E-Prescribing – Do the Current Initiatives Make any Sense?

In recent times there has been a lot of discussion about electronic prescribing (or e-prescribing). In this blog I want to run through just what I believe would constitute a satisfactory e-prescribing system for Australia. The criteria I would apply are as follows.

Criterion 1.

The E-prescribing should be fully compliant with all aspects of AS 4700.3(Int)-2007 : Implementation of Health Level Seven (HL7) Version 2.5, Part 3: Electronic messages for exchange of information on drug prescription.

This would include electronic messaging of standardised content between prescriber and dispenser as well as support of the other medication management functions the Standard envisages.

Criterion 2.

The terminology used is the current version of the Australian Medicines Terminology (AMT) which in SNOMED CT compliant. This is a minor problem at present as I understand this is still a work in progress with a completion date somewhere in 2009.

Criterion 3.

The act of prescribing should be supported by Level 4 clinical decision support based on approved knowledge databases of established quality and consistency.

Criterion 4.

There be effective communication between dispensing and prescribing systems to enable assessment of issues such as compliance and medication abuse, while avoiding any leakage of such information to any third party without the agreement of the patient.

Criterion 5.

There be absolutely no access to prescription data by any commercial interests – most especially any pharmaceutical companies.

Criterion 6.

If any centralised ‘store and forward’ hub networking technology is to be used (as I would prefer) for allowing a prescription to be held until requested by a dispensing computer system then the hub should be controlled as a key piece of national e-health infrastructure by the Commonwealth Government (or a Government owned agency with appropriate governance in place to totally protect the public interest and patient privacy).

Criterion 7.

All access to the National e-Prescribing network should be fully protected by appropriate security, encryption and privacy mechanisms.

Criterion 8.

Access to the National e-Prescribing network should be via a fully open and standardised mechanism with an entity like Australian Health Messaging Laboratory (AHML) certifying compliance before access is permitted.

Criterion 9.

Of course, there should be only one national network with competition being encouraged based on the quality of the prescribing and dispensing systems offered by those who connect to the network.

At present there are three potential offerings in trial or in development on the table.

First we have the NT e-Prescribing Initiative.

Details of the approach being adopted can be found here:

http://publishing.yudu.com/Freedom/Acqew/Pulse+ITMay2008/resources/index.htm?referrerUrl=

(at page 11)

Or here:

http://www.health.nt.gov.au/news/2008/news_14_05_nt_delivers_national_first_electronic_prescriptions.shtml

Second we have the commercial ScriptX initiative.

Details of this can be found here:

http://publishing.yudu.com/Freedom/Acqew/Pulse+ITMay2008/resources/index.htm?referrerUrl=

(at page 17)

Or here:

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

Lastly I am assured that Medicare Australia has been considering how it might get into this space to augment their on-line presence and leverage the data they already hold.

I will leave it as an exercise for the reader to see how close each of these might be to what I believe is desirable.

Essentially I believe we should have a National E-Prescribing infrastructure that is open, fully standardised, fully SNOMED CT based system with hub controlled ultimately by Government.

Competition should be at the prescribing and dispensing client level. Trials of half-baked systems have their place – but they will not lead to the national infrastructure we need.

This is a project Government should support soon so we don’t wind up with a mess of incompatible and non-standardised systems.

David.

EHR Impact – An Important Study of Approaches to e-Health Benefits.

As part of the recent e-Health conference in Slovenia the following study was presented. Here is an interview related to the presentation.

“The main lesson is that ICT is only part of the solution”

At the recent European eHealth Conference in Slovenia, an EU commissioned study on the “Socio-economic impact of interoperable electronic health records and ePrescription in Europe - EHR Impact” was presented. One of the case studies is the computerised patient record (CPR) system at the University Hospitals of Geneva (HUG), which since 1998 has connected their seven hospitals at four campuses. Based on a service oriented architecture and utilising web technologies, it comprises unique patients’ and providers’ identification, access management, unified clinical documentation, order entry for all orders such as laboratory and radiology tests, and management information. HealthTech Wire talked to Prof. Dr. Christian Lovis, Head of the Clinical Informatics Unit at HUG, and Alexander Dobrev, consultant at the research and consulting firm empirica, about the impact of the CPR system on the hospitals.

- (HealthTech Wire) - Based on your initial research results, what are the major benefits of the CPR system for the hospitals?

The major benefits come from the redeployment of resources, including doctors’ and nurses’ time, leading to better quality care; a reduction of risk exposure; and avoidance of over-prescribing laboratory and radiology examinations. The hospital management also uses the system to provide important information for strategic decision-making. Health insurances benefit from fewer hospital admissions, because, e.g., patients in Accident & Emergency departments can often be helped immediately and need not become inpatients until their records are found. HUG also redeploys liberated resources to meet increasing demand.

More difficult to measure, but extremely important, are the benefits to the people involved. All clinical staff have to adapt to changing work flows and processes, and the gains must be of higher value than the extra effort required. We know from our interviews that these personal benefits include being able to focus on clinical tasks instead of searching for records, not having to chase colleagues to decipher illegible handwriting, and the feeling of being less vulnerable and exposed to risks, because the CPR system allows for better-informed decision making. There are gains to patient safety and quality of care – the CPR system provides doctors and nurses with the critical information and decision support they need to reduce the risk of adverse events, and it does so fast, so carers can pay more attention to individual patients.

Has the study shown a return on investment?

The EHR IMPACT study focuses on comprehensive benefit cost analysis, not on return on investment to a single stakeholder. These are different measures, but should be regarded together by decision makers. According to our research, based on accounting data and well-founded estimates, the value of economic benefits at HUG exceeded the value of economic costs on an annual basis for the first time in 2005. The cumulative turning point is achieved about now – 2007/2008, some ten years after the idea for the system in its current form was born. The analysis of the purely financial position is not yet complete but the preliminary results look promising.

More here

http://www.healthtechwire.com/Pressrelease.146+M5b4ee4b5902.0.html

The ongoing project has a web site which can be found here:

http://www.ehr-impact.eu

As part of these studies two evaluations have already started. These are the computerised patient record system at the University Hospitals in Geneva, Switzerland, and the Scottish Emergency Care Summary Programme in the UK.

Presentations on the Geneva project are already available here:

http://www.ehr-impact.eu/downloads/documents/2008-05-07%20eHealth%20Portoroz%20Lovis.pdf

and here

http://www.ehr-impact.eu/downloads/documents/eHealth_2008_Portoroz_dobrev.pdf

These were presented at the conference referred to earlier in the blog.

These presentations and the various papers provided at http://www.financing-ehealth.eu/ deserve careful review by all those interested in justification of e-Health investment.

David.

An Important Conference You Have Never Heard Of!

Earlier this month there was a small conference in Portoroz in Slovenia. The introduction to the conference describes it thus:

“The conference is the continuation of a tradition of annual ministerial or high-level events. These conferences enable the demonstration of contemporary achievements in eHealth and the set-up of guidelines for future efforts so as to ensure the efficient use of information and telecommunication solutions in healthcare.

eHealth has enabled a tremendous development of healthcare systems over the last few years. It has already brought many opportunities to raise the quality and accessibility of healthcare services. It provides a greater efficiency of services which, in today’s era of considerable expectations on the part of every citizen, combined with limited financial resources in the system, has become among the most important goals of healthcare. With the help of information and telecommunication technologies we are introducing new ways to provide medical treatment, ease communications between citizens and healthcare providers, simplify procedures, ensure mechanisms for reducing errors, encourage individuals to manage their own health and, finally, provide data for the management both of risks and healthcare systems.”

The conference web site can be found here:

http://www.ehealth2008.si/

What came out of the full 2 day meeting was the following declaration.

The Portorož Declaration
7 May 2008: eHealth 2008 Conference Declaration

eHealth in a Europe “without frontiers”: Building New Initiatives - Working Together

The potential offered by eHealth, and the evidence of its success, has long been clearly identified. Since 2003, with the creation of a series of eHealth conferences of which this is the sixth various Ministerial and high-level groups, together with the European Commission, have agreed to making Declarations and conference conclusions with a focus on eHealth. Based on these yearly commitments, the Member States have achieved a great deal of progress. Their successes include eHealth roadmaps in all 27 of the Member States, in-depth involvement in the large-scale pilot on eHealth, and considerable penetration in many different countries of the use of electronic health records, much of this based on direct implementation of the eHealth Action Plan for a European eHealth Area.1

People-centred eHealth initiatives provide all Europe's citizens with smarter health environments. They aim to satisfy the need to provide 'the three Cs' continuity of care, comprehensiveness (and integration and coordination) of care, and care in the community to Europeans. Citizens and patients are enabled to become actively and dynamically engaged in the actual process of healthcare and on their own personal health needs. Today, we go several steps further in applying all these agreed goals, advancing them further by:

• Building on national eHealth roadmaps

Each Member State has shared with the others its recent plans and strategies regarding policy priorities in eHealth. Commitment is needed to ensure that roadmaps are updated and distributed regularly, to maintain a solid foundation for building future activities. Information should also be disseminated by the Member States regarding the kinds of electronic tools that can support them in addressing the many, concrete challenges posed by health care systems.

• Organising Europe-wide cooperation

In the context of a project supported by the Commission, a consortium of Member States and industrial stakeholders has committed to developing, designing, prototyping, and validating in a pilot context European Union electronic health services based on two distinct health situations: cross-border access to electronic patient summaries and ePrescription (including e-medication). Other Members of the Union and stakeholders are involved in a “watching brief” of this pilot, through which they understand and assess in what ways they can use the applications that are under development. This Union-wide cooperation will continue to evolve over a 3-year period.

• Combining standardisation and safety in eHealth

The Commission plans to issue a recommendation on cross-border interoperability of electronic health record systems, laying out clear guidelines for arriving at the keenly anticipated scenario of enabling patients to access electronic health records anywhere any time. There is a need to emphasise the improvement to patient safety that ICT can facilitate, especially as a result of the enhanced interoperability of systems. Combining standardisation and safety in eHealth must now be seen as a priority issue by all stakeholders. It is fundamental to define a common understanding through semantics in healthcare.

• Involving all stakeholders, in particular patients, and supporting the eHealth industry, especially small- and medium-sized enterprises

Participation of industry in the planned large-scale pilot on cross-border use of patient summaries and medication data is particularly welcome. The paradigm shift towards clear support for eHealth can be achieved only by involving the key industrial and user stakeholders in developing eHealth solutions from the earliest stage. Industry and user stakeholder groups will continue to be consulted regularly during the formulation of policy in the eHealth field.

• Creating an innovative eHealth market

With its focus on deployment-related implementation, the Commission Communication on 'A Lead Market Initiative for Europe'2 outlined barriers to the development of the eHealth market in Europe. The Communication included specific actions for Member States to contribute to accelerating the development of the market, including support for further pilot actions under the Competitiveness and Innovation Programme and a coordinated action that will relate to possible developments in the legal framework, standardisation, certification and procurement activities.

Building the key next steps - three core and parallel endeavours

Three key initiatives must now begin to operate harmoniously alongside each other in order to overcome the major health challenges that lie ahead over the next ten-year period.

• The first crucial area is the need to plan to deploy telemedicine and innovative ICT tools for chronic disease management. The Commission aims to issue a Communication on this topic in the fourth quarter of 2008. Its objective will be to enable Member States to identify and address possible barriers for wider deployment of telemedicine and to coordinate their efforts.

• Second, but equally important, is the need to introduce an enhanced focus on new research opportunities. A more adventurous exploration of next and future research and technology development steps in Europe is required. Government policy-makers should look ahead in a prospective foresight and envisioning exercise. Thus, they will understand how exciting new directions in research and development are likely to affect policy decisions about health care decisions over a ten-year time horizon, and start to plan for such innovation potential. Citizens’, patients’ and health professionals’ involvement will be key to this process, as well as for the success of present-day implementation of projects.

• Third, is the need for a transparent legal framework agreed between the Member States. It would help to define the responsibilities, rights and obligations of all the different subjects involved in the eHealth process, such as national, regional and local health authorities, health care professionals, patients, insurance companies, and other relevant players. Special attention should be paid to exploring the existing Community legislation that affects eHealth significantly, especially the Data Protection Directive, e-Privacy Directive and e-Commerce Directive. This implies an active dialogue and involvement of all the relevant national authorities in the area of health, personal data protection, technical harmonisation, standardisation, and eCommerce.

Getting on board today: the immediate big step that will enhance the quality of health and social care for over 500 million Europeans

The Member States and the European Commission commit to support together the deployment of high-capacity infrastructure and infostructure for health and social care information networks and services such as telemedicine (teleradiology, teleconsultation, telemonitoring, telecare), ePrescription and eReferral. With continued commitment from all the actors involved, European-wide cooperation on electronic health services will lead to the successful formation of a European health information area. As a result, the health of European citizens and the sustainability of European health care systems will benefit considerably.

1 COM(2004)356: eHealth - making healthcare better for European citizens: An action plan for a European eHealth area.

2 COM(2007)860: A lead market initiative for Europe.
The declaration is found here:

http://www.ehealth2008.si/index.php?id=26&mid=25

So what we have here are the 27 countries of the European Union (many of which are less than 20 years from being under the yoke of the former USSR) recognising that after a decade of investment they are really starting to get places and committing both more effort and more investment at the top strategic level.

I wonder will we see a comparable vision and commitment from the current National E-Heath Strategy process and the new Federal Government. The early signs from the recent budget hardly fill one with confidence.

One really wonders why it is so hard in Australia!

David.

What Exactly Does as Commonwealth Department of Health Takeover Mean?

The following article appeared last week.

E-health goes back to basics

Karen Dearne | May 15, 2008

FEDERAL bureaucrats are back in charge of the e-health reform agenda, with the Rudd Government allocating $60.6 million to solving the "challenges" of complexity, pace of technology development and lack of consultation with stakeholders.

Budget documents say the Government, through the Health Department, "will work with the states, professional groups and consumers, to address the aspects of e-health requiring national leadership and coordination. This includes the development of a national e-health strategy".

The declaration ends the arm's-length approach to e-health adopted by the previous government, which created the largely ineffective National E-Health Transition Authority (NEHTA) to manage the issue then cut existing projects such as the HealthConnect nationwide patient record-sharing system.

Underlining the shift away from NEHTA, the Budget statement adds that the department "will specifically oversee the development of national standards to enable compatibility of e-health systems across the national health network. The department is working to ensure health systems are interoperable, and can safely and securely exchange electronic health information between health professionals with patients' permission".

NEHTA founding chief executive Ian Reinecke resigned unexpectedly in late March, amid increasing calls for a clear strategy and state health departments embarking on their own, separate, health IT projects.

Andrew Howard, chief information officer of Victoria's Human services department, is currently acting chief executive while an international search is conducted for a replacement for Dr Reinecke.

A formal review by Boston Consulting found the authority had failed to communicate with health and IT industry stakeholders whose support was needed to resolve complex technical and workplace reform concerns.

In contrast, the new government has promised to consult with "medical groups, the software industry, other professions and the community to ensure the needs of all are taken into account" and the benefits of e-health properly communicated.

It's understood NEHTA will be required to report directly to department officials, who will "ensure work is delivered within agreed timeframes".

However, e-health has taken a Budget cut of $4 million to $60.6 million in 2008-09, compared with $64.6 million in the previous year.

In 2006-07, the Howard Government left $41.5 million unspent out of $79 million allocated to national health IT projects, as it lost interest in e-health reform.

More here:

http://www.australianit.news.com.au/story/0,24897,23703220-16123,00.html

Superficially this may seem to be good news but I would suggest it needs to be treated with considerable caution. Why?

First, with the unstable and unfocussed shambles that e-Health has been over the last few years, virtually anyone with any long term corporate understanding of the e-Health domain has left DoHA for pastures green.

Second those who remain have done a pretty poor job of providing Federal Co-Ordination of e-Health initiatives and have funded a series of non-strategic pilot projects in a planning vacuum they must have been clear existed.

Third these same people stood idly by while NEHTA ran amok causing frustration, annoyance and anger among virtually every impartial observer of what was going on. Surely the central bureaucracy could have had a major influence on what happened once it became clear just how badly NEHTA was behaving in 2007.

Fourth, what funds they have obtained have not apparently been spent as they should have been, and have presumably been lost to the Tanner razor!

Fifth there is no evidence at all that the very senior Departmental leadership has any interest in, understanding of or concern for e-Health, rather seeing it as a poison chalice that can result in severe career limitation.

Whether having DoHA more involved is a good thing will be easily measurable. If in the budget next year there is not significant new investment planned as a result of the National E-Health Strategy we will all know the unsatisfactory status quo prevails. I for one will be watching closely.

Just how we expect $60 million spent on e-Health Implementation in a Commonwealth Health Budget of $50,728,515 million (that is 0.00018%) to actually make a difference is beyond me! To do anything that would actually make a difference must cost in the billions not the tens of millions!

David.

Richard Dixon Hughes of DH4 Provides Detailed E-Health Budget Analysis.

Richard Dixon Hughes, Managing Director of DH4 Pty Ltd, (an ICT and e-Health Consulting firm) has kindly agreed to allow general access to his detailed budget analysis.

Australian Government Budget 2008-09
Summary of e‑Health and health information measures

Having discussed the budget measures with a number of friends and colleagues, all of whom were interested in getting more information on the implications and outcomes for e‑health and health information activities in Australia, I committed to put together this consolidated document containing a summary and extracts of what I consider to be the more relevant provisions.

Overview

The measures identified appear in several places in the 2008‑09 Budget Papers, with each measure typically being covered in one or more of the following:

· Aggregated into the Expense Measures in the summary expenditure tables at pages 39-76 the start of Budget Paper No 2 Budget Measures 2008-09;

· Expenditure tables and summary descriptions of expenditure measures for the Health and Ageing (H&A) portfolio at pages 201 to 246 of Budget Paper No 2;

· Expenditure cuts and reallocations under Whole of Government: Responsible Economic Management at pages 201 to 246 of Budget Paper No 2; and

· Information, explanations and justifications set out in the 2008-09 Health and Ageing Portfolio Budget Statements (Budget Related Paper No. 1.10), particularly in relation to Outcome 10 (Health System Capacity and Quality).

Key features of the Budget provisions that were identified as having some relationship to current or proposed e-health activities are:

1. Cuts to the previous e-health implementation program. While these totalled $10.5 million over three years and were part of a basket of cuts, it is not clear what the extent and nature of the specific reductions within the e‑Health Implementation Program have been (see Appendix A below for more detail).

2. The role of e‑health being acknowledged in general terms in relation to improving the capacity and quality of the Australian health services (see Appendix B below).

3. Improvements in safety and quality outcomes and in clinical and administrative decision-making are the goals of Department of Health and Ageing Program 10.2 (e‑Health Implementation) as set out in Appendix C below, including the following cornerstone activities:

· providing Australian Government leadership in e-Health, by:

- demonstrating the health care safety and quality benefits; and

- developing health information privacy measures,

· working with states and territories, professional groups and consumers, to address aspects of e-Health requiring national leadership and coordination - specifically development of a national e-Health strategy;

· overseeing the development of national standards to enable compatibility of e-Health systems and alignment with national e-Health policy;

· working to ensure health systems are interoperable, and can safely and securely exchange electronic health information; and

· consulting with medical groups, the software industry, other professions and the community to take their needs into account in pursuing the above.

4. As stated on page 220 of the H&A Portfolio Budget Statements, Administered funds provided for a specified period and not used in that period are subject to review by the Minister for Finance and Deregulation, and may be moved to a future period.

Of the $70.076 million of Administered funds moved between 2007-08 and later years for the Health and Ageing Portfolio, $7,362 was within the e-Health Implementation program.

5. Previous ICT incentives for General Practice are being abolished and a new incentive payment of $6.50 per patient introduced in their place – however the net result is planned to be a saving of $110.7 million over the next 4 years. More information on this measure is provided at Appendix D below.

6. In other e-health related measures being undertaken by DoHA, the following were noted:

(a) The KidsMatter Initiative under the Mental Health programs (Outcome 11) includes activities to ensure that help is available to families by links to web-based mental health services, information systems and programs such as Kids Helpline;

(b) Web-based mental health therapies and interventions to complement face-to-face services, which are supported through the Mental Health – Telephone Counselling, Self Help and Web-Based Support Program (DoHA Program 11.1); and

(c) A KPI for DoHA Program 2.5 (Palliative Care and Community Assistance) is that the CareSearch website meet the information and resource needs of health professionals, volunteers, patients, families and carers.

7. Investment by AIHW continues to capitalise on the “new information environment” offered by information technology and e‑health, but with a less specific program of activities than was suggested in last year’s budget. More details are provided in Appendix E below.

8. As noted at page 445 of the H&A Portfolio Budget Statements: “The NHMRC is developing an integrated data platform to improve accountability, information management and reporting of the Australian Government’s investment into health and medical research. In 2009, a research investment management system, developed by the NHMRC to support the grants management process, will come online. The system will support the full grants management process from application through to grant acquittal, including peer review, approvals, administration and accountability. It will replace the current grants management system and facilitate the growing reporting and business intelligence needs of the NHMRC.”

9. One of the major cost saving measures was the abolition of the Access Card project (being managed within the Human Services portfolio) leading to an all up reduction of $1.2 billion over 5 years. More details are provided in Appendix F below.

10. As indicated in the Portfolio Budget Statements for the Human Services portfolio Medicare Australia is undertaking a range of activities aimed at:

(a) Maximising take-up of electronic Medicare claiming to enhance access, choice and convenience for the public and for providers;

(b) Designing and developing a Unique Healthcare Identifier (UHI) service under contract to the National E-Health Transition Authority, noting that: This service will generate healthcare identifiers for patients, healthcare providers and healthcare locations, and is aimed at facilitating the development of electronic health records in Australia. [at page 91]; and

(c) Aged Care online claiming and refreshing the technology of aged care payment systems.

There was little detail provided about the specifics of how these aspirations would be realised or the investments required.

11. A large number of H&A portfolio programs involve the maintenance of data collections, to assess national health status, program effectiveness and for other purposes. The following are among those specifically mentioned in the H&A Portfolio Budget Statement.

· National Postnatal Depression Initiative – data collection to be developed collaboratively with the states and territories and BeyondBlue to support evaluation and management of the program and for research.

· National Cervical Screening Program - overall coordination of national data collection, quality control, monitoring and evaluation.

· A National HPV Register is being developed on behalf of DoHA by Victorian Cytology Services to provide ongoing monitoring of coverage rates and vaccine effectiveness. Data collection will begin June 2008, with uploading to the electronic system to commence in November 2008 for access by girls and health professionals from January 2009 onward.

· Improving national data on the effectiveness of programs to prevent and treat illicit drug use (including collecting data on the cost and social burden of drug use) [under DoHA program 1.3].

· Medicare Services Program [DoHA Program 3.1] supports access to a range of medical services listed in the MBS and maintains and analyses comprehensive data on services, benefits and costs to patients.

· National Respite for Carers Program – data on carers provided with respite assistance.

· Within Outcome 8 (Indigenous Health):

- participating in the National Advisory Group for Aboriginal and Torres Strait Islander Health Information and Data;

- improving the quality and availability of important statistics relating to the health of Indigenous people;

- funding new work on estimating Indigenous mortality rates;

- developing guidelines for improving Indigenous identification in key health datasets;

- developing social and emotional well-being data; and

- producing the 2008 Aboriginal and Torres Strait Islander Health Performance Framework Report.

· Monitoring the uptake of insurance products and use of services covered health insurance and their impact on private health insurance costs and risk equalisation arrangements - through quantitative assessment of Hospitals Casemix Protocol data, data collected by the PHIAC and consultation with the private health insurance industry.

· Better Arthritis and Osteoporosis Care Initiative - data collection related to funded programs focused on primary and secondary prevention, and best practice management of arthritis and osteoporosis.

· Commonwealth Dental Health Program – collaborative development with states and territories of performance indicators and health data reporting to support more consistent national access to services and provide nationally comparable health data to plan future improvements to dental services.

· Australian Health Care Classification Systems - develop and refine nationally consistent patient health care classification systems and patient level data for emergency departments and outpatient services to support COAG commitment to a more nationally consistent approach to activity based funding for services provided in public hospitals.

On page 191, it is noted that: “The Australian Government is committed to a consistent Australian health care classification system that goes beyond counting activity to measuring outcomes and the success of the health sector in delivering appropriate services to Australians who need them. Funding for this major activity is sourced from Program 13.3 – Public Hospitals and Information.”

· The Hospital Information and Performance Information Program under Program 13.3], including:

- funding the development of national classification systems for patients, their treatment and associated costs to provide a basis for measuring and paying for hospital services under the AHCA;

- National Hospital Cost Data Collection (round 11); and

- Release of Australian Refined Diagnosis Related Groups v6.0.

· Outcome 14 (Biosecurity and Emergency Response) - Strengthening communicable disease surveillance systems to detect, assess and respond to communicable disease threats in Australia and overseas, through the national communicable disease surveillance system, OzFoodNet and the Foodborne Disease Surveillance Program.

· AIHW – working closely with peak bodies responsible for cancer control and state cancer registries to provide data on cancer prevalence and survival rates, and to monitor cancer screening programs.

· ARPANSA - Data collection and analysis of patient dose in CT scanned patients.

· Cancer Australia – improvements to collection and use of cancer data in collaboration with state, territory and professional groups.

· National Centre for Gynaecological Cancers - the development of minimum datasets for gynaecological cancers (to complement the existing national cancer clinical minimum dataset); and consulting on research priorities.

· National Blood Authority:

- Completing development and implementation of the NBA’s new integrated data management system aimed at improving operational data and performance reporting for the sector and to address the challenge of providing nationally relevant information from a disparate set of systems and processes in each jurisdiction (additional funding provided);

- Implementing Australian Bleeding Disorder Registry by June 2009; and

- Completing plans for a National IVIg management system by June 2009.

Concluding observations

It is reasonable for e-health expenditure to be strongly controlled at this time while the nation takes stock of the e‑health environment, develops its next e‑health strategy and identifies the resources, organisational measures and policies needed to achieve it.

An effective e‑health strategy requires effective communication, involvement and collaboration across all aspects of the health system – including specialists, diagnostic services, aged and long-term care, mental health, indigenous health, public and private sector acute care facilities as well as those in the primary and ambulatory care sector, who have been much of the focus to date. All in the health informatics community hope that the e‑health strategy to be produced in 2008-09 will facilitate an effective outcome and ensure that the core policy and infrastructure components needed to achieve e‑health are successfully put in place.

At DH4, we trust you find this synopsis a useful guide.

J. Richard Dixon Hughes,
Managing Director, DH4 Pty Limited

-----

Those who are interested in the detailed appendices (an additional 12 pages of analysis) are invited to contact Richard by e-mail (richard at dh4.com.au).

Thanks Richard for the work.

David.

Useful and Interesting Health IT Links from the Last Week – 18/05/2008

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

These include first:

Institute attempts health IT investment comparison

By: Joseph Conn / HITS staff writer

Story posted: May 12, 2008 - 5:59 am EDT

A dearth of common terminology has long been recognized as a barrier to clinical data analysis and exchange.

Similarly, the lack of a common accounting scheme to report on investments in health information technology has limited the ability of one healthcare organization to compare its level of investment in IT with that of its peers.

In the past 18 months or so, the 53-member, not-for-profit Scottsdale Institute has made two stabs at overcoming that latter impediment, according to Shelli Williamson, executive director of the institute, which has been gathering IT investment data using a common language in a survey instrument developed by Patrick O'Hare, senior vice president and chief information officer of Scottsdale Institute member Spectrum Health, a four-hospital system in Grand Rapids, Mich. The survey done in cooperation with IT market researcher Klas Enterprises, Orem, Utah.

For example, some hospitals and healthcare systems include telephone costs in their IT department budgets while some do not, Williamson said. Some allocate capital and operating expenses for picture archiving and communication systems/radiology information systems, or PACS/RIS, in their radiology departments while others book those expenditures as IT department costs. Depreciation is a jump ball, too, landing sometimes in IT department budgets, and sometimes it is lumped into the overall corporate budget.

More here:

http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20080512/REG/903660099/1029/FREE

This is a very interesting project and a project that should be replicated in Australia to allow a real understanding of just where we are in hospital computing. An idea the Commonwealth Department of Health could consider – and which could be conducted by NEHTA given its links with all the jurisdictions.

Second we have:

EMR deadline does not compute: Falling short of 2014 goals

Although individual physicians have embraced electronic medical record systems, the nation is far from an interconnected, interoperable network. Costs, hassle and a lack of congressional action are among the factors slowing health IT development.

By Dave Hansen, AMNews staff. May 19, 2008.

In 2004, President Bush set a goal of most Americans using an electronic medical record by 2014. In his vision, doctors by then would be using EMR systems with interoperable standards that would allow them to share lab results, images, computerized orders and prescription information with hospitals and other health facilities.

So how much progress has been made in the past four years? Not nearly enough, many EMR experts say.

The nation's medical community is not substantially closer to an interconnected, interoperable EMR system now than it was in 2004, concluded a January California HealthCare Foundation report based on interviews conducted last summer with 22 health information technology experts from across the country.

The reasons for the insufficient progress are many, according to the report, "Gauging the Progress of the National Health Information Technology Initiative." They include slow adoption of EMRs by physician practices, the impractical nature of a national health information network, the difficulty of creating interoperability standards and Congress' failure to pass legislation addressing health IT roadblocks.

Only 14% of physicians have minimally functional EMR systems, found a July 2007 survey conducted by the Office of the National Coordinator for Health Information Technology. The office, created by Bush to guide the work on EMR standards and coordinate public and private efforts, defines minimally functional systems as those on which doctors can record and manage progress notes, order tests, record test results and electronically prescribe medications.

More here:

http://www.ama-assn.org/amednews/2008/05/19/gvsa0519.htm

This quite long article provides a useful collection of statistics and information on the current state of EHR deployment and use in the USA. A good one for the files.

Third we have:

Government plans central citizen database

Mahesh Sharma | May 13, 2008

THE federal Government has moved to establish a centralised database to host and manage all Australian citizens' personal details, so this information can be easily shared and accessed by any department.

The Australian Taxation Office, Department of Immigration and Citizenship, Customs, Centrelink, and other departments, are discussing the possibility of establishing a common registration process to improve information sharing.

The project was being led by the Australian Government Information Management "and it's in respect of a common registration process," ATO chief information officer Bill Gibson said.

"That's exploratory at the moment. There's nothing that exists right now that is a manifestation of this, but we are working with Centrelink, Customs, and other agencies, facilitated by AGIMO.

"That is to work out what would be a common registration process, so that you as a citizen interact with Centrelink, and the registration you go through with Centrelink would be appropriate to be shared with, say, the Tax Office, so we don't have to put you through the same registration process."

He said the discussions were in their "very early" stages.

"There's nothing formally that has been approved it's really in the design and exploration phase at the moment."

A spokesman for AGIMO wasn't aware of the discussions and said the only formal project the department had embarked on in this area was to establish a $42.4 million portal, the Australian Government Online Service Point.

However, this online portal is mainly designed for logging into government websites, as opposed to managing a citizen's identity from a central location, but there are already elements of information sharing between departments.

More here:

http://www.australianit.news.com.au/story/0,24897,23687001-5013040,00.html

Here we go again, yet another attempt at a national electronic identity management system! When are Governments of either hue going to develop a national unified strategy for electronic ID management. One wonders where exactly Medicare Australia and the NEHTA UHI initiative is left in all this.

Fourthly we have:

IBA's eHealth network now connects 30 Australian health funds

14 May 2008

Sydney – 14^th May 2008 – IBA Health Group Limited (ASX: IBA) – Australia's largest listed health information technology company today announced two additional Australian private health insurance funds will connect to its expanding eHealth network for real-time, point-of-care electronic health claiming and payment services.

These latest agreements are with HBF and GMF Health funds. With more than 900,000 members, HBF is the leading provider of health insurance in Western Australia. Also based in Western Australia, GMF Health provides health insurance to more than 60,000 members across Australia.

IBA now has agreements with 30 health funds, which collectively represent 98% of privately health insured Australians. Privately insured Australians can settle their accounts on the spot with their health insurer and health care professional through connectivity to IBA’s HealthPoint claiming service.

HealthPoint gives healthcare professionals and their patients an efficient, easy-to-use single point solution for EFTPOS, patient claims to health funds and, where appropriate, Medicare claims. By automating and streamlining the entire health claim and payment process, IBA’s solutions are enabling health fund insurers to lower costs while providing more efficient and effective services to their members.

Both HBF and GMF are expected to go live with IBA’s HealthPoint service from August/September this year with claiming for optometrists, dentists, chiropractors, physiotherapists and podiatrists.

More here:

http://www.ibahealth.com/html/iba_s_ehealth_network_now_connects_30_australian_health_funds.cfm

This network was a little under my radar I must say. The level of coverage seems to be quite impressive and it is at least one example of an national e-Health related system actually working. More details are found here. http://www.ibahealth.com/html/electronic-health-claims.cfm

ICS Global with its Thelma environment offers similar services. See http://icsglobal.net/thelma.html for information on that system.

The usual disclaimer about ownership of a few shares in these companies applies.

Fifth we have:

ICT Transforming Health Sector

New Era (Windhoek)

NEWS

9 May 2008

By Catherine Sasman

Windhoek

Africa should spruce up its e-health services to ensure improved access to health services as a fundamental human right, argued delegates at the IST-Africa Conference in Windhoek, New Era reports.

It is estimated that more than 33 million people are HIV infected, and that 90 percent of these people are living in settings with limited resources. In Africa, this health pandemic is considered the most important health challenge.

By December 2003 the World Health Organisation (WHO) and the Joint United Nations Programme on HIV/AIDS launched the '3-by-5' initiative to help low- and middle-income countries provide treatment to three million people living with the disease by the end of 2005.

According to Maria Zolfo from the Institute of Tropical Medicine (ITMA) in Belgium, although the '3-by-5' target has not been met yet, the global efforts to scale up access to anti-retroviral treatment (ART) has brought positive changes worldwide.

At the end of 2006 more than two million people living with HIV are treated with ART in low- and middle-income countries.

"Telemedicine is a way to assist delivery of care in remote areas," said Zolfo.

Telemedicine is considered as one of the fastest growing areas of information, communication and telecommunication (ICT) applications that are used in the health sectors for services enhancement.

It started in the 1920s, but has since evolved, and its use in developing countries is reported to be on the increase.

More here:

http://allafrica.com/stories/200805090735.html

It is good to see growing awareness of such needs in Africa. There are a number of quite encouraging success stories with EHR’s making a difference with AIDS management in Africa.

Sixth we have:

Telemedicine a Cost-Effective Alternative to ER Visits

Friday, May 9, 2008; 12:00 AM

FRIDAY, May 9 (HealthDay News) -- Telemedicine is a cost-effective way to replace more than a quarter of all visits to the pediatric emergency department, according to a community-wide study conducted in New York.

Ailments, such as ear infections or sore throats, that virtually always prove manageable by telemedicine made up almost 28 percent of all pediatric ER visits in Rochester, N.Y., during one year, according to investigators from the University of Rochester Medical Center.

Their findings were presented recently at the 2008 Pediatric Academic Societies annual meeting, in Honolulu.

"We learned that more than one in four local patients are using the pediatric emergency department for non-emergencies," lead investigator Dr. Kenneth McConnochie, a professor of pediatrics at the University of Rochester's Golisano Children's Hospital at Strong, said in a prepared statement. "This mismatch of needs and resources is inefficient, costly and impersonal for everyone involved."

McConnochie and his colleagues, who direct a Rochester-based telemedicine program that provides interactive, Internet-based pediatric health-care service to the area, analyzed data for all pediatric visits to the largest emergency department in the city. Based on their experience, they determined at least 12,000 visits were ones they routinely treat with success via telemedicine.

Continue reading here:

http://www.washingtonpost.com/wp-dyn/content/article/2008/05/09/AR2008050901866.html

This is an interesting study and certainly point the way of the future as to how better care could be delivered in remote areas and possibly make a difference for the Aboriginal Community.

Last we have:

Nagging via text messages to help teens remember meds

By LAURAN NEERGAARD
The Associated Press
Monday, May 12, 2008; 3:25 PM

WASHINGTON -- 4gt yr meds? Getting kids to remember their medicine may be a text message away. Cincinnati doctors are experimenting with texting to tackle a big problem: Tweens and teens too often do a lousy job of controlling chronic illnesses like asthma, diabetes or kidney disease.

It's a problem long recognized in adults, particularly for illnesses that can simmer without obvious symptoms until it's too late. But only now are doctors realizing how tricky a time adolescence is for skipping meds, too.

Of necessity, parents start turning over more health responsibilities to their children at this age. It's also an age of angst, sometimes rebellion, and when youths may most hate feeling different from their friends because of medication, special diets or other therapy.

"It's a time of so much change in these kids' lives," says Dr. Marva Moxey-Mims, a specialist in pediatric kidney disease at the National Institutes of Health. "It's very difficult when you've got a life-threatening illness to say, 'Let them make their mistakes.'"

More here:

http://www.washingtonpost.com/wp-dyn/content/article/2008/05/12/AR2008051201430.html

This seems like a sensible idea for that difficult period when compliance is likely to be low (Age 12-18) and mobile phone ownership is high! Will be interesting to see the outcomes of the year long trial.

More next week.

David.

The Trials and Tribulation of Going Paperless with an EHR

The following set of sagas appeared in the last little while.

The Five Biggest Mistakes of EHR Implementation

Five facilities share their stories of EHR disasters so others can learn from their mistakes.

By Ainsley Maloney

"Learn from the mistakes of others. You can't live long enough to make them all yourself."

The above quote by Eleanor Roosevelt is the theme of our article and the hope these five facilities had when they opened up to ADVANCE and bravely shared their stories of EHR disasters and downfalls. One facility watched as money drained out of its practice and its patients switched doctors; another made its physicians' workday even more cumbersome than it had been in the paper world; and a third unknowingly put its patients at great risk just by updating its system. In the end, however, all shared one remarkable similarity: They never gave up on their EHRs.

Read their stories and share their experiences. Hopefully you can learn from their mistakes.

Disaster at the start

In December 2004, Siouxland Women's Health Care, PC, Sioux City, Iowa, decided on an electronic medical record (EMR) to put its five physicians and one nurse practitioner on pen-based tablets.

As the go-live date approached, Julie Barto, BS, MS, administrator, started getting nervous. Absolutely nothing had been scanned in. They hadn't made a single template, and no one had any idea what their EMR tablets even looked like.

Barto called the value-added reseller (VAR) responsible for the EMR's sale and implementation, who assured her that he'd train everyone on site two days before go-live.

Barto didn't like that idea. "When we're talking 'live,' we're talking no paper," Barto said. "We told him 'No. We have to have things scanned; we can't have any downtime, we're an OB/GYN!'"

As the clock ticked down, the VAR finally arrived. He had promised to make the practice paperless and fully operational within five days. The VAR, Barto realized, was delusional.

"We had older physicians who didn't know how to use a computer. They hadn't even e-mailed before this! Things like how to turn on the tablet, we didn't even know that," Barto said. "We knew nothing, absolutely nothing."

Without templates, physicians had to start from scratch with each patient rather than being guided with yes/no checkboxes. They were soon moving so slowly that each provider was only able to handle one patient per hour.

"That's when the disaster happened," Barto said. The VAR hadn't told them to scale back their operations. The practice got so backed up that they had to cancel every appointment on the schedule and accept only emergencies. In the weeks that followed, they continued to call and move hundreds of patients back to different times.

"At first [our patients] were tolerant, but soon became less and less so," Barto recalled. "We definitely lost patients over this. We took a hit financially that first year."

Lesson #1: Know your product before go-live

The VAR, perhaps not surprisingly, was fired. MedcomSoft came in to save the day, said Julie Barto, BS, MS, administrator.

A few lessons can be taken from this. The importance of training and templates before go-live is one. Being cautious of hyped-up claims is another.

"The VAR used the, 'you could be paperless within a very short time' pitch to entice us into purchasing the product. Doesn't that sound pretty attractive? Well it's not realistic," Barto said.

This implementation also taught the vendor a few lessons. Most importantly, every VAR now has to be certified, and MedcomSoft strongly suggests that every client go through extensive training before go-live, said Mary Torrance, the vendor's vice president of implementation and training.

This includes reviewing learning guides and videos 2 months prior, and 46 hours of Web training 6 weeks before. At go-live they send two trainers for every three physicians on site for 5 days to 2 weeks, depending on the practice.

"The beauty of our department is that it's constantly changing and constantly improving," Torrance said. "We're learning something on every install."

It took Siouxland Women's Health Care 6 months to return to normal patient volume and a year to gain back lost revenue. But the good news is that -- once the cost-savings from the EMR were seen through workflow efficiencies, better charge capture and zero transcription costs -- the practice rebounded financially and is now more profitable than ever.

Currently 100-percent paperless, the practice is a proud example that, even when an implementation is a disaster, it doesn't mean it's a failure. "We pressed forward and showed that we could take on a challenge and come out a winner, that's for sure," Barto said. "We chose a very good EMR and stuck with it. That's the key."

Read the other four horror stories here:

http://health-care-it.advanceweb.com/editorial/content/editorial.aspx?cc=110980

While clearly there are other things that can go wrong this article certainly identifies a few of the big ones!

One for the files!

David.

Telemonitoring Shown to Really Make A Difference.

The following appeared in the Washington Post a few days ago.

Home Monitoring Program Improves Outcomes for Heart Patients

Thursday, May 1, 2008; 12:00 AM

THURSDAY, May 1 (HealthDay News) -- Remote monitoring can improve the condition of mobile heart failure patients and may reduce hospital readmissions, according to a pilot study that included 150 patients admitted to Massachusetts General Hospital in Boston.

The patients, average age 70, were randomly selected to receive usual care for heart failure (68 patients) or remote monitoring (42 patients). Forty of the patients declined to participate. The study was conducted by the Center for Connected Health, a division of Partners HealthCare.

The patients in the remote monitoring group received telemonitoring equipment to track vital signs such as heart rate, pulse and blood pressure. They weighed themselves daily and answered a set of questions about symptoms every day. The information was transmitted via the telemonitoring device to a nurse, who would call weekly or more often if a patient's vital signs were outside normal parameters.

After three months, patients in the remote monitoring group had lower average hospital readmission rates (31 percent) compared to patients in usual care (38 percent) and those who refused to participate (45 percent). The patients in the remote monitoring group also had fewer heart failure-related readmissions and emergency room visits than patients in the other two groups.

More here:

http://www.washingtonpost.com/wp-dyn/content/article/2008/05/01/AR2008050102360.html

A detailed press release is also available.

http://americanheart.mediaroom.com/index.php?s=43&item=405

Remote monitoring improves heart failure patients’ health, may reduce hospital readmissions

Study highlights:

• Study from Massachusetts General Hospital in Boston, comparing remote monitoring to usual care in 150 heart failure patients.

• Researchers said all cause and heart failure related hospital readmission rates decreased with the remote monitoring intervention.

• Post-study surveys of participating patients revealed a high level of satisfaction.

BALTIMORE, MD, May 1 — A remote monitoring program can improve the condition of heart failure patients who are mobile and may reduce hospital readmissions, according to a pilot study reported at the American Heart Association’s 9th Scientific Forum on Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke.

The study, conducted by the Center for Connected Health, a division of Partners HealthCare, included 150 heart failure patients admitted to Massachusetts General Hospital in Boston, Mass. Sixty-eight patients (average age 70) were randomized to receive usual care for heart failure. The remaining 82 patients were offered remote monitoring. Forty-two patients accepted the monitoring program; the remaining 40 patients declined to participate. This study reports the findings in the first three months of follow-up on all patients.

“The goal of our Connected Cardiac Care program for this group of patients is to reduce hospital readmissions, provide timely intervention and help them understand their condition using home telemonitoring,” said Ambar Kulshreshtha, M.D., M.P.H., lead author of the study and a research fellow at Harvard Medical School and Massachusetts General Hospital. “Participants showed a trend towards less frequent hospitalization. The group that refused to participate did less well.”

Patients in the remote monitoring group experienced lower average hospital readmission rates (31 readmissions per 100 people) compared to patients in usual care (38 readmissions per 100 people) and non-participants (45 readmissions per 100 people). Patients in the remote monitoring group also had fewer heart-failure related readmissions and emergency room visits than usual care and non-participating patients. Researchers said the results show a positive trend but are based on only three months of follow-up and did not reach statistical significance.

“Participating physicians are pleased with the program and consider it a success,” Kulshreshtha said. “The Connected Cardiac Care program combines patient self-monitoring of their vital signs and symptoms, with nurse intervention to educate patients, help them understand the link between their daily life and their disease and, importantly, coordinate care with their physician. Based on these initial data, Connected Cardiac Care is a win-win for our patients and healthcare providers.”

Patients received telemonitoring equipment to monitor vital signs such as heart rate, pulse and blood pressure. They also weighed themselves daily and answered a set of questions about symptoms every day. That information was transmitted through the telemonitoring device to a nurse, who would call weekly or more often if a patient’s vital signs were outside normal parameters. Researchers also monitored patients’ re-hospitalization rates and emergency care use.

“Patients could see the fluctuation in their vitals and realize they hadn’t taken their medications or weren’t eating right or exercising,” Kulshreshtha said. “A weekly call from the nurse reinforces lifestyle management of the patient’s heart failure.”

Post-study surveys of participating patients revealed a high level of satisfaction:

Ninety-five percent of participating patients in the intervention group said the program improved their heart failure control and helped them stay out of the hospital.

All participating patients said the equipment was easy to use.

Ninety-five percent believed they were able to manage their heart failure better and an equal number had overall program satisfaction.

All participants said their health improved and they received adequate interactions with a homecare nurse.

A previous study by the Massachusetts-based group showed a similar program reduced all-cause hospital admissions by 25 percent in participating homebound patients.

The researchers said they plan to expand the program to target 350 ambulatory patients by summer of 2008 and are developing a method to stratify high-risk patients.

This program has the potential to have “a dramatic impact on improving the lives of heart failure patients and reducing hospital admissions,” Kulshreshtha said.

An estimated 5.3 million Americans have heart failure. Hospital discharges for heart failure rose from 400,000 in 1979 to 1.08 million in 2005, an increase of 171 percent. The estimated direct and indirect cost of heart failure in the United States for 2008 is $34.8 billion, according to the American Heart Association’s Heart Disease and Stroke Statistics – 2008 Update.

“More focus is needed on education and actionable intervention in heart failure patients,” Kulshreshtha said. “Connected Cardiac Care creates an interaction between patients, nurses and doctors that allows for timely medication changes based on a complete clinical picture and helps heart failure patients feel empowered.”

Co-authors are: Joseph Kvedar, M.D.; Alice Watson, M.D., M.P.H.; and Regina Nieves, R.N.

This study was funded by Partners HealthCare.

----- End Release.

This is a really important finding. Heart failure is an important cause of hospital admission, cost and suffering. Reductions in all of this is a good thing indeed!

It is also good to see application of an proper trial / evaluation approach being adopted. We need more hard evidence like this to improve e-health adoption and uptake.

David.