A Useful Policy Brief on Health Information Privacy and Security.

The following appeared a few days ago.

Policy Post 14.9, June 24, 2008

A Briefing On Public Policy Issues Affecting Civil Liberties Online from The Center For Democracy and Technology

Privacy and Security Principles for Health Information Technology

(1) CDT Calls for the Adoption of a Comprehensive Privacy and Security Framework for Health Information Technology

(2) Basics Required in any Health Information Technology Policy

(3) CDT's Suggested Implementation

A lot more here:

http://www.cdt.org/publications/policyposts/2008/9

The document addresses the three areas listed above.

Most useful from a very useful document are these two sections.

First is the set of Core Privacy Principles from Markle.

Privacy and security policies should incorporate "fair information practices" (FIPs) such as those outlined in the Markle Foundation's Connecting for Health initiative:

• Openness and Transparency: A general policy of openness should be enforced for any new developments, practices, and policies with respect to personal data. Individuals should be able to know what information exists about them, who has access to it, and where it is stored.
• Purpose Specification and Minimization: Patients should be made aware of the purpose for data collection at the time the data are collected. The data should not be used for any other purpose without first notifying the patient.
• Collection Limitation: Personal health information should only be collected for specified purposes and should be obtained by lawful and fair means - and where possible, with the knowledge or consent of the data subject.
• Use Limitation: Personal data should not be disclosed, made available, or otherwise used for purposes other than those specified.
• Individual Participation and Control: Individuals should be able to obtain from each entity that controls personal health data, information about whether or not the entity has data relating to them. As well, individuals should have the right to have the data communicated to them in a timely and reasonable manner. Finally, individuals should be able to challenge data relating to them, and have it rectified, completed, or amended.
• Data Integrity and Quality: All personal data collected should be relevant to the purposes for which they are to be used and should be accurate, complete, and current.
• Security Safeguards and Controls: Personal data should be protected by reasonable security safeguards against such risks as loss, unauthorized access, destruction, use, modification, or disclosure.
• Accountability and Oversight: Entities in control of personal health data must be held accountable for implementing these information practices.
• Remedies: Legal and financial remedies must exist to address any security breaches or privacy violations.

Second is a list of issues the US Congress (and our Government) should consider when developing a new Privacy and Security Framework.

The list includes:

• The appropriate role for patient consent for different e-health activities.
• The ability of consumers to have information about when, where, and how their Personal Health Information (PHI) is accessed, used, disclosed, and stored.
• The right of individuals to view all PHI that is collected about them and be able to correct or remove data that is not timely, accurate, relevant, or complete.
• Limits on the collection, use, disclosure, and retention of PHI.
• Requirements with respect to data quality.
• Reasonable security safeguards given advances in affordable security technology.
• Use of PHI for marketing.
• Other secondary uses (or "reuses") of health information.
• Responsibilities of "downstream" users of PHI.
• Accountability for complying with rules and policies governing access, use, disclosure, enforcement, and remedies for privacy violations or security breaches.
• Uses and safeguards for de-identified information.

They then go on to make the very valid point that a ‘one size fits all’ approach to all users of health information is not good enough and that those using differing data sets should have different responsibilities and accountabilities.

All is all a useful contribution indeed!

David.

It is Not Clear Federal Health Minister Nicola Roxon Knows What She is Doing!

I am not sure if the readers of this blog have appreciated yet just what a fundamental change in our Primary Health Care delivery system is being proposed by the new Health Minister. While I have no strong feelings about the proposals I think it is vital they be carefully thought through.

In Australia, the UK, Canada and NZ at present primary care doctors have a very substantial ‘access control’ or gatekeeper function to the rest of the services provided by the health system (especially specialist care, investigations, non-urgent hospital care and allied health services especially). The objective of this approach is to try and ensure ant presenting clinical issue receives an appropriate clinical diagnosis and assessment before the patient is sent on for additional care. Overall the system seems to work pretty well although it is easy to identify occasions when medical involvement in accessing of care may be seen as un-necessary (e.g. physio for minor sports injuries and even –as is done overseas, the management of normal pregnancy).

However, with the gradual reduction in the number of GPs – especially outside the major metropolitan areas – clearly access to GP care for diagnosis and referral has become more difficult – and in some situations borders on the impossible.

What to do – to improve access and to reduce waiting to access care? Options include the use of more practice nurses, development of upgraded nurse practitioners, more use of midwives, train more GPs or dilution of the ‘gate-keeper’ function among others (e.g. super clinics etc).

In deciding what to do we need to be very sure we do not ‘throw the baby out with the bath water’. It is of note that, just as we are having this discussion we see in the USA there is an increasing view of the importance of that function.

AHIP Lists Medical Home Principles

June 26, 2008

The board of America’s Health Insurance Plans, the trade association for health insurers, has endorsed core principles for development of the “medical home” model, including liberal use of information technologies.

Under the medical home model, physician practices are redesigned to be more functional and workflow-friendly, and new processes are developed to focus on quality, safety and alternative reimbursement methods. The care model also calls for adoption of electronic health records, e-prescribing, clinical decision support, secure messaging and Web portal software to facilitate coordination of care among various providers.

More here:

http://www.healthdatamanagement.com/news/medical_home26529-1.html?ET=healthdatamanagement:e489:100325a:&st=email&portal=group_practices

Details of the principles can be found here:

http://www.ahip.org/content/default.aspx?bc=31|44|23691

The third paragraph makes it clear what is intended as ideal with an emphasis on holistic care delivery and a long term co-ordination of care role – supported by technology and allied health staff.

The associated press release makes the emphasis clear

“The patient-centered medical home would replace episodic care with a sustained relationship between patient and physician. This approach redesigns the care delivery model by assessing the level of illness or disease based on sound medical evidence; promoting coordination of care; and improving accountability for outcomes, patient experience, and utilization of services.

While there is current market experimentation going on to determine the appropriate structure for a medical home, the AHIP Board collaborated with other stakeholders to advance a model that focuses on the following:

• Practice redesign so care is delivered in response to a patient’s needs and preferences;
• Clear criteria for patient participation;
• Adoption of health information technology to facilitate evidence-based integrated care;
• Accountability;
• Engaging and educating consumers and improving personal responsibility and behavior;
• Structuring payment to align with measurable improvements; and
• Pilot testing before moving forward with reformed payment models or practice redesign.”

Now the AHIP is not some fringe group – their tag line is “Providing Health Benefits for Over 200 Million Americans.”!

With the US having been the archetypal example of a ‘gatekeeper-less’ health system one is forced to wonder if they know something the Minister has not yet caught up with?

I am not sure what the right answer is in all this but I am sure I don’t want a system that is working quite well changed without very careful consideration of all the options – including the use of more Health IT – and I certainly don’t want change triggered because of the current stridency of the AMA. That would be very sad!

If we change all these roles and responsibilities we need to be sure it will be for the better.

David.

Could NEHTA Have Been Done Better and Cheaper?

The following article appeared last week.

HITSP works on communication, inside and out

By: Joseph Conn / HITS staff writer

Story posted: June 25, 2008 - 5:59 am EDT

The federally supported Healthcare Information Technology Standards Panel (HITSP) has come up with a plan to improve its own internal communications as well as to educate members of the broader healthcare community about its work to promote healthcare IT interoperability.

The 43-page plan was presented and accepted Monday during a meeting of the HITSP by its education, communication and outreach committee. The HITSP was created in 2005 by the American National Standards Institute under a $3.3 million contract with HHS to develop a process to select and recommend appropriate healthcare IT standards.

"The measure of our success is not just harmonizing the standards, it's actual implementation," said HITSP Chairman John Halamka in a telephone interview after the meeting. "You want all systems to be plug and play. You want e-prescribing to be universal."

To do that, Halamka said, will require educating everyone in the healthcare community about HITSP and the availability of the HITSP-vetted standards. And in doing that, "You can't overcommunicate," he said.

Work on the education, communication and outreach plan in February, said its chairman, Walter Suarez, president and chief executive officer of the Institute for HIPAA/HIT Education and Research, Alexandria, Va. According to the plan, the committee "anticipated building a multidimensional package of tools and recognizes that significant maintenance will be required to keep these resources up-to-date."

The tools will include one- and two-page fact sheets on the HITSP process and interoperability specifications, slightly longer issue briefs, lists of frequently asked questions that will be kept current and amended in response to reader input, all of which will be published online. The plan also calls for the issuing of news releases as needed and the writing of articles and, possibly, columns for industry publications. The group also contemplates creating a speakers bureau and library of PowerPoint presentations on specific topics such as the use of HITSP harmonized standards in medication management.

In addition, the plan calls for the development of various case studies of interoperability success stories presented either in print, audio or video format and maintaining "a significant presence" at industry events such as trade shows and annual meetings of member organizations.

One key order of business, the plan's authors recognized, will be overcoming the incomprehensibility of the patois of standards development organizations for many people in segments of the plan's target audience who are not IT geeks, particularly patients, government officials and healthcare organization leaders outside of IT. "The single biggest challenge is the need to translate what we do from what we call 'HITSP speak' to a description and a presentation that is simplified and is provided at a level of language that can be understood by nontechnical people," Suarez said. "If I'm a CEO, HITSP speak is not going to cut it for me. It really requires a translation from the technical world to the nontechnical audience, because the nontechnical people are the ones that make the decisions of either creating the products that are HITSP-compatible or compliant and buying those products.

More here

http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20080625/REG/528301340/1029/FREE

A visit to the HITSP Web site is very worthwhile.

It can be found at www.hitsp.org

Before commenting it is sensible to provide a description of what HITSP does. To quote:

HITSP Background

In the fall of 2005, the U.S. Department of Health and Human Services' Office of the National Coordinator for Health Information Technology (ONC) awarded multiple contracts to advance President Bush's vision for widespread adoption of interoperable electronic health records (EHRs) within ten (10) years. The contracts targeted the creation of processes to harmonize standards, certify EHR applications, develop nationwide health information network prototypes and recommend necessary changes to standardized diverse security and privacy policies.

The American National Standards Institute (ANSI), in cooperation with strategic partners HIMSS, Booz Allen Hamilton, and Advanced Technology Institute, was selected to administer the standards harmonization initiative. The resulting collaborative, known as the Healthcare Information Technology Standards Panel (HITSP), brings together experts from across the healthcare community - from consumers to doctors, nurses, and hospitals; from those who develop healthcare IT products to those who use them; and from the government agencies who monitor the U.S. healthcare system to those organizations who actually write the standards.

The Panel's objectives are to:

• serve and establish a cooperative partnership between the public and private sectors to achieve a widely accepted and useful set of standards that will enable and support widespread interoperability among healthcare software applications in a Nationwide Health Information Network for the United States.
• harmonize relevant standards in the healthcare industry to enable and advance interoperability of healthcare applications, and the interchange of healthcare data, to assure accurate use, access, privacy and security, both for supporting the delivery of care and public health.

Most telling is this FAQ response:

“Who can join the HITSP?

The HITSP reaches across the stakeholder community and facilitates the broadest possible participation of all affected parties. Membership on the Panel is open to groups within any of four major categories: standards development organizations (SDOs), non-SDO stakeholder organizations, government bodies and consumer groups.”

Two other facts are useful to be aware of. First the HITSP has its priorities set by the American Health Information Community which is the peak HIT advisory body chaired by the equivalent of the Federal Health Minister and having a wide variety of government, industry, health informatics and consumer representation.

The membership is found here:

http://www.dhhs.gov/healthit/community/members/

It includes all sorts of heavy hitters including the Chairman of Intel and the Vice-Chairman of Wal Mart!

Second the CCHIT (often mentioned in this blog) works with HITSP to ensure products are certified to meets HITSP standards.

Now, while HITSP has not had a totally criticism free of successful run over the last three years much has been achieved and it seems that the internal mid course review will only make what is a good effort even better.

The emphasis, from the get go, on full and broad consultation and involvement makes a refreshing contrast to the situation in OZ.

HITSP is doing much of what NEHTA is doing and more in some ways. Maybe NEHTA 2 (which must come soon) could look a little more like HITSP. It could really help I think!

David.

Useful and Interesting Health IT Links from the Last Week – 29/06/2008

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

These include first:

Urgent Survey Response Needed!

In a comment on the blog this week I had the following comment:

“The Deloitte eHealth strategy is available online. Perhaps you should ensure that they receive a good response.

https://www.deloittedtermine.com/SPSSMR/ImageCache/ImageCache.aspx?project=NESAUDEL001&file=default.htm”

What is actually on line is a short questionnaire. I suggest all those who read the blog quickly make their contribution to the survey. This is despite the fact that I find the survey both very constrained, quite confusing and lacking any apparent discussion of the drivers of the new e-Health Strategy. There are a range of ‘strategic choice’ questions the survey could and should have addressed.

Second we have:

Behind the Curtain

Epic's unwavering commitment to its unique values has created an unusual recipe for success. What's behind Epic's gains in the clinical IT sphere?

by Mark Hagland

When readers of HCI were asked what vendor they most wanted to read about, respondents picked one company by a wide margin (see graphic on page 28). The results weren't surprising, as one clinical information systems vendor has a truly unusual profile, and its very unusualness has given it a certain cachet. What's more, that company is different not just in one way, but in many. It has a unique operating methodology, sales approach, market strategy, history, and culture. It's even been described by some over the years as a “cult.” That company? The Madison, Wis.-based Epic Systems Corporation.

Of course, there are ways in which Epic does resemble its competitors. It sells corporately designed clinical systems software, which it implements in patient care organizations; it has a team of internal software developers and a team of implementers; and it competes with other core-clinical companies for the same essential base of customers, in both the inpatient and outpatient spheres (though Epic started in the outpatient sphere and moved into the hospital, while most have done the opposite). And it makes money — lots of money ($500 million in annual revenues as of late 2007 — see Epic's entry in the HCI 100, page 52).

Very much more here:

http://www.healthcare-informatics.com/ME2/dirmod.asp?sid=&nm=&type=Publishing&mod=Publications%3A%3AArticle&mid=8F3A7027421841978F18BE895F87F791&tier=4&id=125CB9E22CE6403F9A68D87839295283

This is a fascinating review of the mysterious Epic – which is the provider of core clinical system for organisations such as Kaiser Permanente. They are being amazingly successful and there are lessons in how they go about their work that should be carefully reviewed and discussed.

Third we have:

IBA's Lorenzo health system in tests

Karen Dearne | June 27, 2008

THE long-awaited Lorenzo clinical software suite by IBA Health will be launched in Australia within three to four months and will be available for general release in early 2009.

Despite continuing political sniping over missed deadlines, Lorenzo has been installed in three British National Health Service hospital trusts - Morecambe Bay, Bradford and South Birmingham, and are undergoing final testing ahead of go-live next month, Gary Cohen, IBA Health Group executive chairman said.

Two early adopter sites, in Germany and Holland, have already proven Lorenzo's real-world capabilities and reliability.

"We're starting with these three trusts with Lorenzo release one, and after three to four months' actual operation it will be rolled out to a larger number of hospitals," Mr Cohen said. "The intention is to use these as a staggered and stepped approach, so it will probably take two years to roll it out to all trusts in the three regions.

"So a delay of a few weeks in going live is nothing. The reality is, significant progress has been made in the past 12 months, there are no major issues and we're just getting on with delivering."

More here:

http://www.australianit.news.com.au/story/0,24897,23930668-15306,00.html

Another report is found here:

IBA Health set for Lorenzo release

June 26, 2008 - 1:15PM

IBA Health Group Ltd says it is on track to meet its 2008 financial year earnings guidance and has revealed it will release its flagship software, Lorenzo, in Australia in coming months.

Australia's largest health-care information technology company said it remains on track to meet its earnings before interest, tax, depreciation and amortisation (EBITDA) guidance of between $85 million and $95 million.

The company delivered EBITDA of $32.27 million in 2006/07, up 70 per cent from 2005/06.

IBA Health said its revenue was being impacted by the surging Australian dollar against the British pound.

More here:

http://news.smh.com.au/business/iba-health-set-for-lorenzo-release-20080626-2x87.html

Clearly IBA Health is now getting close to the ‘put up or shut up’ time with Lorenzo. If we don’t see real delivery in the next few months confidence in the company’s capability is likely to be severely eroded. (The usual disclaimer that I own a few IBA shares applies) .

Fourth we have:

IT waste a 'major challenge' to human health: UNEP

June 26, 2008 - 10:29PM

Millions of discarded mobile phones and computers are posing a "major challenge" to human health, the chief of the United Nations Environment Programme said Thursday.

Achim Steiner told a UN conference on waste management on the Indonesian resort island of Bali that 20 million mobile phones were thrown away each year in China.

Meanwhile, the global number of personal computers was expected to double to two billion by 2015.

"The rapid growth and rapid redundancy of all this equipment ... represents a major challenge to the international community in terms of human health and the environment," he said.

He said 20 to 50 million tonnes of electronics waste was produced every year -- enough to load a train that would stretch around the world.

More here

http://news.smh.com.au/world/it-waste-a-major-challenge-to-human-health-unep-20080626-2xkp.html

This is a reminder of a major downside to all the gadgets and computers. There are some really nasty metals and toxins locked up in this stuff that really should be addressed more systematically.

Fifth we have:

Mobiles and internet link to help the mentally ill

Louise Hall Health Reporter
June 29, 2008

MOBILE phones and the internet will be used to help up to 2 million Australians manage their mental health problems.

People can use the technology to track their wellbeing on a day-to-day basis by recording their mood, sleep, activities, medication, physical activity and drug and alcohol use.

The $1.88 million system is being developed by Sydney's Black Dog Institute as part of a growing move towards "e-therapy" as a way to cope with the chronic shortage of services for the mentally ill.

Using secure messaging via the internet or SMS on their mobile phone, patients report their condition daily. Information is fed back on their condition and alerts are sent to their phones or computers when things aren't going well, along with links to appropriate self-help tools.

Black Dog's senior research fellow Judy Proudfoot said the system would assist those at risk of depression, anxiety or stress to recognise symptoms and seek support, as well as help existing sufferers manage their illness.

More here:

http://www.smh.com.au/news/technology/mobiles-and-internet-link-to-help-the-mentally-ill/2008/06/28/1214472837799.html

I also came across this press release in the last few days.

http://www.swinburne.edu.au/corporate/marketing/mediacentre/core/releases_article.php?releaseid=1142

Internet therapy helps treat panic disorder

Online psychological treatment (etherapy) can be as effective as face-to-face therapy for treating mental health disorders, according to a new study by Swinburne researchers.

Published in the Journal of Medical Internet Research, the study found that therapist assisted etherapy is highly effective for the treatment of panic and panic-related symptoms.

It revealed that when online treatment programs are supported by health professionals they can achieve patient outcomes comparable to best-practice face-to-face therapy.

“Mental illness is a growing problem worldwide,” said lead author and psychologist Kerrie Shandley. “In Australia, it accounts for 13 per cent of health problems and one in 10 adults report that they suffer from a long-term mental or behavioural problem.”

“The management of anxiety and depression generally falls to family doctors who may lack the time and resources to deliver appropriate psychological treatment to their patients, so other methods for delivering effective therapy need to be developed.”

The study found that when panic disorder sufferers used the etherapy program ’Panic Online’ in conjunction with support from a general practitioner, their panic disorder and panic-related symptoms were reduced with around 30 per cent losing their symptoms altogether.

The study followed 96 people with a primary diagnosis of panic disorder who completed the Panic Online program over 12 weeks. Fifty-three of the participants had face-to-face assistance from their GP, who had received specialist training in cognitive behavioural therapy, and 43 had assistance from a clinical psychologist via email.

The participants completed a telephone interview conducted by a psychologist and a series of online questionnaires to assess panic-related symptoms over the course of the treatment and at a six-month follow-up.

“Both groups were shown to significantly improve over time”, Shandley said. “There were no noticeable differences between the participants who had assistance from their GP and those who had assistance from a clinical psychologist.”

----- End Release.

I also understand that “Internet based mental health therapy (has) received a boost thanks to a $.1.5m Federal Government grant to establish the National e-Therapy Centre for Anxiety Disorders (NeTCAD).

The service, based in Swinburne, will offer internet based clinical treatment programs for anxiety disorders, train postgraduate psychology students in the science and practice of e-therapy and develop online treatment programs for other psychological problems.”

This is all really good news to see studies that are showing such techniques can work – but even better that these services are certainly very accessible as well as being cost effective.

Sixth we have:

Backflip over OneSchool online student database

James O'Loan | June 23, 2008

THE controversial OneSchool online student database is being watered down after a public backlash against its instigator, Education Queensland.

School principals are leading the erosion, with one northside Brisbane primary school principal writing to parents advising them that photos of students do not need to be posted on their profiles.

The photos were, according to Education Queensland, to be posted along with students' academic performance, career aspirations and extra curricular activities.

The move follows Education Minister Rod Welford's defence of OneSchool when he dismissed the idea that hackers would target the database of nearly half-a-million students as "ridiculous, extreme and hypothetical".

Eatons Hill State School principal Clyde Campbell's letter to parents stated OneSchool was a "fundamental component of the Government's Smart Classrooms strategy".

He said the decision to omit photos was "a decision taken by the school" and reassured parents the new centralised system would be even more secure than the individual student management system it used previously.

More here:

http://www.australianit.news.com.au/story/0,24897,23907719-16123,00.html

Well it seems there has been the outbreak of just a little common sense here. It is clear Education Queensland needs a student management system..the issue is really about how much information is needed in that system and what protections are in place to prevent abuse. I hardly see how recording extra-curricular activities and career aspirations should be compulsory! If people volunteer such information fine..compulsion is just silly!

Last we have out slightly technical note for the week:

Third of IT admins admit snooping with privileged passwords

Power and anonymity equals risky business, says password management vendor.

Gregg Keizer 23/06/2008 08:36:30

One in three IT administrators say they or one of their colleagues have used top-level admin passwords to pry into confidential or sensitive information at their workplace, according to a survey by a password-management vendor.

Nearly half also confessed that they have poked around systems for information not relevant to their jobs.

"We asked these questions last year, too," said Adam Bosnian, vice president of product strategy and sales for Cyber-Ark, a Newton, Mass.-based maker of password file security management software. "And we got similar results. So on one hand, the results weren't surprising. What was surprising initially -- and this time around, too -- is that people admit to it."

Last month, Cyber-Ark polled approximately 300 senior IT professionals at a London security conference and trade show, asking them a dozen questions about their password practices. The majority of those surveyed said they work for companies with more than 1,000 employees.

The fact that a third acknowledged they had abused an admin password to access out-of-bounds information shouldn't surprise anyone, said Bosnian. "Everyone thinks that IT administrators are the trusted ones, and it's all the rest that we need to worry about. But admin passwords not only give administrators a lot of power, they also provide a lot of anonymity."

More here:

http://www.computerworld.com.au/index.php?id=1907566447&eid=-255

This is a worry, but not unexpected. What it tells me is that we need to have systems that foster the maintenance of security while at the same time making sure all those who have such roles understand (through education etc) the trust and responsibility they carry – to keep all the things they discover in the course of their work to themselves. This should be backed up by regular review of audit trails to detect bad behaviour and a clear and transparent penalty process for abuse.

More next week.

David.

E-Health and the Terrible Floods in the US MidWest.

The follow press release appeared a day or two ago.

FSSA Announces Indiana Flood Victims eHealth Support Center

INDIANAPOLIS--(BUSINESS WIRE)--Today, the Indiana Family and Social Services Administration (FSSA) announced the creation of the Indiana Flood Victims eHealth Support Center (1-877-788-5888) as a part of the relief effort for disaster victims across the state. This support center will provide doctors with medical information of flood victims, to the extent obtainable, for treatment purposes. FSSA is leading the effort between the Regenstrief Institute, Indiana Health Information Exchange (IHIE), who is handling the calls, and Electronic Data Systems (EDS).

“Governor Daniels called upon state government to assist the disaster victims in any and all ways possible. The support center is just one of several initiatives taking place to help Hoosiers get back on their feet,” said FSSA Secretary Mitch Roob. “With the eHealth Support Center, we will be able to give providers all the information we have available in a timely manner, resulting in a higher quality of care for patients.”

Medical information is being made available through the Indiana Network for Patient Care (INPC). The INPC is a secure clinical data repository that is populated with healthcare information in collaboration with central Indiana hospitals, outpatient centers, pharmacies, imaging centers, laboratories, public health departments and insurance providers.

“We are pleased to be able to support flood evacuees and their doctors in this time of need,” said Dr. J. Marc Overhage, Director of Medical Informatics at the Regenstrief Institute, Inc. and President/CEO of the Indiana Health Information Exchange. “The ability to provide medical information that would otherwise be lost or inaccessible is going to make a difference in the care of many Hoosiers. We applaud FSSA in making this collaboration a reality.”

Calls will be taken 24 hours a day, seven days a week. Requests that are made to the Indiana Flood Victims eHealth Support Center (1-877-788-5888) during business hours (7:00am – 5:00 pm EST) will be processed within one hour. Calls made after hours will be processed the next business day.

For additional information about the eHealth Support Center, patients and physicians should visit: www.ihie.com/indianaflood. For more information on disaster relief efforts visit: www.emergency.in.gov .For more information about FSSA, visit: www.fssa.in.gov. For more information about EDS, visit: www.eds.com . Additional information about the Indiana Health Information Exchange may be found at: www.ihie.com. Information about the Regenstrief Institute is available at: www.regenstrief.org.

URL for release:

http://www.businesswire.com/portal/site/google/?ndmViewId=news_view&newsId=20080620005411&newsLang=en

This is really a good thing to see the infrastructure be quickly brought into action to support those who have been displaced and possibly separated from their usual services and carers. This is, of course, what did not happen with Cyclone Katrina.

One can only hope planning to deliver such services is part of the disaster planning that is undertaken in Australia – given the bad run we have had with cyclones and the like recently.

David.

The New England Journal of Medicine Assesses the Real EHR Use in the USA

The following abstract is from a full article published in last week’s NEJM.

Electronic Health Records in Ambulatory Care — A National Survey of Physicians

Catherine M. DesRoches, Dr.P.H., Eric G. Campbell, Ph.D., Sowmya R. Rao, Ph.D., Karen Donelan, Sc.D., Timothy G. Ferris, M.D., M.P.H., Ashish Jha, M.D., M.P.H., Rainu Kaushal, M.D., M.P.H., Douglas E. Levy, Ph.D., Sara Rosenbaum, J.D., Alexandra E. Shields, Ph.D., and David Blumenthal, M.D., M.P.P.

ABSTRACT

Background Electronic health records have the potential to improve the delivery of health care services. However, in the United States, physicians have been slow to adopt such systems. This study assessed physicians' adoption of outpatient electronic health records, their satisfaction with such systems, the perceived effect of the systems on the quality of care, and the perceived barriers to adoption.

Methods In late 2007 and early 2008, we conducted a national survey of 2758 physicians, which represented a response rate of 62%. Using a definition for electronic health records that was based on expert consensus, we determined the proportion of physicians who were using such records in an office setting and the relationship between adoption and the characteristics of individual physicians and their practices.

Results Four percent of physicians reported having an extensive, fully functional electronic-records system, and 13% reported having a basic system. In multivariate analyses, primary care physicians and those practicing in large groups, in hospitals or medical centers, and in the western region of the United States were more likely to use electronic health records. Physicians reported positive effects of these systems on several dimensions of quality of care and high levels of satisfaction. Financial barriers were viewed as having the greatest effect on decisions about the adoption of electronic health records.

Conclusions Physicians who use electronic health records believe such systems improve the quality of care and are generally satisfied with the systems. However, as of early 2008, electronic systems had been adopted by only a small minority of U.S. physicians, who may differ from later adopters of these systems.

The Full Text is available (for free) at the URL below.

http://content.nejm.org/cgi/content/full/NEJMsa0802005?query=TOC

The study has been warmly received by a number of commentators.

The following long article provides a lot of detail.

EHR access sparse in ambulatory-care environment

By: Joseph Conn / HITS staff writer

Story posted: June 19, 2008 - 5:59 am EDT

The summary report on a comprehensive survey, funded by government and private organizations, of physician adoption of electronic health-record systems finds that after more than four years of federal ballyhoo of health information technology, only 17% of physicians in the ambulatory-care environment have access to an EHR.

Just 4% of physicians in ambulatory care have available a “fully functional” EHR system, including patient-safety features such as drug-drug and drug-allergy alerts and full electronic prescribing.

Anticipating just such a low adoption rate, researchers graded on a curve, giving partial credit to physicians who have something less than the best EHR system in their offices. Another 13% of physicians surveyed have such “basic” EHRs with a minimum set of functions.

Given that 83% of ambulatory-care physicians don’t have an EHR, “the U.S. healthcare system faces major challenges in taking full advantage of EHRs to realize its health goals,” according to an executive summary of the published survey in the June 19 issue of the New England Journal of Medicine. A copy of the full report should be released July 2.

The survey was conducted between September 2007 and March 2008 by the Institute for Health Policy at Massachusetts General Hospital, Boston, the Harvard School of Public Health, George Washington University and RTI International, working under a contract with the Office of the National Coordinator for Health Information Technology at HHS. The initial contract was awarded in 2005 to develop a standardized methodology to measure the rate of adoption of EHRs among physicians and hospitals.
More here:

http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20080619/REG/785336712/1029/FREE

There is additional Coverage here:

'Full function' EHRs may not get full CMS incentives

By: Joseph Conn / HITS staff writer

Story posted: June 20, 2008 - 5:59 am EDT

Only 4% of U.S. physicians in ambulatory care have access to an advanced, "fully functional" electronic health-record system, but even those top-tier systems may not be fully featured enough to qualify for maximum payments under the new CMS pilot program to boost EHR adoption.

Still, most healthcare information technology experts contacted for this story reacted favorably to the release of the executive summary of what may be the most authoritative and methodologically solid study of EHR use to date.

The summary was published in the New England Journal of Medicine. The survey work was conducted under two $600,000 grants from the Robert Wood Johnson Foundation and another $3.6 million grant from the Office of the National Coordinator for Health Information Technology at HHS, the latter of which paid for both the ambulatory-care EHR survey and a separate hospital IT survey that is yet to be completed. A final report on the ambulatory survey is due July 2.

The survey of 2,758 physicians was conducted between September 2007 and March 2008 by the Institute for Health Policy at 902-bed Massachusetts General Hospital, Boston, the Harvard School of Public Health, George Washington University and RTI International.

See full article here:

http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20080620/REG/739079971/1029/FREE

The New York Times also covered the report.

See:

http://www.nytimes.com/2008/06/19/technology/19patient.html?_r=1&oref=slogin

Most Doctors Aren’t Using Electronic Health Records

A very important aspect of these studies is that a methodology has been developed that really assesses the quality and depth of the EHR being used. This is clear recognition of the fact that it is only when the more advanced forms of functionality are not only present, but actually used, will the hoped for benefits and improvements in care quality be achieved.

It would be invaluable if such a detailed study were carried out in Australia.

I look forward to the full paper on July 2.

David.

Health Information Exchange – Some Really Sound Thoughts and Why NEHTA might be Off Course.

The following post appeared on the e-CareManagement blog a day or two ago.

Untangling the Electronic Health Data Exchange

Posted by Vince Kuraitis on June 19, 2008

by David C. Kibbe MD, MBA

The purpose of this post is to help a non-technical audience untangle some of the confusion regarding health data exchange standards, and particularly come to a better understanding of the similarities and differences between the Continuity of Care Record (CCR) standard and the CDA Continuity of Care Document (CCD). But what I’m most interested in is getting beyond the technical, political, or economic positions and interests of the proponents of any particular standard to arrive at some principles that demonstrate in plain language what we are trying to achieve by using such standards in the first place.

Frankly, I don’t give a hoot about what standardized XML format for capturing clinical data and information about a person becomes the norm in the health care industry over the next several years. I do care that the decision is made by the people, institutions, and companies who use the standards, and not made by a quasi-governmental panel or a group of “industry experts” whose economic or political interests are served by the outcome, and dominated by a particular standards development organization with whom they are very cozy.

In other words, I do want free and open market forces to be able to operate freely and openly as health information exchange evolves, in part because I believe market forces will work in the direction of continuously improving health IT, whereas in my experience top-down efforts are often protective of established interests and discouraging to innovation.

Herein lies the problem, in my opinion, with the standards adoption process that the Office of the National Coordinator of HIT (ONC) and HITSP have overseen during the past four years.

It is the epitome of a top-down, large established player-controlled, and anti-competitive juggernaut in which a “one size fits all” paradigm has been promoted and lobbied for. In this case, HITSP has “selected” the CCD and not the CCR standard, despite the market forces that seem to be continuing the use of the CCR standard. This is simply stupid and likely will turn out to be futile.

I am one of the many volunteer co-developers of the Continuity of Care Record standard, which has been developed under the auspices of ASTM International, a not-for-profit organization that develops standards for many industries, including avionics, petroleum, and air and water quality. The CCR is sponsored by the American Academy of Family Physicians and numerous other physician groups. I am also the 2008-2010 chair of the E31 Technical Committee on Healthcare Informatics, the leadership group within ASTM that is working with Google Health and many other individuals and organizations on the implementation and use of the CCR standard in this country and abroad.

Much more here:

http://e-caremanagement.com/untangling-the-electronic-health-data-exchange/

It needs to be said that while there is a risk of some sort of partisanship in all this David Kibbe is a man who knows what he is talking about. Some of the points he makes I find really compelling – especially in the light of some of the choices NEHTA is making in the same domain at present.

Of special importance is the last paragraph of the blog.

“Which brings me to the finale of this post, namely, to state in plain language that interoperability can only be approached in incremental stages when so much health data and information exists in non-structured formats. The principle to uphold is the encouragement of any and all efforts to innovate in the direction of computability and interoperability, even if some of these appear less than perfect or even piece-meal. One size will not fit all uses or use-cases, and what is good for consumers’ PHRs may not be the same thing that works in a very large medical enterprises. Control over standards by large enterprises and/or their vendors is spurious, anti-competitive, and probably won’t be effective. The standards are supposed to make our lives simpler, not more complicated.”

What Dr Kibbe is saying you is you have to start simple and grow – not do a NEHTA and come up with untested – and probably unusable – 100+ page documents defining how to do a discharge summary or referral.

He also clearly recognises the inapplicability of the top down ‘we will instruct and you will comply’ approach, so beloved of NEHTA, in the e-Health domain.

A great read. Certainly a blog to subscribe to notifications of updates!

David.

Just Why are NEHTA’s Plans for the Shared EHR a Secret?

The following is adapted from the NEHTA web site (captured 22/06/2008)

http://www.nehta.gov.au/index.php?option=com_docman&task=cat_view&gid=130&Itemid=139

Shared Electronic Health Record

NEHTA is working to develop specifications and requirements for a national approach to shared electronic health records. These records will enable authorised healthcare professionals to access an individual's healthcare history, directly sourced from clinical information such as test results, prescriptions and clinician notes. The shared electronic health record will also be able to be accessed by individuals who have received healthcare services.

Specifically, NEHTA will focus on developing:

• Operating concepts for a national approach to establishing and maintaining shared electronic health records;
• Policies, requirements, architecture and standards for a national approach to shared electronic health records; and
• A business case to substantiate and validate the proposed approach.

For the health system within Australia to reap the full benefits from the IT, governments and healthcare providers need to make the case for undertaking further investment including the development of a national system of shared electronic health records. The case for the required level of investment depends on the credible quantification of the costs and benefits of providing such.

Contact

Dr Andrew Goodchild - Shared Electronic Health Record Design

Fact Sheets

Shared Electronic Health Record Fact Sheet 19/08/2006

Context and Strategic Direction

Standards for E-Health Interoperability v1.0 - 08/05/2007

Review of Shared Electronic Health Records Standards v1.0 - 21/02/2006

What this shows us is that it is over 14 months since NEHTA has published anything on the Shared EHR.

However we have had Dr Haikerwal running around the country spruiking the plans for having a new electronic record implemented over the next few years – following the receipt of funding from Council of Australian Governments which is to meet in October this year.

See:

http://www.misaustralia.com/viewer.aspx?EDP://20080620000020806080&magsection=news-headlines-list&portal=_misnews&section=news&title=Electronic+health+system+on+the+mend&source=/_xmlfeeds/mis/news/feed.xml

It seems, from the reports I have received, NEHTA has been conducting briefings about such a plan to a collection of clinical and consumer peak bodies. (The last one was on June 18 in Canberra).

The obvious concern is just what they are telling these audiences and what commitments are being made that have not been subjected to any technical scrutiny other than the NEHTA staff. The situation we have here is that NEHTA (a publicly funded organisation) is providing private briefings on topics where it has by no means the monopoly on expertise trying to get very substantial ($billions I would not be surprised) funding to keep itself in existence while having been reviewed by the Boston Consulting Group recently as a failed organisation – especially in the area of Shared EHRs (now somehow renamed Individual EHRs).

In the meantime we also have the following:

3 years away">Surprise, surprise - e-health records >3 years away

17 June 2008

The Australian Doctor website reports today that Australia “is at least three years away from introducing shared e-health records for every patient — despite $150 million being sunk into e-health programs over the past eight years.”

Federal Health Minister Nicola Roxon, when interviewed by the Australian Financial Review last week, refused to commit to a 2012 deadline for a national e-health record system.Clinical leader of the National e-Health Transition Authority (NEHTA) and ex-AMA president Dr Mukesh Haikerwal told Australian Doctor, “There is no element of the reform agenda that can succeed unless we have a decent underpinning by a robust e-health system.”NEHTA is believed to be looking initially at a minimum-quality data set - limited to information such as allergies, hospital history and medical conditions to ensure there is enough information “to treat the patient safely”.

For more see:

http://wellingdigital.com.au/

Worse we have a National E-Health Strategy being developed by Deloittes which NEHTA is clearly making bets on the outcome of. This is a governance and management farce. Either NEHTA or Deloittes are setting the direction for the future of e-Health. I know which is should be and it isn’t NEHTA!

Deloittes need to be allowed to finish their work – have it made public for consideration by all relevant stakeholders - and at this point NEHTA should be invited to consider how it can actualise whatever is recommended.

I believe both Ms Roxon and Mr Hockey (the Opposition spokesman) should be asking some hard questions of NEHTA right now as to just what they are up to and how they justify it. At the very least the public (and not just a select few) is entitled to know what they have in mind!

David.