Others Are Noticing the Australian E-Health Mess.

There is always the risk – when typing away in the ivory tower – that one can become a little out of touch. I have thus found it very re-assuring that increasingly other observers are noticing the mess we seem to be making of e-Health.

A couple of examples.

Ready, set… slow

Friday, 11 July 2008

What’s the hold-up on a national, linked electronic health system? Kathryn Eccles finds out.

BEING called to hospital at 2 am to assess a patient with chest pain is part of an average week for Dr Peter Rischbieth.

At his most recent early morning call-out, the RDAA president would have been forced to rely on a 73-year-old patient and her relatives for a medical history were it not for his computerised practice. But a few clicks of the mouse were all that was needed to compare the patient’s current ECG with one from a month earlier.

The comparison showed Dr Rischbieth the ECG was normal for that patient, saving her an 80 km journey to Adelaide, an $800 ambulance bill, the cost of a back-up ambulance crew to provide cover, and time waiting in casualty.

E-health, even at its most basic level – allowing doctors to access patient notes from the local hospital – is not only proving cost effective, it is also saving time and lives.

Research shows that computerised prescribing systems can significantly lower medication mistakes and adverse drug events. And, given that about one in 10 general practice patients experiences an adverse drug reaction over a six-month period (MJA 2006;184:321-24), the potential to make a difference is huge.

This is why progressing the e-health agenda across the country is crucial, says Dr Rischbieth.

…..

And, for many doctors, this lack of symmetry is where the frustration lies. Patience is wearing thin among GPs who have been waiting what seems like an eternity for a functional national system to develop.

They want to see a system that can provide crucial medical details at the touch of a button, that allows professionals to ‘talk’ to each other via secure messaging; to write and process prescriptions electronically; and to scrap the clutter of paperwork.

While all of this does happen to an extent in some areas at a local level, national progress could be described as glacial.

Original plans to introduce a national shared electronic health record were based on a 2010 timeframe.

But that now looks unlikely, with 2012 looking like a more realistic, but still challenging, goal.

Groups in charge of driving the process include the National E-Health Transition Authority (NEHTA), which has been entrusted by the Council of Australian Governments (COAG) to develop standards for the seamless delivery of e-health across every state and territory.

Consultancy firm Deloitte Touche Tohmatsu has been handed $1.3 million by COAG to prepare a national e-health strategy, due later this year.

Former chair of the now-defunct General Practice Computing Group Dr Ron Tomlins believes the extended timescale is simply because NEHTA has “picked the pineapple up by the wrong end”.

“They should be focusing on resources that people already have and encouraging them to use them better and more appropriately rather than search for some... magic solution.”

More here (if you have access to Medical Observer)

http://www.medicalobserver.com.au/medical-observer/news/Article.aspx/Ready,-set%E2%80%A6-slow-

Equally we have the following from another source.

Government dragging the e-health chain in Australia

10 July 2008

Excerpted from a special report I wrote for this week’s Australian Doctor

Jim Clark was known as Silicon Valley’s $3 billion man: the first person to start up three companies that were each capitalised at $1 billion or more. Starting in the 1980s with Silicon Graphics, a pioneer of film and CGI animation, he grew bored with that and helped found Netscape, which launched the world’s first widely used web browser, in the early 1990s.

…..

Clark had the right idea, but back in the last decade he was too far ahead of the curve to make it work. Now, however, e-health is an idea whose time has come.

“E-health is an idea whose time has not only come, it is overdue,” says Associate Professor Ron Tomlins, associate professor of general practice at the University of Sydney, who spent several years as chairman of the General Practice Computing Group.

Professor Tomlins said government and professional initiatives in Australia over the past 10 years that put computers, powerful software and broadband in practices have prepared a foundation that will enable GPs to harness the new online technologies that have been developing independently over the same period.

As more and more doctors turn to the Internet as a professional information source, more than 80% now report that the Internet is essential to their practice, according to research in the US by Manhattan Research. Consumers today, meanwhile, get more health information from the Internet than from their doctors, according to market research firm iCrossing.In Australia, trials of electronic health records and other online applications are under way in most states (see Case studies), while the Federal Government tries to set standards through the National E-Health Transition Authority (NEHTA) to ensure consistency, portability and security of records.

In Canada, the government has set a target of 50% of the population to have electronic personal health records by the end of 2009. In Australia, meanwhile, the government is “dragging the chain”, according to Professor Tomlins, with NEHTA recently announcing that it would be another 10 years before personal health records were in established use in Australia. Professor Tomlins said NEHTA is not moving fast enough, pointing out that it underspent its budget by almost $40 million last financial year.

“General practice is frustrated as hell in the lack of interest from the Commonwealth,” Professor Tomlins said. “The state governments are moving things along with projects such as Healthelink in NSW, SHER [shared electronic health records] and secure messaging projects in the Northern Territory and chronic health management programs in South Australia. But there’s a real danger that they won’t be interoperable and we will end up with a rail gauge situation.”

But regardless of that danger, Professor Tomlins says, the increase in data available to GPs puts them in a good position to use new technologies to improve patient care. “GPs have spent the past few years building up electronic databases for their practices,” according to Professor Tomlins. “Tools are now available to use that data to better understand how better care can be delivered to their patients. They can conduct clinical audits to mine that data, both clinical and financial, and benchmark themselves against other practices to find ways to improve the way care is delivered.

More here

http://wellingdigital.com.au/2008/07/10/government-dragging-the-e-health-chain-in-australia/

All I can add is that the time for messing around should be close to past. We have the Deloittes National E-Health Strategy due in 6-7 weeks and hopefully after that is released (and that it is will be a bit of a test given it can hardly be flattering) we will have a platform for discussion to move the agenda forward.

One hope is that I am hearing from a range of sources that the NEHTA Acting CEO is making a difference! – If this turns out to be sustained it is a very good development. If you read Andrew – and I know your staff do – keep it up!

I sure hope so!

David.

NEHTA’s Clinical Briefing Papers for Your Reading Pleasure.

Some will be aware that in the last month or so NEHTA has been running a range of sessions to brief clinicians on its plans for Health Identifiers and the Individual EHR.

As many will be aware for some reason the Health Informatics Community was not represented at these briefings.

For this reason I thought it would be a good idea to let the readership of the blog see some of what was presented and discussed

Please download the information from this link.

http://www.moreassoc.com.au/downloads/NEHTA eHealth Summit.zip

There seems to me to be a good deal more detail on all sorts of things than we have seen to date, and certainly NEHTA has updated the house documentation style dramatically.

I would really love views (as comments on the blog) from Health Informatics professionals on the plans outlined here. NEHTA still seems to think it can speak ‘ex-cathedra’ rather than getting expert comment before asking clinicians and the public what they think.

I can’t see any restrictions on these documents so I think it is good to have them more widely distributed.

Anyway NEHTA is a publicly owned company and we own them so we are entitled to know just what it is they are up to! – Unless there is financial risk to the Commonwealth – and there is not -they have no right to be so secretive.

Enjoy!

David.

Useful and Interesting Health IT Links from the Last Week – 13/07/2008

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

These include first:

Public leery of electronic health-record security

By: Joseph Conn / HITS staff writer

Story posted: July 8, 2008 - 5:59 am EDT

There are three key take-aways from a recent survey on the scope of the healthcare data-security problem.

Only one of them is about its size, which is to say, huge.

Another is that the level of public awareness about the problem is surprisingly high compared with public familiarity about other civic issues, according to an expert who collaborated with the polling firm in putting the survey together.

Finally, substantially more people think electronic health-record systems are riskier than paper-based records.

Alan Westin is a principal with the Privacy Consulting Group, Teaneck, N.J., and a professor emeritus of public law and government at Columbia University. Westin worked with Harris Interactive on the survey instrument used to poll 2,454 adults online between June 9 and June 16. Harris Interactive did not include a "margin of error" estimate with the poll results.

Asked, "To the best of your knowledge, have your medical records or health information, or those of a family member, ever been lost or stolen from an organization that had those records?" about 4% of respondents answered "yes," with about 3% reporting it was their own records that had been lost or stolen.

More here:

http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20080708/REG/626135643/1029/FREE

Again we have survey evidence of the concern people have about their medical records slipping out of their control. We ignore such concerns at our peril!

Second we have:

Large hospitals, IDNs drive use of RFID in healthcare settings

By Bernie Monegain, Editor 07/08/08

The market for or radio frequency identification (RFID) in healthcare is booming, according to a new report from the Spyglass Consulting Group.

The adoption and investment in RFID solutions - primarily to track high-value mobile assets, patients and staff members - represents a 204 percent increase from Spyglass' 2005 RFID study, said Gregg Malkary, Spyglass' managing director.

"It solves a real problem of tracking assets, patients and staff," he said.

"RFID investments are growing exponentially as healthcare organizations develop a better understanding of the technology and how it can be used to solve real problems within their facility," Malkary added. "RFID solutions are being deployed to enhance patient safety, increase operational efficiency and optimize business workflow processes. Larger organizations are more likely to make RFID investments than smaller hospitals because they have larger physical footprint making it more difficult to track things."

The Spyglass study found that 76 percent of larger healthcare organizations have invested in RFID-based solutions.

More here:

http://www.healthcareitnews.com/story.cms?id=9516

It is interesting to see how rapidly this technology is being adopted in the health sector. The article warning about the possibility of interference with some medical devices (cited in the full article) with the use of this technology clearly needs to be confirmed soon to make sure a lot of work is not wasted!

Third we have:

Mergers trimming players in healthcare IT field

By: Jean DerGurahian/ HITS staff writer

Story posted: July 7, 2008 - 5:59 am EDT

Health information technology might be a booming business, but industry players agree: It's one tough market.

Faced with reluctant physicians who don't see the bottom-line value of costly electronic systems in their practices, vendors have embarked on plans to better align their products with providers' needs while trying to educate their customers about IT services. Many of those plans include mergers and acquisitions—a sign the market is maturing, insiders say.

In the first half of 2007, the health IT industry saw several large-scale mergers between vendors, especially in the electronic health-records segment. Most recently, SureScripts and RxHub last week announced they had merged to become the largest electronic drug-prescribing network in the country. Another proposed deal involving Raleigh, N.C.-based Misys Healthcare Systems purchasing a controlling interest in Allscripts Healthcare Solutions, Chicago, passed the waiting period for Justice Department antitrust review, Allscripts announced in early June.

Driving the consolidation are high barriers to entry and the larger, more-established competitors who continue to eat market share, said Mike Davis, executive vice president of the analytics division of the Healthcare Information and Management Systems Society. The market is crowded, and only a few players have stayed on top over the past decade, he said. "We've got some dominant vendors," pointing out companies such as Cerner Corp., Epic Systems Corp. and McKesson Corp.

More here:

http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20080707/REG/411750011/1029/FREE

It is interesting to see the way the system is shaking out in the US.

For Australia we are now in the situation where we have two major providers who are well established in the major hospital sector (Cerner and IBA), Global Health in the small hospital sector also has a significant present and only 2-3 major GP system providers – with one (HCN) still pretty dominant.

It would be good to see some more balance in the GP sector in Australia with more pressure to provide really usable and functionally rich systems. Significant market dominance is never a good thing in my view.

Fourth we have:

CCHIT Certifies 18 More EHRs

July 3, 2008

The Certification Commission for Healthcare Information Technology in recent weeks has certified specific versions of 18 more ambulatory electronic health records systems under 2007 certification criteria.

Several of these products received pre-market conditional certification, meaning they will be fully certified once use at a physician office is verified.

CCHIT now has certified 50 EHRs under 2007 criteria. The commission no longer is accepting applications for 2007 certification, although there may be products that have not yet completed the process. The commission on July 1 began accepting applications for certification under 2008 criteria.

More here:

http://www.healthdatamanagement.com/news/certification26584-1.html?ET=healthdatamanagement:e495:100325a:&st=email&channel=electronic_health_records

The steady progress the Commission for the Certification of Health IT is making is really impressive. As they move to the 2008 criteria the functional and technical standard required to be certified is becoming reflective of a really first rate system. Given 100% conformance is required there are soon going to be some very good ambulatory care systems available for US clinicians.

Fifth we have:

Australian Medical Association hypocritical on Medicare

Article from:

By Sue Dunlevy

July 11, 2008 12:00am

ONE health minister has been sued for defamation by an AMA president, another had to spend $300 million to avert a hospital strike when the doctors' insurance fund went bust and now new Health Minister Nicola Roxon is at war with the doctors' union.

This time it is the Health Minister apparently on the front foot, freezing the AMA president Rosanna Capolingua out of Kevin Rudd's 2020 Summit, refusing her a place on new health committees and threatening to let nurses take over many of the doctors' traditional roles.

But Roxon is about to learn, as her predecessors did, that this old-style doctors' union has a very powerful influence over this nation's health system.

And there is no greater proof of this than the way the AMA has for nearly a decade thwarted repeated government attempts to eliminate the need for you to visit a Medicare office to get your Medicare rebate.

Nine years after former Health Minister Michael Wooldridge first promised patients they could get their Medicare rebate paid direct to their bank account from their doctor's office, only 10 per cent of Medicare rebates are being paid this way.

More than $700 million of taxpayers' money has been spent on equipment and systems to streamline the payment of Medicare rebates direct from a doctor's office, but doctors won't adopt the system.

The government is even offering doctors a bonus worth up to $1000 to use the system.

They also pay them 18c every time they process a Medicare rebate in their office.

But instead of a reduction in the number of people visiting a Medicare office, there has been an increase - up from 80,000 to 85,000 a day.

More here:

http://www.news.com.au/dailytelegraph/story/0,22049,23999743-5001031,00.html

From Australia’s second most conservative tabloid this is quite a blast at the AMA. It also reminds us – if any reminding was needed – that without strong support from the medical profession even the simplest e-Health initiative is likely to flounder badly!

Sixth we have:

Input sought on e-health

Abstracted from The Australian Financial Review

NEHTA in Australia is seeking public submissions on a privacy blueprint for individual electronic health records (IEHRs). The process is an important part of resolving some of the concerns regarding access to sensitive information that would be stored in IEHRs.

More here:

http://www.businessspectator.com.au/bs.nsf/Article/Input-sought-on-e-health-GBUDZ?OpenDocument

It is important that anyone with an interest do carefully review and comment back to NEHTA on their thoughts on the privacy blueprint. (www.nehta.gov.au).

The report is found here:

http://www.nehta.gov.au/index.php?option=com_docman&task=doc_download&gid=495&Itemid=139

E-Mail comments can be sent to privacyblueprint@nehta.gov.au

Comments are due by August 8, 2008

Last we have our slightly technical note for the week:

A Patch to Fix the Net

A major flaw in the basic design of the Internet is being repaired by a large group of vendors working in concert.

By Erica Naone

On Tuesday, major vendors released patches to address a flaw in the underpinnings of the Internet, in what researchers say is the largest synchronized security update in the history of the Web. Vendors and security researchers are hoping that their coordinated efforts will get the fix out to most of the systems that need it before attackers are able to identify the flaw and begin to exploit it. Attackers could use the flaw to control Internet traffic, potentially directing users to phishing sites or sites loaded with malicious software.

Discovered six months ago by security researcher Dan Kaminsky, director of penetration testing services at IOActive, the flaw is in the domain name system, a core element of the Web that helps systems connected to the Internet locate each other. Kaminsky likens the domain name system to the telephone company's 411 system. When a user types in a Web address--technologyreview.com--the domain name system matches it to the numerical address of the corresponding Web server--69.147.160.210. It's like giving a name to 411 and receiving a phone number, Kaminsky says.

The flaw that Kaminsky found could allow attackers to take control of the system and direct Internet traffic wherever they want it to go. The worst-case scenario, he says, could look pretty bleak. "You'd have the Internet, but it wouldn't be the Internet you expect," Kaminsky says. A user might type in the address for the Bank of America website, for example, and be redirected to a phishing site created by an attacker.

More here:

http://www.technologyreview.com/Infotech/21058/?nlid=1199

This flaw has been widely reported and certainly seems to be been a major issue in internet security that has been well handled co-operatively. It is interesting how such issues can be around for so long. There was also a report this week of a bug in a key part of the Unix on which both MacOS and others are based that has taken 33 years to be tracked down and fixed!

More next week.

David.

Evidence Based Medicine – An Idea Whose Time Must Soon Come!

The following appeared a little while ago.

The Benefits of Evidence-based Medicine in EHR Systems

June 10, 2008

Evidence-based medicine is often admired but seldom practiced. It is rarely practiced because few physicians have the time to critically appraise the medical literature; an unfortunate reality considering the impact on quality of care, and the fact it could be changed.

When integrated into an electronic health record (EHR) system, evidence driven decision support is presented to the physician at the point of thought, providing crucial evidence-based literature that promotes timely and informed medical decision making. Further integration with a single platform solution that includes an electronic prescribing module provides the physician with objective, medication therapy decision support at the point of prescribing.

Integrated seamlessly into a practice’s EHR, e-prescribing provides additional information, including the cost, efficacy and adverse effects of various medication-based therapeutic alternatives to help the physician make the best prescribing decisions.

Three published estimates suggest that physicians are directing 80% of the spending in our $2 trillion health care market. Yet if you consider the information that we physicians bring to these spending decisions, frankly, it is primitive and pathetic. Imagine physicians as purchasing agents with $2 million annual budgetary authority. Studies show that we physicians don’t know how much the drugs and diagnostic tests that we order cost, and we lack comparative information about their effectiveness and adverse effects. Furthermore, our compensation is largely disconnected from the quality and cost-effectiveness of our performance. Is it any wonder that the U.S. has the most expensive health care in the world, while perennially ranking near the bottom of industrialized countries in metrics like healthy life expectancy?

Health information technologies, especially EHR systems, are often promoted as the solution to much of what ails our health care system. The implementation of technology has become a powerful political issue, but in such a fractured healthcare system, adoption remains a constant struggle for small and medium-sized practices.

Evidence-based medicine (EBM) promises to displace Authority Based Medicine, wherein practicing clinicians simply followed the recommendations of expert thought leaders in the healthcare community. These thought leaders were usually identified by their affiliation with distinguished academic medical centers with successful college football programs.

Much more here:

http://ehrscope.com/blog/the-benefits-of-evidence-based-medicine-in-ehr-systems/

This article makes a series of useful points.

First among them is the level of control that physicians have over health expenditure. Linked to this it would seem that there is a real obligation to use that control wisely. As the article goes on to make clear there are a number of barriers to that happening. Among these is just the scale of the knowledge management task modern medicine poses to practitioners as well the difficulty there can be in accessing reliable, trustworthy evidence on what the appropriate thing to do is in real time with the patient sitting in front of you.

Second, as is laid out later in the article, there is compelling evidence that EBM saves both lives and money.

Third there is now increasing evidence that provision of paid incentives for quality of care can not only change behaviour but also still save substantial sums of money.

What is needed is to have available clinical systems which make the search for evidence and then its application to care seamless and as effortless as possible. Also we need systems – such as those being developed by Pen Computing in Australia – that make quality audit and clinician feedback as seamless as possible.

There is an opportunity to make a huge difference with such systems. We have started down the path but there is much more to do both in system and incentive design as well as information provision and decision support.

David.

Software Errors Can Kill – We Need to Recognise the Issue!

The following article appeared a few days ago.

Flaws in medical coding can kill

Spread of computers creates new dangers, FDA officials warn

By Jonathan D. Rockoff | Sun reporter

June 30, 2008

WASHINGTON - After a routine piece of medical equipment started mysteriously killing hospital patients a few years ago, the federal government turned to a small team of its software experts in suburban Maryland for help.

The team's discovery - a flaw in a computer code that caused a drug pump to administer heavy overdoses - led to a recall, warnings and rewriting of the equipment's software. The discovery also illustrated a new threat behind some lifesaving medical devices.

Microprocessors run everything from patient monitors to artificial pancreases, and potential software flaws are a growing concern. A product might not malfunction because it was poorly designed or badly made - the traditional suspects - but because the computer code running it includes a mistake. The impact of that glitch can be increasingly serious because the latest automation is removing the doctors and nurses who watched for machine mix-ups.

"The world of technology is allowing us to do things we never thought possible, and it's largely a great advance," said Larry G. Kessler, who directs the Food and Drug Administration Office of Science and Engineering Laboratories, which oversees the team of software sleuths at White Oak in Montgomery County. "Where it gets to be scary is, we used to have more human intervention. With software doing more now, we need to have a lower tolerance for mistakes."

Of 23 recalls last year that the FDA classified as life-threatening, three involved faulty software.

Manufacturers test and inspect the software on their products, such as dialysis systems and patient monitors, before putting devices on the market. But they've been slow to follow the FDA in adopting new forensic technology because it is costly and still evolving, industry officials say. As a result, FDA software specialists are amassing evidence to show companies the value of the new testing. Meanwhile, traditional software checks, while good at detecting some flaws, are not thorough enough to find every mistake, according to computer scientists.

"If architects worked this way, they'd only be able to find flaws by building a building and then watching it fall down," said Paul Anderson, vice president of engineering at GrammaTech, which has sold forensic software technology to the FDA and medical device companies.

Finding a killer buried in a medical device's source code is not straightforward detective work. The directions for an implantable defibrillator might run over 100,000 lines - as long as War and Peace - and cover a multitude of possible actions that could take a decade for the device to run through. Fitzgerald's team of investigators doesn't have that kind of time, especially when patients are dying.

Much more here:

http://www.baltimoresun.com/news/health/bal-te.fda30jun30,0,912831.story

This is a really important article in my view as it reminds us just how potentially dangerous it can be to assume the operational software in both devices and indeed in clinical systems can be – and how hard it can be to discover just what the problem is.

The application of techniques used to check the software that controls space rockets – static analysis – seem like just the right thing to do. It seems to be likely it will not be long before this and other techniques become mandatory for all new devices and systems. That may not be a bad thing!

David.

NEHTA Privacy Blueprint for the IEHR – How Much Progress Does it Reveal?

In this article I review the Privacy Aspects of the recently released document.

The document can be found here:

http://www.nehta.gov.au/index.php?option=com_docman&task=cat_view&gid=-1&Itemid=139

There are a few positive points to be made about this document.

First, it does appear to have headings that cover all the major issues.

Second , it has been developed with the input of a range of people – according to Appendices F & G – that I know to understand most of not all of the issues.

Third it is clearly written and nicely comprehensible to non-specialists in the privacy / EHR domain.

So far, so good – so what is wrong?

A few things as I see it.

1. Given the importance of this topic – a document at even this high level has been a very long time coming. The initial material is now close to two years old.

2. Much of the analysis found in this document was available 3 years ago – having been developed by Clayton Utz in January 2005 for the HealthConnect Program. I can’t see this present document advances the state of play much at all. (Sadly these documents have all been pulled down off the web by the re-vamp of the Commonwealth Health Department web site following the Labour victory. If you want a copy for your files let me know. The full 3 documents are about 1.4 Megs as .pdf files)

3. It is not clear why, if there are Draft Privacy Impact Statements that have already been developed, that these are not also made available for discussion and review.

4.NEHTA is seeming very uncertain on the way forward with most of the major issues – while I recognise this is a consultation paper one would have liked clarity as to just what NEHTA is proposing in each area.

5. NEHTA seems on a number of topics to be rather too concerned about cost and/or technical difficulty rather than ensuring public confidence.

Overall I think we are quickly reaching a point where NEHTA needs to say, clearly, what is exactly proposed, what the cost and functionality tradeoffs are why they want to go down specific paths. This is the document that should attract the detailed comment – not this rather short and rather less than decisive effort.

Of course all this assumes one thinks the IEHR concept is a good one. Until vastly more detail – including costs, real benefits, provider engagement strategies, data quality strategies, timelines, technologies, security approaches, private sector interface approaches and strategies and implementation phasing and delivery are provided we and COAG run a real risk of buying a ‘pig in a poke’. We must not let that happen without vastly more information – provided before COAG meets – not after!

David.

Post 500 = NEHTA’s Individual Electronic Health Records System – A Really Scary Proposal!

As mentioned late last week NEHTA has just released the Privacy Blueprint for the Individual Electronic Health Record.

The document can be found here:

http://www.nehta.gov.au/index.php?option=com_docman&task=cat_view&gid=-1&Itemid=139

In this blog I want to explore the nature of the IEHR proposal. In a later blog I plan to consider the privacy related aspects of this document.

This is covered in pages 4-9 of the document.

The first thing to note is that the IEHR proposal is a slightly elaborated Shared EHR proposal as developed by HealthConnect between 2002 and 2005 – until the sudden defunding in July 2005. To quote a footnote.

“A national approach to an Individual Electronic Health Records system is also referred to as “IEHR” throughout this document. The IEHR was previously known as the Shared Electronic Health Record (SEHR).

Elsewhere it is made clear that the IEHR is to be an IEHR Service (which presumably someone – Government, Medicare Australia, an IEHR Agency or the Private Sector maybe – will provide) and that all those who have an Individual Health Identifier will be able to enrol in the service.

Just as in the HealthConnect Business Architecture Version 1.0 (16/10/2003) there are initial health profiles and event summaries. (So much for dramatic progress over the last 5 years!)

The present plan calls for an IEHR to be made up of:

1. A Summary Health Profile.

The contents of this are planned to be:

• Allergies, Alerts and Adverse Reactions: Known susceptibilities from past history or investigations and other risk factors;

• Current Medications and Ceased Medications: Current and recent treatment regimes as well as medications that may have been ceased. With each medication the indication for prescribing should be recorded and when medications are ceased, the reason for ceasing should also be captured (e.g. an adverse event, the medication wasn’t effective, etc);

• Problems and Diagnosis: Active or persistent disorders as well as covering things that significantly affect the certainty of an asserted finding;

• Family and Social History: Presence or absence of family and social history relevant to the ongoing care of the individual, as provided by the individual;

• Immunisations: An individual’s history of immunisation;

• Implanted Devices: Presence of implanted devices such as pacing wires, joint prostheses and medication implants;

• Screening Results: Findings from screenings undertaken, the last date and outcome of PAP Smears, Mammograms;

• Key Physiological Measurements: Height, Weight, BMI;

• Planned Activities: A description of activities that should be performed. This may include care plans for certain individuals; and
• Procedures: Histories of recent procedures and past procedures that may be relevant to or compromise long term health.

2. Event Summaries

These will be of individual clinical encounters – e.g. an admission, a lab result or whatever.

3. A Supported Self Managed Care Record.

Here the individual can record their observations, comments etc.

Sensibly have a record will be at the discretion of the individual and it will be possible to de-activate a record if desired.

It is also claimed there will be excellent governance and control arrangements to ensure proper consumer protection and privacy etc.

With the exception of point 3 the HealthConnect Business Architecture V1.9 covered most of this is December 2004.

However, even though this NEHTA proposal has been a long time coming (it has been worked on since 2005 to my certain knowledge) we see little that addresses the core problems that are associated with a centralised Shared EHR.

I have explored these in depth in the past here:

http://aushealthit.blogspot.com/2008/04/few-of-wrinkles-of-shared-electronic.html

and here:

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

and here:

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

among others.

We also now learn that at the end of the year (and not early in 2008 as initially suggested) will a business case to develop this IEHR Service be submitted.

What to say? The number of problems with all this are huge! Among the key issues are deciding what information goes and does not go to the shared record, how to cover gaps in the record when a specialist (or a nurse practitioner) does not use an EHR, how to persuade anyone to contribute to the shared record, how to have trustworthy data quality within the record, who owns the shared record and so on.

What I fear will happen will be some unworked through business case proposal will be submitted, enthusiastically adopted by Ministers who do not know better (why do you think anyone who knows about all this has been excluded from recent consultatory meetings?) and the difficulties and complexities that I have been writing about for years will then emerge as they have in the UK Shared Care Record Approach. (The UK have spent billions on their centralised system only to face huge resistance from clinicians and all sorts of issues in getting ‘data fit for sharing’!)

I believe the centralised, shared EHR is a fundamentally flawed architecture. The funds would be better spent upgrading GP and Specialist Clinical Computer Systems and getting clinical messaging working between the health sector actors. Once that is working – as in places like Denmark – then maybe consider some centralised emergency data storages of critical data as a second step.

Remember doing an IEHR of the sort NEHTA are planning will cost billions of dollars – I am not sure there is the stomach for such investment right now – and neither should there be given what could be done with considerably less.

The National E-Health Strategy needs to define a more bottom up locally driven approach to e-Health that will facilitate incremental, progressive transition towards a National Health Information Network and not towards a centralised IEHR. It is by no means clear that this IEHR initiative should be expending a cent until the National E-Health Strategy is finalised and agreed. This whole – very expensive – effort could turn out to be a total waste of time and money. Indeed I think it will!

I look forward to their report in a month or two. Maybe it will put a stop this NEHTA silliness and fondness for the dangerously grand project.

David.

PS:

This is the 500^th Post to the Blog…thanks to all those who read. Please comment as often as possible as this adds vastly to the value of the blog for me and others!

We now have had over 50,000 visits to the site (80,000+ page views) since March 2006!

D.

Useful and Interesting Health IT Links from the Last Week – 06/07/2008

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

These include first:

Electronic antibiotic stewardship—reduced consumption of broad-spectrum antibiotics using a computerized antimicrobial approval system in a hospital setting

K. L. Buising^1,2,*,, K. A. Thursky^1,2,, M. B. Robertson³, J. F. Black^1,4, A. C. Street^1,2, M. J. Richards^1,2 and G. V. Brown^1,2,4

¹ Victorian Infectious Diseases Service, The Royal Melbourne Hospital, Parkville, Vic. 3050, Australia ² Department of Medicine, Centre for Clinical Research Excellence in Infectious Diseases, University of Melbourne, Parkville, Vic. 3050, Australia ³ Clinical Pharmacology and Therapeutics Department, The Royal Melbourne Hospital, Parkville, Vic. 3050, Australia ⁴ The Nossal Institute for Global Health, University of Melbourne, Parkville, Vic. 3010, Australia

Objectives: Antibiotic stewardship is important, but the ideal strategy for providing stewardship in a hospital setting is unknown. A practical, sustainable and transferable strategy is needed. This study evaluates the impact of a novel computerized antimicrobial approval system on antibiotic-prescribing behaviour in a hospital. Effects on drug consumption, antibiotic resistance patterns of local bacteria and patient outcomes were monitored.

Methods: The study was conducted at a tertiary referral teaching hospital in Melbourne, Australia. The system was deployed in January 2005 and guided the use of 28 restricted antimicrobials. Data were collected over 7 years: 5 years before and 2 years after deployment. Uptake of the system was evaluated using an in-built audit trail. Drug utilization was prospectively monitored using pharmacy data (as defined daily doses per 1000 bed-days) and analysed via time-series analysis with segmental linear regression. Antibiograms of local bacteria were prospectively evaluated. In-hospital mortality and length of stay for patients with Gram-negative bacteraemia were also reported.

Results: Between 250 and 300 approvals were registered per month during 2006. The gradients in the use of third- and fourth-generation cephalosporins (+0.52, –0.05, –0.39; P <> glycopeptides (+0.27, –0.53; P = 0.09), carbapenems (+0.12, –0.24; P = 0.21), aminoglycosides (+0.15, –0.27; P <>P = 0.08) all fell after deployment, while extended-spectrum penicillin use increased. Trends in increased susceptibility of Staphylococcus aureus to methicillin and improved susceptibility of Pseudomonas spp. to many antibiotics were observed. No increase in adverse outcomes for patients with Gram-negative bacteraemia was observed.

Conclusions: The system was successfully adopted and significant changes in antimicrobial usage were demonstrated.

More here:

http://dx.doi.org/10.1093/jac/dkn218

or

http://jac.oxfordjournals.org/cgi/content/abstract/dkn218v1

This is a nice demonstration of how a focussed decision support system can improve the quality of prescribing (and reduce costs almost certainly) while having no negative impact on the clinical outcomes. Antibiotic selection in very sick patients is always a matter for the experts and having a supportive expert system makes very good sense.

Second we have:

ID theft hits $1bn: ABS

Karen Dearne | July 01, 2008

AUSTRALIANS lost almost $1 billion to fraud and scams last year, according to the Australian Bureau of Statistics' first survey of personal fraud.

More than 800,000 fell victim in some way to at least one instance of fraud, representing 5 per cent of the population aged 15 and older. Of those, 453,100 lost money, incurring a combined financial loss of $977 million. The median loss was $450.

Identity fraud accounted for 499,500 victims, with 77 per cent of these reporting fraudulent transactions on their credit or bank cards.

All victims of credit or bank card fraud incurred a financial loss: 25 per cent lost less than $100; 26 per cent lost between $101 and $500; and 3 per cent lost more than $10,000.

The remaining 23 per cent suffered identity theft, involving unauthorised use of their personal details. These people reported forged documents had been used to conduct business, open accounts or take out loans illegally in their name.

More here:

http://www.australianit.news.com.au/story/0,24897,23952995-15306,00.html

These figures seem very high I must say – but on the basis that they are close to reality one has to wonder why there is not more public concern. The impact of this level of fraud on trust of systems (be they banking systems or e-Health systems) must be significant and not helpful I fear.

Third we have:

Victoria's health software ready

Monday, June 30, 2008; Posted: 06:48 PM

Jun 30, 2008 (The Australian Financial Review - ABIX via COMTEX) -- Victoria's Department of Human Services is about to implement new software for the management of patient medical information in the state's hospitals. The rollout is part of the $A360m HealthSmart project.

More here:

http://www.tradingmarkets.com/.site/news/Stock%20News/1725320/

The full article is available here:

http://www.misaustralia.com/viewer.aspx?EDP://20080701000020849516&magsection=news-headlines-home&portal=_misnews&section=news&title=Victoria%27s+health+software+ready

This is a very optimistic read on the progress of HealthSmart. One can only hope it turns out the the adoption of the clinical solutions do actually progress rapidly. I for one am happy to watch and wait to see actually implementation and go-lives occur.

Fourth we have:

Mobile phone a 'life-saver'

• Saved

Louisa Hearn
June 30, 2008

Most of us would dial triple 0 for help in a life and death situation. Now our mobiles can also issue life-saving CPR instructions thanks to a new animated download launched by the Red Cross on Sunday.

The technology, jointly developed Tasmanian company Multi-Ed Medical and mobile networking giant Ericsson, is an animated program with an audio voiceover that gives a detailed overview of steps required for CPR.

Available through any Australian mobile phone service, the animation will can be viewed on any handset capable of displaying 176 x 144 pixel video content in the 3GPP file format.

More here

http://www.smh.com.au/news/technology/mobile-phone-a-lifesaver/2008/06/29/1214677836696.html

The instructions are downloadable:

“The CPR animation costs $3 and can be purchased directly from the Red Cross website or by texting 'CPR' to 19 951 515.”

It is always good to see innovative use of new technology. I think it should be downloaded before the event – hardly would like to be texting for instructions with the collapsed patient in front of me! I am not sure availability should not be funded nationally so it is free for all those with appropriate mobiles.

Fifth we have:

Flying doctors spend $2.7m on bush health records

Suzanne Tindal, ZDNet.com.au

30 June 2008 03:57 PM

The Royal Flying Doctor Service (RFDS) has entered into a five-year AU$2.7m contract with IBA Health to create a standardised system for its electronic health records.

The new system will help the Service's health professionals with its 12,000 annual clinical appointments across regional Australia.

Clinicians will be able to remotely access a patient's medical history, including allergies, immunisation records and current medications, via the internet-based system, and update the information during check-ups.

In time, it is hoped the system will also be accessible in aircraft. The RFDS Queensland operations are already using Telstra Next G to achieve this.

Some areas the RFDS visits don't have internet access. For these places, the RFDS will work together with IBA to develop a customised system which will allow "briefcasing" of medical records — taking files that are needed on laptops and synchronising them with the system when the clinician again has an internet connection.

More here:

http://www.zdnet.com.au/news/software/soa/Flying-doctors-spend-2-7m-on-bush-health-records/0,130061733,339290194,00.htm

This looks like a very useful ‘shared record’ initiative. I hope someone has planned evaluations of the clinical impact as part of the implementation. The devil I am sure will be in the detail of which information is shared, how privacy and confidentiality is handled and so on.

A detail press release is here:

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

iSOFT to provide EMR for Royal Flying Doctor Service

It is interesting to note this project was an initiative of the previous Government in election mode!

Flying Doctors to access medical records

October 3, 2007 - 2:47PM

The Royal Flying Doctor Service (RFDS) will have ready access to the medical records of more than 750,000 residents in remote Australia under a new project backed by the federal government.

Communications Minister Helen Coonan said the federal government would provide $2.7 million towards the eHealth for Remote Australia project.

The project will give RFDS and other authorised health professionals mobile access to medical histories, allergy, immunisation, current medications and other health information, Senator Coonan said.

"The funding will enable health professionals from the RFDS to provide better health care for people in rural and remote Australia," Senator Coonan said.

"The RFDS will have the right information available for the right person, in the right place at the right time to enable assessment to be made during flight and preparations to be made on the ground to receive the patient."

More here

http://www.theage.com.au/news/National/Flying-Doctors-to-access-medical-records/2007/10/03/1191091175189.html

Sixth we have:

Students slice into virtual patients

Nick Miller

June 30, 2008

A WORLD-FIRST surgery simulator, invented by the CSIRO and Melbourne University, allows medical students to practice operations with unprecedented realism.

The simulator lets students "feel" bone and flesh under their virtual drill while using force-feedback pens. It also enables them to see the operation through a 3-D microscope showing a live, animated model of the anatomy they are operating on.

"There have been other computer simulators, but when it's just a mouse melting away the bone you don't feel part of it, you don't get that true connection," said Professor Stephen O'Leary, a senior surgeon at the Royal Victorian Eye and Ear Hospital, who worked to develop the machine. "This brings engagement and realism to the process."

It was also valuable, he said, to be able to stop and "rewind" an operation to show a student what went wrong. It was a great learning tool that would save time and hone the skills of Australia's trainee surgeons, he said. In the future it could even be programmed with scans from an individual patient, so a surgeon could practice before an operation.

More here:

http://www.smh.com.au/news/science/students-slice-into-virtual-patients/2008/06/29/1214677854975.html

This sounds like fantastic stuff. Good to see such expertise exists in Australia and is being used to do such important stuff. Operating on the middle-ear – which the simulator trains for – is very difficult and the chance of permanent damage is high. Maximum preparation before approaching the real patient is a very good thing.

Last we have our slightly technical note for the week:

A requiem for Windows XP

We remember the pros, and a few cons, of the most popular version of Windows to date

InfoWorld staff (InfoWorld) 02/07/2008 08:07:30

Despite an outpouring of demand -- including more than 210,000 people who signed InfoWorld's "Save XP" petition, Microsoft held firm and Monday discontinued sales of XP in most cases. So, we bid adieu to Windows XP.

Sure, any copies of XP in use will continue to run, so the venerable operating system isn't leaving us entirely. And enterprises, small businesses, and some consumers will still be able to install XP as a "downgrade" to Windows Vista Business or Ultimate. And until February 1, 2009, system builders will be able to install XP on "white box" PCs they assemble, which also ironically includes Apple Macs that are bundled with Parallels Desktop or VMware Fusion by resellers such as MacMall and CDW. Finally, low-cost, low-power desktops and laptops such as the Asus Eee PC can ship with Windows XP until 2010.

But it is the end of an era nonetheless.

In response to XP's passing, several InfoWorld editors and contributors shared their memories of XP.

More here:

http://www.computerworld.com.au/index.php?id=1065455962&eid=-255

We all resist change and I must say the transition to Vista is hardly transparent and a number of aspects of Vista are just plain annoying. However, it does do all that XP does – and more – with greater – if not perfect – safety and reliability. Sadly this is all as the cost of needing massively increased resources in terms of memory etc. A simpler, cleaner and less flashy Vista would have been more satisfactory from my perspective – so I plan to stick to the familiar XP for as long as it is supported – which is at least the next 4-5 years.

By then there will be a better Vista (whatever it is called) and a better MacOS I am sure!

More next week.

David.