalese and human nature are not ample reason to throw privacy to the wind. Other than my doctor, it's really nobody's business what my diagnosis is, or was, or could be.

Third we have:

Practicing Patients

By THOMAS GOETZ

Todd Small was stuck in quicksand again. It happened, as always, on the floor of the Seattle machine shop where he worked. His shift complete, Small was making the 150-yard walk from his workstation to his car, when he realized that his left leg was sinking deep in the stuff. Though this had happened before — it happened nearly every day now — he stopped and glanced down at his feet. His Nikes looked normal, still firmly planted on the shop’s concrete floor. But he was stuck, just the same. His brain was sending an electrical pulse saying “walk,” but as the signal streaked from his cerebellum and down his spinal cord, it snagged on scar tissue where the myelin layer insulating his nerve fibers had broken down. The message wasn’t getting to his hip flexors or his hamstrings or his left foot. That connection had been severed by his multiple sclerosis. And once again, Small was left with the feeling that, as he described it, “I’m up to my waist in quicksand.”

For the 400,000 Americans with multiple sclerosis, Todd Small’s description will most likely ring true. Muscle stiffness is a hallmark of the disease, and “foot drop” — the term for Small’s quicksand feeling — is a frequent complaint. The condition is usually treated, as it was in Small’s case, with baclofen, a muscle relaxant that works directly on the spinal cord. Every day for 14 years, he took a single 10-milligram pill. “My neurologist always told me if you take too much it will weaken your muscles. So I never wanted to go over 10 milligrams.” It didn’t seem to have much effect, but he carried on as best he could.

Small would have continued just as he was had he not logged on last June to a Web site called PatientsLikeMe. He expected the sort of online community he’d tried and abandoned several times before — one abundant in sympathy and stories but thin on practical information. But he found something altogether different: data.

More here:

http://www.nytimes.com/2008/03/23/magazine/23patients-t.html?_r=1&oref=slogin

This is a very useful review of the impact of Web 2.0 on the health sector. I see these sort of innovations are very important in the drive to assist patients get more involved in the planning and delivery of their health care.

Well worth a browse!

Fourthly we have:

E-health on the mend

March 25, 2008

Health care is one of Australia's biggest social and political issues. From monitoring the aged to remotely performing intricate surgery, electronics and the internet are vitally involved. Nick Miller reports.

SIR Jonathan Michael loves the big-time, showy end of e-health. There's the time he watched a kidney operation done robotically in Guy's Hospital in London - controlled by a surgeon in the US.

"That's very much the high-tech, dramatic end of the spectrum," says the deputy managing director of health care at BT Health, who visited Australia last month.

The first time he was impressed by the potential of combining IT with clinical care was more prosaic, but profoundly effective. It was when he was working as a clinician in a kidney unit in Birmingham.

"We were using electronic prescriptions in the kidney unit," he says. "Patients with kidney disease have real risks with drugs that they should not be prescribed because of the dangers associated with reduced kidney function. With constantly changing junior doctors not knowing the details of individual patients, there was a real risk the wrong drugs could be prescribed to patients with kidney failure.

More here:

http://www.smh.com.au/news/biztech/ehealth-on-the-mend/2008/03/24/1206207011913.html

Nice to see the views from an enthusiast from the UK. The commentary later in the article regarding things that are happening in Australia did not really make me think the headline is all that valid.

Fifth we have:

Nurse's job to cook the books: doctors

Natasha Wallace Health Reporter

March 25, 2008

NSW Health appointed a nurse whose job was to massage triage data in the emergency department of a Sydney hospital to make it look favourable, emergency doctors say.

The nurse, appointed just before the state election, was there specifically to ensure computer data met triage targets, the vice-president of the Australasian College of Emergency Medicine, Sally McCarthy, said yesterday.

This follows revelations in the Herald yesterday that managers at Gosford and Ryde hospitals were so under pressure by the health department to meet targets that some had falsified "time seen" data - the record of when treatment began on a patient.

On the nurse, Dr McCarthy said: "They had somebody looking at that, basically harassing other staff and putting in data themselves. That's not somebody to provide care for patients. That's simply someone to click off on the computer to basically show that patients were seen within benchmark times. It was really just an attempt to get the data looking good."

While the NSW Minister for Health, Reba Meagher, insisted the Gosford case was isolated, Dr McCarthy said the doctoring of data was more widespread and was made easier after the department about 18 months ago widened the definition of when treatment began to include nursing care in several instances.

An emergency physician at Prince of Wales Hospital, who could not be named because she was prohibited from speaking to media, said yesterday that "there have been numerous verbal directives from hospital administrators to change data".

More here:

http://www.smh.com.au/news/national/nurses-job-to-cook-the-books-doctors/2008/03/24/1206207010878.html

If true, and as far as I can tell there has not been any denial, this is just an awful story. Having any staff falsify records has very worrying medico-legal and ethical implications. The NSW Health Department really seems to be utterly and disturbingly out of control.

Sixth we have:

Database to link patients and doctors

Leo Shanahan

March 25, 2008

PATIENTS could find out about the performance of hospitals and doctors under the Labor Government's plan for a national health database.

The database would end a "ridiculous" system of information collection on patients and hospitals, federal Health Minister Nicola Roxon said. It might also mean that doctors in interstate hospitals could study a patient's care history when necessary.

Ms Roxon said the National Health and Hospital Reform Commission, along with the Health and Welfare Institute, were working towards a national database of hospital and patient information.

"Jointly they are now working on how we get that data collection consistent across states, what could be publicly available and working on how we are able to compare not just as consumers, but as governments, about what's working," she said.

"It's ridiculous given the high quality of the system we have, we could vastly improve it, but that we don't know these things is very frustrating and inadequate."

National data collection on patient care and hospital performance is almost non-existent because states hold varying types of information on different databases that cannot be viewed by hospitals or governments interstate.

The federal database is likely to contain information on patient care and history, performance of hospitals and doctors in the public and private system, waiting lists and performance of area health services.

Continue reading here:

http://www.theage.com.au/news/national/database-to-link-patients-and-doctors/2008/03/24/1206207012399.html

Given the previous article, one really has to wonder just how reliable any statistics generated by state governments will be. Quality assurance of this data will clearly be vital!

This quote from later in the article is also a bit of a worry.

“Ms Roxon said she agreed with many of the recommendations on data collection coming from a report released last week by the Australian Centre for Health Research, which included an ID number that would enable hospitals to read information on patients in other states.”

Has anyone told this research centre or the minister that work to deliver this has been underway for the last 18 months via NEHTA. What nit-wits.

Last we have

The Web's best free stuff

There's a wealth of downloadable software and online services, but free doesn't necessarily mean good. Here's some of the best of the bunch

By Preston Gralla and Erik Larkin, PC World, IDG News Service

March 24, 2008

Free: It's the magic word for an ever-expanding wealth of downloadable software and online services. Free doesn't necessarily mean good, however, and hunting for freebies can mean sifting through a lot of junk.

That's where we come in. We surfed, clicked, and installed to find sparkling free gems capable of planning your time, keeping you in touch, and tuning and securing your PC, not to mention glitzing up your desktop, helping you stay productive, and entertaining you with music, videos, photos, and games. We paid special attention to programs and services you may not have heard of before.

We also singled out two free offerings--one download and one online service --as the best of the bunch. We want to hear your picks for the best freebies, too, whether they appear in this article or not. Please let us know by joining our forum discussion.

Continue reading this very long article here:

http://www.infoworld.com/article/08/03/24/The-Web-best-free-stuff_1.html

This is an amazing collection of free and useful downloads and services. Well worth a browse for those interested in what one can do for free with your PC.

More next week.

David.

What Does the Acting NEHTA CEO Need to do Pronto?

With the resignation of NEHTA’s old CEO major change is needed promptly.

If I were to be asked I would suggest the following.

1. Publish all the consulting advice that NEHTA has received so all stakeholders can form a view as to just what is worthwhile in what NEHTA has commissioned, and understand what NEHTA has been advised to assess just how reasonable past actions have been.

2. Release, for stakeholder comment, all completed or near completed project working papers for stakeholder comment to ensure alignment of NEHTA’s activities with present needs.

3. Appoint the new independent Board Members ASAP.

4. Give all those who work for NEHTA a 2 day detailed course in health sector values and culture so they understand just who it is they are actually working for to develop systems for.

5. Ensure everyone at NEHTA recognises that there is more to the health system than is represented by the present Board and that these clients have been virtually totally ignored for the last 4 years. GPs, Specialists, Private Hospitals, Diagnostic Providers, Vendors and so on all need a voice.

6. That NEHTA adopt a mode of dealing with the Health Sector appropriate for its role as a service provider and supporter to the sector and not as an arrogant director and instructor.

7. Work out just who are the clients for the Identifier Systems and engage them quickly to understand just what market really needs and ensure it will be delivered.

8. Review all other programs and decide how they need to be modified to suit the health sector’s current requirements.

9.Establish SNOMED CT delivery as a dedicated and separate entity with its own budget and funding.

10. Establish a good working relationship with the Health Informatics Society, the Australian College of Health Informatics and the Coalition for e-Health.

11. That NEHTA participate fully, properly and respectfully in Standards Australia development processes as all other stakeholders already do.

12 Sort out just what this ScriptX plan actually means. See blog before last!

Transparency, respect, co-operation and understanding of the sector are vital for success!

All I can do is wish Andrew Howard the best of British good luck!

David.

Dr Ian Reinecke Resigns – Oh Happy Day!

In a really fabulous announcement the greatest block to e-Health progress in Australia, in my view, has finally announced his resignation from NEHTA.

Founding CEO to leave NEHTA

31 March, 2008, Dr Ian Reinecke, the founding Chief Executive Officer of the National E-Health Transition Authority, has announced his decision to leave NEHTA.

Chair of the NEHTA Board Dr Tony Sherbon thanked Dr Reinecke for his leadership of NEHTA since October 2004.

Dr Reinecke was responsible for establishing NEHTA as a company in 2005 and the subsequent development of a work program that now involves more than 150 staff working on a range of complex e-health projects.

“Following funding support from COAG, Dr Reinecke has negotiated the contract to establish unique health identifiers for all Australians as well as their health care providers,” Dr Sherbon said.

“This project is now well underway and Dr Reinecke's efforts will prove to be of great benefit in the near future to millions of Australians.

"Dr Reinecke has also overseen negotiations for Australia to join the world's most significant alliance for the international coordination of clinical terminology development. This development has significantly accelerated the development of information standards throughout Australia.

“Under Dr Reinecke’s leadership NEHTA has taken the evolution of e-health in Australia to a new level where much of its work is ready for implementation to improve the quality of electronic health information for clinicians and consumers,” Dr Sherbon said.

Dr Reinecke will leave NEHTA on Friday 4 April 2008 to resume his career as a consultant and corporate adviser.

"The Board of NEHTA wishes Dr Reinecke the very best for the future and looks forward to his successful pursuit of his new career direction ", Dr Sherbon said.

Dr Sherbon said he was pleased to announce Andrew Howard would act as Interim CEO of NEHTA while an international search was conducted to recruit Dr Reinecke's replacement. Mr Howard is currently the Chief Information Officer of the Victorian Department of Human Services. Mr Howard has an extensive background in e-health and 15 years international consulting experience with Accenture.

"I am confident that the NEHTA program will continue on its current course under Andrew Howard's leadership," Dr Sherbon said.

“The staff of NEHTA are extremely capable and are focused on delivering the key outcomes set by all of the Australian governments.

“The Board will continue to work closely with management towards the delivery of further e-health reforms expected in the coming months," he added.

I must say the reason for the resignation looks pretty obvious.

The following press release from last year is the clue.

----- Begin Release

NEHTA HERALDS E-HEALTH MILESTONES

and announces its action plan for adoption success

17 December 2007

Australia's e-health reform agenda took a forward step today with the release of an action plan by the National E-Health Transition Authority (NEHTA).

The Board of NEHTA also endorsed a business case for developing a national platform for personal electronic health records to be put to the Council of Australian Governments (COAG) early next year.

The NEHTA action plan outlines key areas for ensuring the successful adoption of measures to improve the electronic communication of critical health information.

"After working to build foundations for electronic health since the organisation was established in 2005, we are now in a position to begin to deliver some concrete applications of our work," NEHTA's Chair Dr Tony Sherbon said.

"The new Federal Government has signaled health reform and improvements in state and federal relations as major policy objectives," said Dr Sherbon. "Given also the government's emphasis on

the provision and use of broadband communications, NEHTA is well-positioned to play its role in advancing e-health as part of this new agenda," he said.

"The recent independent review found NEHTA had made significant progress on our goals to date and made a number of recommendations about NEHTA's future. The action plan we are announcing today flows directly from our acceptance of all the recommendations in the review," Dr Sherbon said.

Dr Sherbon identified the action plan as also being an acknowledgement of where NEHTA now needs to go in order to expedite e-health reform in Australia.

"We have come to a point where many of the foundations to enable e-health are in a position where we can now move towards implementation and adoption. Seeking funding to establish a national system of personal electronic health records is also on our immediate horizon. The action plan that we have released will assist this process," he said.

Dr Sherbon said the case for personal electronic health records was compelling. "The safety and quality benefits are manifold. We understand the issues of equity and privacy and firmly believe that

the approach developed by NEHTA will address these to the satisfaction of all our stakeholders and the Australian public."

NEHTA's Action Plan for Adoption Success and the independent review of NEHTA conducted by the Boston Consulting Group are available on the NEHTA website at www.nehta.gov.au.

----- End Release.

He failed to get these funds for his Board from COAG last week, so with his major Shared EHR strategy in tatters, he has been given the flick. That is sure how it looks to me!

Can’t say I am in the least bit sorry. Now maybe the blog can focus on more educational and supportive activities!

The good thing I see in all this is that National E-Health Strategic Planning as to what to do next can now happen without a NEHTA 'elephant in the room'

David.

ScriptX – Just What is it and Where is This Heading?

The following press release appeared a day or so ago, along with an ASX announcement under the symbol COO.

Corum Health joint venture pioneers e-prescriptions

27/03/2008

Corum Health Services is pleased to announce the joint venture to develop the first widely available system for electronically transmitting prescriptions between doctors and pharmacies. Endorsed by the Pharmacy Guild of Australia, ScriptX has the potential to dramatically improve patient care by improving the safety and efficiency of prescribing, while protecting patient privacy and choice of pharmacy.

Our joint venture partners, Health Communication Network Limited and Fred Health, have worked with us to:

• Enable doctors to securely electronically send prescriptions to an encrypted hub for retrieval at a patient’s pharmacy of choice

• Provide a universal standard, so that all doctors, medical facilities and pharmacies throughout Australia can access ScriptX, no matter what software they use

• Preserve patient choice, rather than directing scripts to a particular pharmacy

• Observe all privacy laws and regulations

• Increase efficiency and reduce errors in transcribing handwritten prescriptions

• Provide secure access codes for doctors and pharmacies

• Improve the handling of owing scripts and retrieval of repeat scripts

“We are delighted to be providing electronic prescriptions to all doctors and pharmacies, while maintaining the highest standards of patient privacy. This industry-wide solution is a significant breakthrough in the interaction between Doctors, pharmacies and ultimately the customers.” said Mark Winnett, Managing Director, Corum Group.

“For doctors, this will be a vital milestone in supporting patients with overall medication management, including seeing that patients are getting the medication that they need. This is an important step on the e-health journey towards improved health care for patients,” said John Frost, CEO, Health Communication Network.

“Anything that aids the safety of patients is well worthwhile, and a national electronic prescribing system could provide the basis for real improvements in public health and community care. ScriptX is a major breakthrough, backed by substantial industry leadership and commitment towards improved patient health outcomes, through ongoing innovations designed to streamline and safeguard prescribing,” said Bill Scott, Chairman, Fred Health.

“The Guild is pleased to endorse and support plans for the national electronic prescribing system ScriptX, which will improve the safety and efficiency of prescribing in Australia, with the aim of more effective medicine management and better health outcomes for patients,” said Kos Sclavos, National President of the Pharmacy Guild.

The Pharmacy Guild of Australia has pre-purchased 10 million transactions on the ScriptX gateway for Guild members to use at no charge. The ScriptX gateway is due to be launched Australia-wide by March 2009.

About Corum Health Services
Corum Health Services is a leading provider of pharmacy software solutions, enhancing the point-of-sale, dispensing and business operations of more than 2,300 Australian pharmacies. Brands include Corum, Amfac and Pharmasol.

For more information please contact: Mark Winnett, Managing Director, Corum Group Limited, 02 9289 4699

The press release can be found at the following URL:

http://corumhealth.com.au/news-detail.aspx?cid=1&navid=-1&newsid=24

Media Release: End of Paper Prescriptions Nearer?

The Pharmacy Guild of Australia is assisting in driving innovation in the health sector by announcing its endorsement and support for a national electronic prescribing system ScriptX where prescriptions are sent in a secure encrypted gateway from doctors to an “electronic mailbox” and later retrieved by the patient at the pharmacy of choice.

“ScriptX will improve the safety and efficiency of prescribing in Australia, with the aim of more effective medicine management and better health outcomes for patients. It also maintains patient choice and privacy, while streamlining the prescription process, “ said Kos Sclavos, National President of the Pharmacy Guild.

ScriptX does not store information on patients or any prescription details and information held while waiting for the prescription to be filled is held in a fully encrypted form to ensure privacy and it is prohibited for details to be sent to third parties other than with the full consent of the patient.

ScriptX and the Guild have entered into a historical agreement to allow patients to elect for limited information to be sent via ScriptX to the Guild’s new Medication Care Pharmacy Programs such as MedsIndex, which assist patients with dosages, medication management and compliance.

Initially, paper prescriptions will be issued alongside the e-prescription until the Guild and other health professionals are confident that the system is working. At that stage an approach will be made to Government to plan the phasing out of paper based prescribing. The Guild has worked with the Federal Government on many successful health IT initiatives.

ScriptX is a joint venture between the three leading primary health IT vendors in Australia including the Health Communication Network, Corum Health and Fred Health. All medical and pharmacy software vendors will be able to use the gateway.

The Guild has entered into a commercial arrangement where it will purchase 10 million transactions for its Guild pharmacies for first stage implementation. The system is based on a pharmacy user pay system although Federal Government support will be sought following phase I implementation. In addition the ScriptX system is free for doctors to use.

For further media enquiries contact Michael Pittman, Media Manager of the Pharmacy Guild of Australia on 02 6270 1888; John Frost, CEO of Health Communication Network on 0402 383 658; Mark Winnett, Managing Director of Corum Group on 0434 658 800; or Paul Naismith, CEO of Fred Health on 0417 341 899.

The release is found at the following URL:

http://www.guild.org.au/content.asp?id=1742

Also worth reviewing is a Q & A found at

http://www.guild.org.au/uploadedfiles/National/Public/News_and_Events/Media_Release_Archive/Q%20and%20A%20ScriptX(1).pdf

Background is also available here (as well as an explanation of MedsIndex):

Scores help patients keep pace with prescriptions

Adam Cresswell, Health editor | March 29, 2008

PATIENTS will be scored on how closely they follow their doctor's orders in taking their prescribed medications, in a move designed to lift adherence rates and improve outcomes for people with chronic conditions.

The scores will be expressed as a "mark" out of 100, and will be colour-coded to indicate increasing levels of concern as scores get lower. Pharmacists will be encouraged to help patients whose scores are slipping into the red, by packing multiple medicines into blister packs that make it easier to see which drugs are due to be swallowed at particular times.

For more difficult cases, patients may be asked to see their GP for a home medication review, which is designed to simplify a patient's drug regimen.

However, the scores are not designed to imply fault or blame, and no penalties or sanctions will apply to people with low scores.

The new scheme will work by comparing the time it takes patients to return to a pharmacy to have a repeat script filled, with the time it would have taken them had they taken all the previous doses at the appointed times. It was launched by Parliamentary Secretary for Health Jan McLucas at a pharmacy conference this week.

The MedsIndex scheme has been devised by the Pharmacy Guild, which has already run it as a successful four-month pilot, mainly in Victoria and Queensland.

Pharmacy Guild president Kos Sclavos said research showed patients' adherence to dosing schedules plunged rapidly in line with the number of daily medicines they were supposed to take.

Among patients taking one pill per day, compliance was about 80 per cent, but fell to 72 per cent for those taking two pills -- and to just 64 per cent among patients taking three pills every day.

Sclavos said even an 80 per cent compliance raised concerns, as "drug manufacturers don't confirm their drugs remain efficacious if you are missing one dose in five".

More at:

http://www.theaustralian.news.com.au/story/0,25197,23442127-23289,00.html

There are a few comments that need to be made about all this:

First it is important to be aware of the following:

“The number of prescriptions dispensed in 2005-06 subsidised under the PBS was 168 million. This compared with 170 million in 2004-05.”

When we add private prescriptions to this number the total will be well over 200 million annually. The 10 million free is all of a free 3-4 week introductory offer!

Second with 200 million transactions per year even a 20 cent user pay for the pharmacists per transaction can rack up $40 million per year. A nice little earner for what will amount to operating a few secure servers, paying for some internet bandwidth and running some software which once developed would be almost cost free! I wonder who is hoping to profit from all this.

Third this has the feel to me of an attempt to establish what amounts to a commercial private monopoly on e-prescribing in Australia with the objective of entrenching the market power of the three participants. I am by no means sure this is the way to go and would prefer to see Scriptx as an entity which is at arm’s length from the joint venture partners and which is both not for profit and able to be joined by other interested entities (e.g. other practice management system providers).

Additionally I am not sure I think, what will become a crucial part of the e-health infrastructure in Australia if the venture succeeds, should be held in private hands. If there is a case for Medicare Australia to be providing identity services for the health sector I think there could also be a case for Medicare to operate the e-prescribing gateway. Certainly, given the need for data security and operational continuity, the option needs to be carefully considered before this all goes too far. Frankly this is a service Medicare should have been providing for the last five years!

Fourth I note that, while HCN is part of a major ASX listed corporation (Primary Healthcare), Corum is a worryingly small entity with a share price that was $4.00 in 1998 and which is now only 8 cents. The company’s revenue has actually declined since 2003/4 to now be only $17million p.a. Not, at first review, the ideal partner in a critical national e-health infrastructure service.

Fred Health is privately held and from its web site seems to be involved with, among other things, data mining of prescription data for the pharmaceutical industry among others.

See:

http://www.pcanu.com.au/prnetwork.html

Not an activity I am all that keen on I must say. This is hardly re-assuring.

“In conjunction with some of the world’s largest research companies, PRN also provides pharmacy data for use in research, usage reporting as well as scan data from retail activities. PRN adheres to the strict legislative requirements of privacy and confidentiality to ensure that all data protects both the interests of the participating pharmacist and their patients. The program requires that pharmacies intending to take part give formal consent before they begin.”

I wonder do patients know this is going on and I wonder how much the pharmacist is paid?

Last I wonder just how standards compliant what is proposed is. For successful interoperation nationally a high level of standards compliance is vital. I wonder what input, if any, Standards Australia work and NEHTA have had in making sure the gateway is genuinely open and interoperable.

There is a good deal of water to go under the bridge on this I suspect.

We can all watch and see how things play out. Right now, while keen to see progress, I am not quite sure this is quite the progress I want.

Time will tell.

David.

-----

Note: News will appear tomorrow.

D.

Computerised Physician Order Entry (CPOE) – A Vital In Hospital Technology

The following article appeared in Modern Medicine a few days ago

CPOE adoption, priority varies among surveys

By: Joseph Conn

Story posted: March 10, 2008 - 5:59 am EDT

The quest for computerized physician order entry has been one of fits and starts—mostly fits—since 1972, when aerospace contractor Lockheed Corp. and El Camino Hospital in Mountain View, Calif., teamed up to develop what is generally regarded as the first CPOE system in America.

Twenty-eight years later, the Business Roundtable launched the Leapfrog Group to address the patient-safety and quality-improvement challenges outlined in the seminal 1999 Institute of Medicine report, To Err is Human.

Leapfrog hoped to harness the buying power of its corporate members to pressure the healthcare industry to make improvements. It settled on pushing hospitals to install CPOE systems as one of its three initial “leaps,” along with promoting the hiring of hospital-based intensivists and evidence-based referrals for certain surgeries. Since CPOE is regarded as one of the most complex clinical information technologies, the Leapfrog Group was criticized widely for pushing CPOE, calling it “a bridge too far.”

Still, a majority of the 145 participants in Modern Healthcare/Modern Physician’s latest IT survey confirmed that CPOE is an important element in their IT plans. Asked if their organization has either a CPOE system in operation or one currently being implemented, 58.3% of respondents indicated they had. Of those who said no, nearly 45.6% said they would contract for a CPOE system in the next 12 months.

Because the Modern Healthcare/Modern Physician survey is self-reported, adoption rates for CPOE and other electronic health-record systems have been higher compared with penetration rates reported in other surveys based on random samples. Leapfrog, which also relies on a self-reported survey, but with a much larger sample of 1,280 participants, as of August 2007 found that just 10% of its respondents had met that organization’s standards for having a functioning CPOE system. Another 4% of hospitals committed to having one by 2008.

More here:

http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20080310/MODERNPHYSICIAN/620525636/-1/newsletter06

What is interesting is that while CPOE is on most wish lists the more important issue is why adoption is so slow and what can be done to improve things.

Before exploring this it is important to be clear that the evidence is in that – when properly implemented – CPOE can have a very beneficial impact on clinical error rates.

See http://en.wikipedia.org/wiki/Computer_physician_order_entry

By proper implementation I mean that the system is well designed to be easy and intuitive to use, that it is properly configured with appropriate decision support databases and that the users are properly trained to use the system effectively.

The main reason implementation and adoption is slow is that the necessary users (the doctors) do not like to be made accountable for their decision making. They have yet to really accept it is not possible to know all the evidence available and to do the right thing 100% of the time – while the evidence this is true is totally overwhelming. They should be grateful for any help they can get that will make their care better and safer – but for reasons of what must be little more than pride or ego they kick back and resist.

The other reason we see little CPOE in Australia is that national leadership is totally lacking in recognising the importance of implementing this. At the very least we need so major trial implementations to prove it will work. If we can have GPs using a similar technology to prescribe in their surgeries hospital doctors can do it in our hospitals!

David.

It Looks Like NEHTA has Missed Out on Shared EHR Funding!

In December last year we were told:

http://aushealthit.blogspot.com/2007_12_01_archive.html

NEHTA HERALDS E-HEALTH MILESTONES

and announces its action plan for adoption success

17 December 2007

Australia's e-health reform agenda took a forward step today with the release of an action plan by the National E-Health Transition Authority (NEHTA).

The Board of NEHTA also endorsed a business case for developing a national platform for personal electronic health records to be put to the Council of Australian Governments (COAG) early next year.

The NEHTA action plan outlines key areas for ensuring the successful adoption of measures to improve the electronic communication of critical health information.

"After working to build foundations for electronic health since the organisation was established in 2005, we are now in a position to begin to deliver some concrete applications of our work," NEHTA's Chair Dr Tony Sherbon said.

"The new Federal Government has signaled health reform and improvements in state and federal relations as major policy objectives," said Dr Sherbon. "Given also the government's emphasis on

the provision and use of broadband communications, NEHTA is well-positioned to play its role in advancing e-health as part of this new agenda," he said.

"The recent independent review found NEHTA had made significant progress on our goals to date and made a number of recommendations about NEHTA's future. The action plan we are announcing today flows directly from our acceptance of all the recommendations in the review," Dr Sherbon said.

Dr Sherbon identified the action plan as also being an acknowledgement of where NEHTA now needs to go in order to expedite e-health reform in Australia.

"We have come to a point where many of the foundations to enable e-health are in a position where we can now move towards implementation and adoption. Seeking funding to establish a national system of personal electronic health records is also on our immediate horizon. The action plan that we have released will assist this process," he said.

Dr Sherbon said the case for personal electronic health records was compelling. "The safety and quality benefits are manifold. We understand the issues of equity and privacy and firmly believe that

the approach developed by NEHTA will address these to the satisfaction of all our stakeholders and the Australian public."

NEHTA's Action Plan for Adoption Success and the independent review of NEHTA conducted by the Boston Consulting Group are available on the NEHTA website at www.nehta.gov.au.

----- End Release.

Well the March COAG meeting has come and gone..lots on Water and Health as you will know already..but not a peep on e-Health.

See:

http://www.coag.gov.au/meetings/260308/index.htm

The relevant parts are:

COAG Reform Agenda: Reforming and Investing for the Future

All Governments today made an historic commitment to a comprehensive new microeconomic reform agenda for Australia, with a particular focus on health, water, regulatory reform and the broader productivity agenda.

On health and hospitals, the Commonwealth agreed to commit an immediate allocation of $1 billion to relieve pressure for 2008-09 on public hospitals. This $1 billion is made up of the indexation of the previous Commonwealth allocation for 2007-08 plus a further $500 million in additional new money. Overall this means an increase in Commonwealth funding for public hospitals for 2008-09 of 10.2 per cent. This decision reverses the national trend of Commonwealth cutbacks to hospital funding over the past five years.

COAG also agreed that in developing the new health care agreement there would be a review of the indexation formulas for the years ahead. COAG also agreed that the new Australian Health Agreement should move to a proper long-term share of Commonwealth funding for the public hospital system.

COAG agreed that the new health care agreement would be signed in December 2008 with a commencement date for the new funding arrangements of 1 July 2009.

COAG also agreed for jurisdictions, as appropriate, to move to a more nationally-consistent approach to activity-based funding for services provided in public hospitals – but one which also reflects the Community Service Obligations required for the maintenance of small and regional hospital services.

COAG agreed to the introduction of a national registration and accreditation system for health professionals and steps to address health workforce skills shortages.

And:

Health and Ageing

In addition to the decisions on health funding already described, COAG agreed to the implementation of health reform in three stages.

• The first stage involves immediate action on Health Workforce Registration and transitional arrangements for the current healthcare agreement. These lay the foundation for longer term reform of the health system.
• The second stage involves COAG consideration at the December 2008 meeting of the new National Healthcare Agreement as part of the broader SPP Financial Framework. There will also be potential NP payments for medium-term health reform from July 2009.
• In the third stage, when the National Health and Hospitals Reform Commission (NHHRC) report of June 2009 is available, COAG will consider additional longer term health reform to be implemented either as updates to the National Healthcare Agreement or as new NP agreements over time.

COAG also took a major step towards improving Australia’s health system by signing an Intergovernmental Agreement on the health workforce. This agreement will for the first time create a single national registration and accreditation system for nine health professions: medical practitioners; nurses and midwives; pharmacists; physiotherapists; psychologists; osteopaths; chiropractors; optometrists; and dentists (including dental hygienists, dental prosthetists and dental therapists). The new arrangement will help health professionals move around the country more easily, reduce red tape, provide greater safeguards for the public and promote a more flexible, responsive and sustainable health workforce. For example, the new scheme will maintain a public national register for each health profession that will ensure that a professional who has been banned from practising in one place is unable to practise elsewhere in Australia.

In another boost to the health workforce, COAG agreed that Skills Australia would be asked to advise COAG at its July 2008 meeting on the possible allocation of up to 50,000 additional vocational education and training places over three years from 2008-09 for areas of national skills shortage in health occupations (including vocationally-trained nursing, emergency care and allied health occupations).

COAG also agreed key health reform priorities for further work ahead of consideration of proposals by COAG no later than October 2008.

----- End Release

Seems sanity has prevailed and we will at least wait for the National E-Health Strategy before rushing off…thank heavens! The December 2007 blog archive explains my relief in detail.

David.

NEHTA’s Future – The Article from Pulse+IT March 2008 – With an Update

A week or so ago Pulse+IT published an article I contributed.

See the following URL:

http://www.pulsemagazine.com.au/index.php?option=com_content&task=view&id=311&Itemid=1

Where to next for NEHTA?

Very late December, 2007 the National E-Health Transition Authority (NEHTA) released a report developed by the Boston Consulting Group (BCG) reviewing NEHTA’s performance since establishment. A response to the BCG report, prepared by NEHTA, was released on the same day.

The ‘BCG NEHTA Review’ had been finalised in October 2007 and the NEHTA response on December 6, 2007. If it was not for reasons of media management in immediate proximity to the Christmas holiday period, the reason for the delayed release of the two documents remains unclear. That there was a long congratulatory piece (see reference) published in association with the document’s release would lend some support to that view.

Delayed release aside, it is the purpose of this article to critically review each document in turn.

The BCG NEHTA Review

The review document is the outcome of a consultative process (with a call for public submissions) that ran from July to late October 2007. The review involved interviews with over sixty stakeholders and consideration of some nineteen written submissions.

The major findings of the review were:

1. NEHTA has raised the profile of e-Health in Australia.
2. NEHTA has largely focused its efforts in the right areas to facilitate the emergence of an appropriate e-Health infrastructure in Australia.
3. NEHTA’s initial work plan was overly ambitious – why NEHTA lacked the insight to recognise that is not explained – but a revised, less ambitious plan is now only a few months behind its reframed target dates.
4. NEHTA has put in place recommendations for terminology and secure messaging standards, but is yet to have reference implementations available. Additionally there is no certification process in place to assess interoperability.
5. NEHTA has been unable to recruit an adequately skilled workforce to deliver on many of its plans. While a lot of documentation has been developed, the implementation of much of this documentation is yet to be achieved meaning it is unclear how well some of the major projects will be delivered.
6. The delay in staff recruitment has meant many initiatives are very substantially underspent.
7. NEHTA has dealt with virtually all stakeholders, other than its jurisdictional masters, with a lack of transparency and virtually no effective communication leading to very considerable annoyance and frustration on the part of many stakeholders.
8. While NEHTA has delivered much documentation, actual ‘proof on concept’ implementations are yet to happen.
9. As far as Shared Electronic Health Records (EHR) are concerned, NEHTA won’t be delivering in the 2009 timeframe and so should focus on building support for the concept and ensuring issues such as privacy are properly addressed. The BCG report says NEHTA has done a lot of high-quality work in this area but has not let anyone external to the organisation assess it – so there is really no agreed status of all this.

It should be noted that the BCG report suggests that by mid 2009 there is a good chance terminology, secure messaging, supply chain improvements and identifiers will be in place but that the Shared EHR is unlikely to make much progress.

The essential recommendations of the review were:

1. Start communicating sensibly and openly with stakeholders. Move from the theoretical to more practically focused ‘proof of concept’ implementations and re-organise around project delivery.
2. Fix staff shortages – possibly by recruiting overseas or outsourcing.
3. Put in place accreditation and implementation / interoperation functions.
4. Create a much more representative Board to guide the organisation and build stakeholder trust.

In summary what the report says is that NEHTA has not recognised ‘Lesson 101’ of working in the health sector – i.e. you must communicate, listen and engage – and have thus essentially “fallen at the first hurdle”. Unless this is rapidly changed it is likely success will elude them in the long term is the very clear subtext of the BCG Report.

NEHTA’s RESPONSE

In response to the BCG report, NEHTA developed a 10 page document titled ‘Action Plan for Adoption Success’. In this document, NEHTA responded to each of the formal recommendations and agreed to each of them – however I am still wondering what the title of the document actually means – it is hardly an action plan and there is much more at stake than adoption.

Recommendation 1: Create a more outwardly-focused culture.

NEHTA says it recognises the need for this and has developed a plan to achieve it.

Recommendation 2: Reorient the workplan to deliver tried and tested outputs through practical ‘domains’.

In an important shift, NEHTA now says it will work with partner organisations to make deliverables that actually meet a need – e.g. pathology messaging, referrals and e-prescription – while continuing to deliver identification, authentication and terminologies.

Recommendation 3: Raise the level of proactive engagement through clinical and technical leads.

NEHTA plans to recognise the importance of the various clinical groups. Unfortunately it did not list nurses, allied health or specialists as targets – but we can wait and hope.

In a worrying example of ‘non-openness’, NEHTA reveals it has finalised a submission for the Council of Australian Governments for a Personal e-Health Record (PHR) and the first the public will really know anything about it is when it is approved. To quote:

“NEHTA will increase its engagement with healthcare consumer audiences. The focus of this program is on raising awareness of the proposed personal e-health record, and will establish a basis for a significant increase in engagement once the business case for the personal e-health record is approved.”

I must note it is by no means clear if the proposed Personal e-Health Record is the same thing as the Shared EHR of the recent past. If ever there was a candidate for full and open stakeholder review and discussion, this is it!

Recommendation 4: Accelerate resourcing through outsourcing, offshore recruiting and more creative contractual arrangements.

NEHTA admits there is a problem – but seems hesitant to go overseas. It does however seem keen to outsource some key operations.

Recommendation 5: Reshape the organisation structure to address revised priorities.

This response actually reveals some interesting elements. First there are now three (not two) National Infrastructure Programs:

1. Unique Healthcare Identifiers Services
2. The National Authentication Service for Health
3. Clinical Terminologies

As far as I am aware, this was the first mention of an authentication service. It was apparently approved in October 2007 by the NEHTA board and it seems to be intended to replace – in a year or three – HESA, Medicare and other private authenticators.

Second, we discover there is to be a NEHTA Conformance, Compliance and Accreditation program whose scope is yet to be fully revealed.

Third, we discover – very belatedly – that NEHTA will also examine requirements for clinical registries, GP desktop systems, e-consulting, and decision support techniques and tools to determine the scope of any future involvement by NEHTA. Frankly, if NEHTA is not involved deeply in each of these domains, the organisation is a waste of time in my view!

Recommendation 6: Add a number of independent directors to the NEHTA board to be broader advocates of e-health, and to counter stakeholder perceptions of conflict of interest.

While it is great the recommendation has been accepted (if not yet actioned at the time of writing), it would have been good to see some admission that the present board structure was unsatisfactory and worked very poorly. NEHTA have clearly ignored primary care and the private sector, and it is excellent the BCG has pointed this out.

The Need For A Plan

The main question is “what is missing here”. Given all the apparent agreement between the reviewer and reviewed, a number of major things concern me about all this.

My first major issue is that the last paragraph of the executive summary, identifying the need for a national Health IT Strategy, has simply been ignored by the NEHTA Board.

“In parallel, planning for the next phase of eHealth coordination and implementation needs to commence now or momentum could be lost. An eHealth strategy and eHealth policies need to be developed. Further analysis and debate by NEHTA and its members on the future vision for eHealth and the role of a central agency (as described above) is needed now to generate a plan by mid 2008. Regardless of the funding scenario and any future role of NEHTA II, we believe that the ‘transition’ NEHTA is tasked to support has at least another five to ten years to run.”

I welcome all the recommendations, cited above, as far as they go - but feel they do not point to where the real work is needed - i.e. a National e-Health Strategy.

This analysis needs to be in-depth and fundamentally assess where e-Health is up to now, what has worked and what has not and then design a practical and pragmatic route to an e-Health enabled future for the Health Sector.

My second major concern is that while it is clear there have been a very large number of issues with the way NEHTA has operated - there is no apparent accountability for the mis-steps being accepted by the Board and Staff of NEHTA.

That said, the BCG report’s findings seem to me to accurately reflect the view of external stakeholders (Health IT experts, Health Providers and IT experts) but the impact is diluted by continual use throughout the report of the views of the NEHTA staff on the quality of the job they are doing. The staff and Board are hardly likely to be objective regarding their own performance!

It is clear from the BCG report that NEHTA has received a ‘fail’ from its customers, while the staff are so disconnected from reality they cannot even grasp why they are seen as having done such an indifferent job.

My third major concern is that we now seem to have NEHTA recommending a business case for a National Shared EHR (or Personal e-Health Record or whatever) to the Council of Australian Government – and the public has had no apparent input – other than via a discredited NEHTA Board and a few bureaucrats. This is hardly the new open, engaging and consultative NEHTA! This is frankly unacceptable in my view.

My fourth concern is that with this review completed, it is not clear that there will be any assessment of NEHTA’s success in getting back on the rails. I, for one, think a reassessment in 12 to 18 months is vital.

My fifth major concern is that to date, there is no evidence that NEHTA (or the BCG) really understands that its client is the entire Health Sector and that its efforts need to be shaped in a way that addresses the needs of all the sector’s components and treats the health sector as an integrated whole.

In summary, the BCG report addresses some of the operational, cultural and engagement failures of NEHTA, while failing to firmly recommend the development of a national e-Health plan to achieve value from NEHTA’s work. Without this, NEHTA will remain an unguided missile operating without strategic context and at risk of continuing to underperform.

For the BCG to let NEHTA escape from this review without a clear articulation of the need for a National E-Health Plan and a strong recommendation for the work to be done is really very poor indeed.

References

Hewett J. Healing Australia via broadband. Available at http://www.australianit.news.com.au/story/0,24897,22935859-24169,00.html [Accessed on 7/2/2008].

-----

I added a comment in early March just after publication and well after the deadline had passed!

-----

March 2008 Update!

At least we now see plans emerging, as has been suggested for 18 months, for a Plan to be developed. I hope it is a considered, strategic, quality, visionary, detailed and consultative plan!

We will see!

David

-----

In the last few weeks what has been becoming clear is that the NEHTA ‘of old’ is not going to be left alone to pursue its secretive and unclear agenda without some intervention from the new Commonwealth Government. The new, soon to be developed, National Health IT Strategy will clearly form a view as to what part of the NEHTA’s work plan should proceed, what should be accelerated, what should cease and what should be re-focussed. It is also now inconceivable COAG and AHMAC will be making any new major funding commitments until the new Strategy reports back to AHMAC.

I think it is clear that in the next six months the e-Health landscape in Australia is likely to look very different.

David.

The AHIC Future Directions Paper is Hopelessly Misconceived and Already Obsolete.

In the last week a paper developed by the luminaries of the Australian Health Information Council has been released , having been finalised in sometime in August, 2007. The paper purports to suggest the Future Directions in E-Health for Australia for the next five years.

The release of the paper was publicised on the blog a few days ago.

See:

http://aushealthit.blogspot.com/2008/03/ahic-future-directions-paper-now-in.html

The recommendations made are as follows:

“1.1 Recommendations

In considering its advice, AHIC recommends the following:

1. That a comprehensive national eHealth strategy be developed in consultation with the Jurisdictions, industry, the community and health services, and that this strategy encompasses the advice of AHIC contained in this document.

2. That AHMAC recognise that eHealth is the cost of doing business in the 21st century healthcare and that this will require continuity of investment, accepting that products and hardware will need to be continuously implemented and upgraded in an ongoing cycle of capacity building.

3. That AHMAC recognise that Jurisdictions have many of the necessary eHealth components already and that what is needed is an effective system of knowledge exchange that can accelerate implementation rather than develop new products when existing ones can be used.

4. That a time limited implementation function/ body that is responsible for “connecting up”, building upon existing work and integrating eHealth nationally should be established and funded by AHMAC.

5. That a core set of functioning components of an Australian SEHR should be operating across Australia by 2012.

6. As part of the implementation function/ body, that an implementation plan and resources schedule should be developed to deliver the AHMAC national eHealth Strategy. The processes should be flexible and adaptable over time to the changing/evolving nature of information management and information communication technology.”

Implicit in all this is that at present there is no National E-Health Strategy and that there should be one. On that we are as one!

The second clear implication is that NEHTA is not the implementation body to get e-Health improvement done. Again vehement agreement.

The third clear implication is that we need much better and safer systems throughout the sector and some certification / control of such systems is vital – again I agree.

With these things said the key problems I see with the paper are as follows:

First the perspective adopted that you can essentially ignore the whole of the ambulatory health sector is just amazing in its stupidity. The thinking about a Shared EHR all seems to forget it that the information that needs to be in it has to be provided by GP’s and Specialists in the field. I can see “general practice” mentioned twice in the whole document and “ambulatory” not other than in a reference. This whole document flows from a centralist, bureaucratic perspective that has been the cause of many of the problems to date (think NEHTA). Anyway AHIC should say we need a plan, and leave it at that – not then try and apply their perspective as they do in Recommendation 1.0.

Second, the depth of research for a paper aiming as supporting the implantation of a national strategy is really quite uncomprehensive and I would assess it as dangerously understating the current state of knowledge. Also, sadly the references there are don’t even appear to be linked to the text. There is good evidence out there that e-Health works in terms of quality, efficiency and safety and increasingly that it can also save money. To say it is just a ‘cost of doing business’ simply is not a good enough justification for the large investment that will be required.

Third, it is increasingly clear there are serious options available to the Shared Centralised EHR, considered here, which can offer substantial benefits, which have not been even mentioned. Patient held Personal Health Records are the most obvious and I am sure there are others.

Fourth, the timeframes suggested here are essentially fantasy. With the best will in the world serious Shared EHR implementation is a 5+ year project (2009-1014) at least.

Fifth, despite the claims of some, there is no evidence that just ‘connecting up’ a collection of random unsustainable initiatives is going to get anyone anywhere. This is ‘fairies at the bottom of the garden thinking’

Sixth has anyone recognised that decision support is something that ideally happens at the point of care on the basis of a full information set. This is simply not what a shared summary record provides – and no one plans to share full local EHR centrally as far as I understand.

Seventh, there just does not seem to be any recognition of the now crucial concepts of EHR enabled ‘rapid learning’ and other more innovative use of full – as opposed to summary EHRs – as is all that can be provided in large scale centralised systems.

See:

http://aushealthit.blogspot.com/2007/02/weekend-treat.html

Eighth, it is clear AHIC has simply no idea of what is involved in making even the outline of the environment pictured on page 24 reality. The complexity and effort in doing this is really quite something and I believe is a decade long project.

Last the claim they Australia is well advanced in e-Health is just internally contradictory and frankly Table 1 is a conceptual nonsense. If we are well advances it’s obvious a plan free approach works. As the whole point of the document is to recommend a plan one is forced to conclude the authors clearly recognise there are huge gaps which need to be addressed.

This paper needs to be considered as an artefact of another era (the secretive, non-consultative Howard era) and the Consultants engaged to develop the national e-Health strategy should give it the weight it deserves – not much!

David.