Useful and Interesting Health IT Links from the Last Week – 19/10/2008

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

These include first:

Keeping Your Own Health Chart, Online

By ANNE EISENBERG

BUSY people can easily forget to take their medications, or to write down symptoms or reactions during a course of treatment — information that could later be meaningful to a doctor.

New tools are being developed that may help harried patients, including those with chronic health conditions, monitor their medications, home tests and other details. The information can then be posted to a Web page that the patient can choose to share with a doctor, pharmacist, friend or caregiver.

Zume Life, of San Jose, Calif., for example, is testing a small hand-held device, the Zuri, that prompts users to take their pills on schedule and to keep track of health-related matters like diet and exercise.

“We’re going after users who are mobile, social, active people” who need to follow a health routine in the midst of busy lives, said Rajiv Mehta, the chief executive of Zume Life.

All of the data from this pocket-size electronic minder, which beeps or flashes when it’s time to take a pill, are uploaded to a Web portal. There, users can inspect, for example, graphs or charts of their exercise or other activities of the last few days or week. And, if the users wish, a caregiver can do so, too.

The Zuri will cost about $200 when it is released in the spring, Mr. Mehta said. Users will also pay about $40 to $50 a month for Web services. A software version of the device that will run on an iPhone is also in the works.

Kathleen Weaver, a high school teacher of computer science in the Dallas Independent School District, is testing a Zuri, using it to keep track of symptoms as well as medication related to diabetes, cardiovascular complications and a persistent cough.

“If I had to write all of this down, I don’t think I could,” she said. “I’m busy all day taking care of other people.”

People who are monitoring their health at home may also take advantage of new online data-storage services being developed by Google, Microsoft and other companies. HealthVault (www.healthvault.com) by Microsoft lets users upload data directly to their account from about 50 devices, including many blood pressure and heart rate monitors, blood glucose meters and weight scales, said Sean Nolan, a computer scientist and chief architect of the Microsoft Health Solutions Group in Redmond, Wash.

Much more here (free registration required):

http://www.nytimes.com/2008/10/12/business/12novel.html?_r=1&oref=slogin

This new set of devices is a new frontier for most patients and how they might really get some value from Personal Health A recommended read!

Second we have:

HCN refutes NPS claims drug prompts dupe GPs

13-Oct-2008

By Paul Smith

MJA GPs are at risk of being duped by drug company advertising in Medical Director prescribing software that can easily be mistaken for decision-support prompts, the National Prescribing Service claims.

The owners of the software, HCN, has rubbished the claims, saying the prompts were not adverts and were not used to “promote” medications.

The NPS, writing in the Medical Journal of Australia (21 July), alleged that drug companies were using new marketing strategies with the introduction of what it described as “drug support prompts”.

“These prompts are linked to specific drugs and contain sponsored information from a pharmaceutical company,” the authors wrote. “Users of the software may find it difficult to identify these prompts as a form of advertising because their format and design are similar to clinical decision support prompts such as drug interaction alerts.

“If promotional messages are to be permitted in clinical software, at the very least they should be clearly labelled as such, so that the user can distinguish them from genuine decision support.”

More here (registration required):

http://www.australiandoctor.com.au/articles/e2/0c0587e2.asp

The original letter is found here (free registration required):

http://www.mja.com.au/public/issues/189_02_210708/ree10190_fm.html

No matter what HCN says there is just no excuse, in my view, for there to be any drug advertising in any clinical software – fullstop. There is a great market distortion in the costing of GP software that has been caused by Medical Director’s use of advertising and it is my view the use of advertising to sponsor clinical software is anathema.

Third we have:

Gershon slams Government ICT management as weak

Report identifies seven key areas and recommends slashing budgets

Trevor Clarke (ARN) 16/10/2008 17:16:00

The Gershon review has slammed the Australian Government’s use and management of ICT as weak while recommending budget cuts of up to 15 per cent.

In the report, author Sir Peter Gershon, who also undertook a similar review of the UK Government’s procurement strategy, claimed the Federal Government ICT marketplace was “neither efficient nor effective”.

“The current model of very high levels of agency autonomy, including the ability to self-approve opt-ins to whole-of-government approaches in the ICT domain, leads to sub-optimal outcomes in the context of prevailing external trends, financial returns, and the aims and objectives of the current Government,” he wrote.

The long-awaited review into government ICT, initially requested by Minister for Finance and Deregulation, Lindsay Tanner, in April this year, was released October 16 and contains seven key findings and several recommendations.

The report highlighted weak governance mechanisms as contributing to the failure of agencies to realise benefits from ICT-enabled projects. It also identified a lack of scrutiny on funding, and “a disconnect between the stated importance of ICT and actions in relation to ICT skills”.

Gershon also criticised the existing sustainability program and added the absence of a whole-of-government strategic plan for datacentres could cost taxpayers up to $1 billion over 15 years if a more coordinated approach wasn’t implemented.

More here:

http://www.computerworld.com.au/index.php?id=1008218670&eid=-255

Additional coverage is also found here.

Sweeping changes for federal ICT

Karen Dearne | October 17, 2008

BUREAUCRATS will lose control over selecting their own computers and technologies in a proposed return to central planning and purchasing aimed at slashing the $16 billion annual spend by federal government agencies.

Peter Gershon, head of Finance Minister Lindsay Tanner's razor gang, says the present approach is masking inefficiencies, while agency autonomy on buying decisions has led to fragmentation and wasteful duplication.

More here:

http://www.australianit.news.com.au/story/0,24897,24509962-15306,00.html

The reports are found here:

The Gershon report can be found at www.finance.gov.au/publications/ict-review/index.html or the PDF version.

The main issue to e-Health that flows from this review is that, at present at least, there are some pretty systemic issues in Commonwealth IT that need to be addressed. We certainly do not need any major e-Health initiatives to be undertaken by the Commonwealth directly. There needs to be careful consideration as to how e-Health is to be provisioned going forward to ensure these deficiencies are fully and safely addressed to prevent project failure and avoid waste of scarce funds.

Fourth we have:

Identity fraud the focus of week-long spotlight

National Identity Fraud Awareness Week kicks off: Aussie males the most gullible when it comes to scams, but professional women are the number one target.

Andrew Hendry 13/10/2008 07:51:00

National Identity Fraud Awareness Week opened today and will continue until the end of the week in a bid to raise awareness of identity theft and fraud, as well as to educate businesses and the general public on taking care when distributing personal information either physically or online.

A Web site promoting the campaign cites Australian Bureau of Statistics research indicating that identity fraud has become the fastest growing crime in Australia.

But while May’s Unisys Security Index survey found identity fraud to be the greatest concern for Australians -- topping terrorism and the meeting of financial obligations -- 70 percent of us throw out enough personal information like credit card statements and bills to put ourselves at risk of identity theft.

ABS research conducted between July and December 2007 and released this June found that almost half a million Australians had fallen victim to ID fraud in the 12 months preceding the research, of which over three-quarters was credit card fraud, totalling close to $1 billion in losses. The Australian Federal Police peg the annual cost of identity fraud at up to $4 billion.

According to the ABS, 54 percent of credit card fraud victims were male and 46 percent female, with an average loss of $2,156 per person. The 25 to 34 years age group had the highest number of victims, while professional women in their 20s and 30s were the most common targets.

Much more here including tips on how to save yourself:

http://www.computerworld.com.au/index.php?id=652321946&eid=-255

This article is a worry from an e-Health perspective as it makes it clear many people are not security conscious with respect to technology and don’t really know how to protect important information – like the access control to their bank account! Trust in e-Health records will struggle until we can evolve and develop a better educated population on these matters I fear.

Fifth we have:

IT's biggest project failures & what they teach us

Think your project's off track and over budget? Learn a lesson or two from the tech sector's most infamous project flameouts.

Jake Widman (Computerworld) 10 October, 2008 10:03:00

Every year, the Improbable Research organization hands out Ig Nobel prizes to research projects that "first make people laugh, and then make them think."

For example, this year's Ig Nobel winners, announced last week, include a prize in nutrition to researchers who electronically modified the sound of a potato chip to make it appear crisper and fresher than it really is and a biology prize to researchers who determined that fleas that live on a dog jump higher than fleas that live on a cat. Last year, a team won for studying how sheets become wrinkled.

That got us thinking: Though the Ig Nobels haven't given many awards to information technology, the history of information technology is littered with projects that have made people laugh -- if you're the type to find humor in other people's expensive failures. But have they made us think? Maybe not so much. "IT projects have terrible track records. I just don't get why people don't learn," says Mark Kozak-Holland, author of Titanic Lessons for IT Projects (that's Titanic as in the ship, by the way).

When you look at the reasons for project failure, "it's like a top 10 list that just repeats itself over and over again," says Holland, who is also a senior business architect and consultant with HP Services. Feature creep? Insufficient training? Overlooking essential stakeholders? They're all on the list -- time and time again.

A popular management concept these days is "failing forward" -- the idea that it's OK to fail so long as you learn from your failures. In the spirit of that motto and of the Ig Nobel awards, Computerworld presents 11 IT projects that may have "failed" -- in some cases, failed spectacularly -- but from which the people involved were able to draw useful lessons.

You'll notice that many of them are government projects. That's not necessarily because government fails more often than the private sector, but because regulations and oversight make it harder for governments to cover up their mistakes. Private enterprise, on the other hand, is a bit better at making sure fewer people know of its failures.

So here, in chronological order, are Computerworld's favorite IT boondoggles, our own Ig Nobels. Feel free to laugh at them -- but try and learn something too.

A great deal more here:

http://www.cio.com.au/index.php?id=1265363203&eid=-601

This article is a ripper for the collectors of ‘what not to do lessons’. A mandatory read!

Last we have the slightly more technical article for the week:

Gartner names 10 strategic technologies for 2009

Cloud computing and business intelligence high on the priority list for 2009.

Brad Reed (Network World) 15/10/2008 13:00:00

Research firm Gartner has revealed its list of the 10 most important strategic technologies for 2009, which includes cloud computing and business intelligence.

The majority of the technologies on this year's strategic technologies list are the same as the ones included on last year's list, such as green IT, mashups, Web-oriented architecture and unified communications. Among the most notable additions this year is cloud computing, which Gartner has in the past defined as "a style of computing where massively scalable IT-enabled capabilities are delivered 'as a service' to external customers using Internet technologies."

In other words, cloud computing is a way for companies to have key services delivered to them through the Internet rather than through an in-house data center. Gartner says that the biggest benefits of cloud computing are its "built-in elasticity and scalability, which not only reduce barriers to entry, but also enable these companies to grow quickly."

More here:

http://www.computerworld.com.au/index.php?id=901359769&eid=-6787

The article goes on to identify three other additions to the list. Worth keeping an eye on for those who have a role in planning future Health IT initiatives to make sure the most relevant technologies are considered.

More next week.

David.

E-Prescribing and E-Referral Moving Forward in the USA

The e-Health Initiative recently released this news item.

Health Care Stakeholders Release “How-To” Guide to Help Clinicians Switch from Paper to E-Prescribing Systems

Challenges, Opportunities Await Providers Investing in New Technology

BOSTON, MA – OCTOBER 7, 2008 – The eHealth Initiative (eHI), in collaboration with the American Medical Association, the American Academy of Family Physicians, the American College of Physicians, the Medical Group Management Association, and the Center for Improving Medication Management (Center), issued the first comprehensive, multi-stakeholder-informed “how-to” guide to help clinicians make informed decisions about how and when to transition from paper to electronic prescribing systems. A Clinician’s Guide to Electronic Prescribing was released at the Centers for Medicare and Medicaid Services (CMS) National e-Prescribing Conference in Boston today and follows the agency’s decision earlier this year to offer financial incentives--beginning in 2009--to providers who adopt e-prescribing.

“We know e-prescribing is an efficient way to improve health care delivery, decrease medication errors, and prevent potentially dangerous drug interactions,” said eHI Chief Executive Officer Janet Marchibroda. “However, the transition from a paper to electronic system is quite challenging. This guide is meant to remove some of the mystery around e-prescribing and help physicians begin to realize some of the many benefits e-prescribing can bring to their patients and their practices.”

Developed with the strategic guidance of a multi-stakeholder Steering Group comprised of clinicians, consumers, employers, health plans, and pharmacies, and in partnership with four major medical associations, the guide is designed to meet the needs of two target audiences: The first section of the guide targets office-based clinicians who are new to the concept of e-prescribing, and who seek a basic understanding of what e-prescribing is, how it works, what its benefits and challenges are, and the current environment impacting its widespread adoption. The second section of the guide targets office-based clinicians who are ready to move forward and bring e-prescribing into their practices. It presents fundamental questions and steps to follow in planning for, selecting and implementing an e-prescribing system. The guide also provides a list of key references and resources readers may consult to help make the transition to e-prescribing as smooth as possible.

“E-prescribing holds great promise for improvements in patient safety and advances in care coordination, and the AMA is committed to helping physicians adopt this technology,” said American Medical Association Board Member, Steven J. Stack, M.D. “This guide is an important resource for physicians and can aid in the adoption and implementation of e-prescribing.”

“With all the momentum toward e-prescribing and its accelerated growth, it is important to assist physicians and other prescribers to ensure that e-prescribing is implemented well in order for the full range of benefits can be achieved,” said Steven E. Waldren, MD, MS, Director, Center for Health-IT at the American Academy of Family Physicians and Center for Improving Medication Management Board member. “This Guide provides substantial detail not only on how to get started but what challenges to expect and how to overcome them.”

In June, eHI and the Center for Improving Medication Management released a report detailing the latest figures on e-prescribing, including the progress made, the obstacles that remain, and recommendations for how different stakeholders in the system can support the migration from paper-based prescriptions to an electronic system. Among the findings from the report were the following:

• More than 35 million prescription transactions were sent electronically in 2007, a 170 percent increase over the previous year.
• At the end of 2007, at least 35,000 prescribers were actively e-prescribing. Estimates indicate there will be at least 85,000 active users of e-prescribing by the end of 2008.
• While e-prescribing is growing rapidly, the adoption level at the end of 2007 represents only about six percent of physicians.
• Only two percent of eligible prescriptions were transmitted electronically in 2007.
• The biggest challenges to widespread adoption of e-prescribing by providers are financial burdens, workflow changes, continued needs for improved connectivity and technology, and the need for reconciled medication histories.

Accompanying the June report were corresponding guides that offer practical information for health care payers to support effective adoption, and for consumers to better understand e-prescribing’s benefits and use.

The full prescriber guide and the earlier e-prescribing reports are available at www.ehealthinitiative.org.

The full release is found here:

http://www.ehealthinitiative.org/news/2008-10-07.mspx

This release announces the latest piece of work in the area:

There is more and relevant links to reports found here:

Practical Guidance on Accelerating the Use of Electronic Prescribing to Improve the Quality, Safety and Efficiency of Health Care

The eHealth Initiative in collaboration with the Center for Improving Medication Management, with the strategic guidance and input from a diverse Steering Group made up of the many stakeholders in health care, including clinicians, consumers, employers, health plans, health IT vendors and pharmacists and pharmacies, has developed a series of reports designed to help the U.S. health care system transition from a largely paper-based system of prescribing to electronic prescribing, to support more effective medication management.

A series of guides and reports have been issued over the last four months to support the effective adoption of e-prescribing to drive improvements in the quality, safety and effectiveness of health care:

• Electronic Prescribing: Becoming Mainstream Practice
• A Clinician's Guide to Electronic Prescribing
• A Consumer's Guide to Electronic Prescribing
• A Guide for Health Care Payers to Improve the Medication Management Process

Click here for the June 11, 2008 release on "Electronic Prescribing: Becoming Mainstream Practice," and the corresponding guides supporting both consumers and payers.

Click here for the October 7, 2008 release on "A Clinician's Guide to Electronic Prescribing".

The report is useful in that it describes how things work in the US as well as providing the reasons why it is a useful step forward in improving patient safety. There is also valuable discussion on the various barriers to use and so on.

With the US putting a significant incentive framework for actual electronic prescription transmission it is time we stated to move beyond prescription printing and developed a national, secure and open system to have this also happen in Australia. The time has definitely come!

On a slightly different but related track the California Health Care Foundation has released another great document.

Bridging the Care Gap: Using Web Technology for Patient Referrals

Jane Metzger and Walt Zywiak, CSC

September 2008

Arranging referrals for specialty or follow-up care typically involves a disjointed sequence of phone calls, faxes, and slips of paper. Besides being inefficient, this system frequently results in unsuccessful, duplicate, and inappropriate referrals, which can have serious health consequences for patients.

Some providers, particularly public health systems and others working in the safety net, are now turning to advanced electronic solutions to modernize and improve the referral process. These applications — some of them homegrown — help standardize the screening and decision-making steps of a patient referral, improve tracking and communication, and strengthen data collection.

More here:

http://www.chcf.org/topics/view.cfm?itemID=133761

Document Downloads

Bridging the Care Gap: Using Web Technology for Patient Referrals (728K)

There is also a good summary article here:

E-Referrals: Health 2.0’s Next Big Thing?

Kathryn Mackenzie, for HealthLeaders Media, October 7, 2008

A new process that could streamline referrals, effectively lighten the load on the ER, and save millions of dollars? While it may sound too good to be true, a new report from the California HealthCare Foundation outlines the benefits of modernizing the referral process by making use of Web-based systems.

Making referrals for specialty or follow-up care is typically a fairly manual process—the originating physician may make a phone call or fax a request to a specialist, but in most cases that's as technologically advanced as it gets. More likely, the patient will receive a slip of paper and instructions to make an appointment for follow-up care. Recently some providers have updated their referral process by making use of Web-based systems designed to help automate and standardize the referral process.

To date, the primary users of so-called e-referring are public health systems and safety net hospitals seeking to reduce overcrowding in the emergency room by referring patients to a primary care provider in the community, according to the report.

http://www.healthleadersmedia.com/content/221032/topic/WS_HLM2_TEC/EReferrals-Health-20s-Next-Big-Thing.html

These two reports provide more than enough reading for the weekend!

David.

Systems Thinking and Modelling Workshop for Healthcare - Late November

A friend passed on the following invitation.

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I would like to invite you to a 2 day workshop on Systems Thinking and Modelling for Health on November 27 and 28 at UNSW.

This is an introductory course for health professionals, students and researchers to understand the dynamics of health and care systems, particularly unintended consequences of policy, practice, management, workforce and technology interventions.

The concepts are illustrated using simple computer models drawn from real world problems over the past two decades by two experienced practitioners, Mark Heffernan and Geoff McDonnell.

Please see the attached details and registration form or the following weblink

http://www.chi.unsw.edu.au/CHIweb.nsf/page/Workshops

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For those interested in how the health system works and how to improve it this will be a very valuable workshop.

David.

Sometimes We See Some Real Academic Nonsense Published!

The following appeared in Australian Doctor this week.

Performance-pay side effects cause concern

10-Oct-2008

By Paul Smith

MJA

PAYING GPs to hit performance targets undermines professional autonomy and job satisfaction, according to leading international academics.

State governments and leading Australian health reformers are pushing for a pay-for-performance approach in a bid to drive up primary care quality and improve patient outcomes.

Drawing on the results of the introduction of the policy in the UK’s National Health Service, where 25% of GP income is tied to meeting performance targets, researchers from Kings College, London, said it had led to substantial improvements in intermediate clinical outcomes. They included blood pressure, cholesterol and glycosylated haemoglobin controls as well as the proportion of heart attack and stroke patients treated with aspirin.

Health inequality gaps between the least and most deprived neighbourhoods had also narrowed.

Writing in the Medical Journal of Australia (21 July), Dr Mark Ashworth and Professor Roger Jones, of the university’s department of general practice and primary care, said that “taken together these achievements should translate into substantial national public health gains”.

But they warned that the UK Government had used pay-for-performance — dubbed P4P — as a “big bang solution” and the system was failing to capture the elements of general practice in which many GPs found the greatest professional satisfaction.

More here (needs registration)

http://www.australiandoctor.com.au/articles/e1/0c0587e1.asp

The full editorial is to be found here (free registration required):

http://www.mja.com.au/public/issues/189_02_210708/ash10534_fm.html

Most interesting I find is that while ‘pay for performance’ is clearly working to make a difference there is concern that it might destroy professional autonomy.

Let us be quite clear here. The framework seeks to encourage important evidence based clinical behaviour and imposes some measures which encourage clinicians to conduct their practices in a way that suits patient needs. Patients are thus getting better and more patient focussed care – which seems to me to be a very good thing.

The complaints centre around apparently restricting professional autonomy and not measuring things in the patient interaction. The following quote, from the article, seems to reflect the view:

“More fundamentally, P4P has divided GPs on issues of professionalism. For some GPs, the electronic QOF prompts that accompany a consultation with a patient act as useful reminders and allow the GP to give more thought to deeper issues during the consultation. For others, these prompts represent the intrusion of a reductionist, points-driven approach to patient care that undermines professional autonomy. Furthermore, it is readily apparent that measures of patient satisfaction, patient enablement, listening skills, continuity of care, and many of the aspects of general practice that give GPs their greatest professional satisfaction lie outside the scope of any of the performance indicators.”

There are two points I would make. First, it is possible to measure most of what is mentioned in the quote – so it simply needs some clinician push to make the changes – not just complaining from the side.

The second point is that if professional autonomy means the freedom to ignore evidence of correct practice because you don’t like it that is not autonomy but stupidity!

The GP systems in the UK make conformance with the guidelines easy to capture and record as I understand it and there is no real reason not to follow evidence other that in situations where patient complexity demands adjustments (not all that common).

I really wonder what these academics are trying to say other than we want to right to ignore evidence and couldn’t be bothered trying to improve an already proven to be useful system?

Very odd.

David.

Stating the Bloomin’ Obvious On Health IT.

The following appeared in e-Health Insider a few days ago.

ASSIST says idea NHS like a bank 'fundamentally flawed'

08 Oct 2008

NHS informatics professional body ASSIST has published a paper saying the original NHS National Programme for IT plan of one size fits all approach “does not work”.

The paper says attempting to treat the NHS as if it were a bank when the NPfIT strategy were misguided, and failed to understand the NHS.

ASSIST says there has been too much focus on standardisation of system rather than standards, and stresses that both national and local systems have a role to play but cannot succeed if they are imposed.

It says a revised strategy must reflect the shift to a pluralistic, federated model of care delivery, in which information follows the patient.

The paper calls for changes to NPfIT to take account of the changed policy environment, for mistakes to be acknowledged and lessons learned.

ASSIST, which is affiliated to the British Computer Society, says the standardised systems approach of the original NPfIT strategy, emerged from a “misguided attempt” to see the health service as analogous to a big business.

“We reject the notion that the NHS is analogous to a bank (especially in the current 'credit crunch'!), a global telecommunications company or an airline, and this believe that focusing on their ICT models for a healthcare environment was fundamentally flawed.”

…..

ASSIST makes the following recommendations

• Focus on the basics before trying the ambitious

• Do not lose or threaten hard won successes

• Focus on standards not standardisation

• Achieve a balance between technology, systems, people, process and culture

• Ensure much earlier and more integrated policy planning at both national and local levels

• Invest in a systematic health informatics research and development programme

• Avoid structural change

• Avoid stand-alone data demands

• Avoid insular systems development

• Invest in developing informatics skills, leadership and the profession

Jon Hoeksma

The full long article, can comments are here:

http://www.e-health-insider.com/news/4219/assist_says_idea_nhs_like_a_bank_%27fundamentally_flawed%27

The submission that prompted the article is found here:

Independent Review Commissioned by Conservative Party

ASSIST has made a formal submission to an Independent Review Group, commissioned by and reporting to Stephen O'Brien MP, the Conservative Shadow Health Minister.

The Review Group has been established to inform the future policy for the use of information technology in the NHS, health and social care in England.

ASSIST's submission was developed through a facilitated workshop for senior informaticians held on Wednesday 24th September 2008, with other ASSIST members contributing by correspondence. ASSIST is grateful to John Farenden and Tribal for leading the workshop, continuing Tribal's long-term support of ASSIST.

More here:

http://www.bcs.org/server.php?show=ConWebDoc.22027

View the formal submission here

Pages 12-14 are the crucial bit.

The home page for ASSIST is here(and is worth a visit):

http://www.bcs.org/server.php?show=nav.7898

This is remarkably like the conclusion of the Environmental Scan done for the Victorian E-Health Strategy.

http://www.health.vic.gov.au/ictstrategy/environment-scan.pdf

(Note this is a new, much better version of the document in terms of accessibility and searchabilty from a week ago.)

See especially pages 25 - 27.

“The Environmental Scan has identified some common critical success factors which will greatly enhance the chances of eHealth initiatives succeeding. These are:

• High level sustained commitment over several years with levels of investment of at least around 3% of Gross Operating Revenue.

• Clearly stated simple goals that can be measured.

• Manageable scop and timeframes (2-3 year planning horizon)

• Involvement of clinicians at all stages of the process.

• Enforcement of standards with some local flexibility in implementation of common systems.

From this research the following broad conclusions have been drawn with detailed examples contained within the body of this document.

1. Have a Plan

It is important to actually have a plan! The plan must be clear, simply understood by all stakeholders and offer an attractive vision of the proposed future. Additionally the plan must have the various components discussed in the introductory section. More than that the plan needs, if unintended consequences are to be avoided, to have a broad scope covering both the private and public sectors, where relevant, and also ensuring coverage of the needs of both the ambulatory, service and hospital sectors.

The plan also needs to be actively managed and reviewed every three to four years to make sure planned objectives are being met and to ensure there is a clear and current way forward.

It is clear from the cases discussed in the scan that the approach of developing an agreed plan and regular re-visitation of that plan has a beneficial effect in terms of objective progress made compared with lack of a plan.

2. Get Commitment

It vital to have high level political / managerial commitment to the key aspects of the plan. This is best achieved by creating a ‘burning platform’ based on the impact Health IT has on patient (i.e. voter) safety and the quality of care that is received or on the argument of the current sustainability of the health system as a whole (or both).

3. Be Prepared to Invest

It is clear that not providing an realistic level of funding for eHealth initiatives has very negative consequences. This means that not only is it important to have a clear plan but also to have a compelling business and operational justification for the investment. In Australia planning was undertaken for the HealthConnect initiative in the absence of such a compelling case and when the time came for the (significant) investment to be made the then Government decided it was all too hard and five years work was essentially wasted.

4. Set Reasonable Time Frames

It is important to set reasonable time frames to achieve the various milestones in the implementation plan. Implementation of a National or Regional EHealth Strategy is a complex and quite difficult task and setting over ambitious milestones can lead to loss of confidence on the part of those on the ground if too many milestones are missed. It is important to have sensible milestones in place to ensure progress is being made at an acceptable pace.

5. Recognise Change Management Constraints

There are real constraints on the scale of change that can be applied uniformly before implementation becomes unwieldy. The apparent ease with which smaller countries (with comparable levels of development) seem to make progress compared with larger ones is hard to ignore. The lesson to be drawn from this is that it is important to structure any national initiative to recognise the degree of inertia and lack of strategic and implementation flexibility that can be found in larger countries and to work to mitigate this issue.

6. Develop Incentives to Participate

There is considerable evidence that the use of incentives can assist in reducing the ‘friction of change’. As an example, in virtually all countries where there has been widespread adoption of EHRs in ambulatory care those who pay for the health system have provided some form of (usually financial) incentive to obtain widespread adoption. Examples include the Practice Incentive Payments in Australia and the provision of systems without any physician expense in the Kaiser system.

7. Tailor Plan to Existing Health IT Capability

When planning it is vital that the plan be tailored to existing Health IT capability and that gaps in the capability (be it lack an adequate number of Health Informaticians, inadequate internet connectivity, lack of appropriate standards or whatever) be identified and addressed.

8. Balance Technical Risk with Proven Technology

It is clear that there needs to be a balance struck between technical risk and complexity and the possibility of the implementation of obsolete or out of date systems. While most suggest that in ordinary times IT systems should be refreshed very five to seven years many core systems in hospitals seem to have lives measured in decades. The importance of getting system and technology selection as close to the mark as possible is obvious in these circumstances.

The other issue that needs to be considered is that if very advanced technology is utilised there is an increased risk of project delays as technological obstacles are overcome. The key in all this is a balance between ‘bleeding edge’ and ‘early possible obsolescence’.

9. Make Technology the Servant of the Health System

It is important to make sure the technology is the servant of the health system and that the technology is responsive to the needs of those who have to use the system. Experience suggests that initiatives which are driven by responding to the needs of the particular health system are the most likely to succeed.

10. Planned Incremental Approach

The deliberate adoption of a planned incremental approach that builds on earlier successes has a better likelihood of success than a ‘big bang’ approach.

Understanding the lessons of these experiences will go a long way towards avoiding repeats – especially getting the balance of local versus central control of implementations right.

Lots of food for thought in working out how Australia should proceed nationally.

David.

Some Views on Privacy and Health IT.

There has a fair bit recently appear on privacy.

Privacy obsesses lawyers, not patients

COMMENT: James Gillespie and Stephen Leeder | October 04, 2008

JUST how worried are Australians about the privacy of their health records? This question has dogged the long and tortuous history of efforts to change to electronic health record systems. If we are to have a health service where information of relevance to the care of a patient is readily available, anywhere, any time, to those caring for them, substantial changes will be needed in the way we manage medical records.

Against this, privacy concerns are regularly adduced as the reason why progress cannot be made in using data derived from the care of individuals for improving the health service. The public, it is often said, is paranoid about the privacy of personal health records. This predominantly legal concern plays into the hands of professional and bureaucratic groups who have resisted more open scrutiny of these and other data (such as Medicare) that might reveal their own shortcomings.

Do patients trust their doctors and the broader systems to keep personal, and often sensitive, records away from unauthorised view or use? Many of the problems of our healthcare system - from unnecessary deaths from medication and hospital error to the fractured management of chronic illness - have been traced to communication problems. General practitioners, pharmacists, physiotherapists and hospital-based specialists have been unable to get easy access to a patient's medical history - their medications, allergies and past encounters with the health system. The vast majority of medical communication is untouched by advances in information technology.

Yet the power of the technological imperative, as manifest in IT, will change all of this. As new, more flexible internet technologies overcome the cost and technical obstacles that blocked information sharing, faster and more effective transfer of information has raised fears, though whether in the minds of patients is rarely proved, of new assaults on the privacy of patients' health records.

So what do Australians think about privacy and their health records? The Menzies Centre for Health Policy and The Nous Group recently surveyed a representative sample of 1200 Australians aged 18-plus on their attitudes to the health system.

One group of respondents was reminded that during a period of illness, patients are frequently treated by a series of health professionals. Should those charged with the care of the patient all have direct access to their records? Or should they rely on taking a medical history from the patient each time the patient passes from one carer to another, as happens now with astonishing frequency? There was an overwhelming consensus - 90 per cent - in favour of direct access for all treating health professionals to the patient's records: one record, available to all carers.

…..

James Gillespie is deputy director and Stephen Leeder the director of the Menzies Centre for Health Policy at the University of Sydney

See full article at the Australian.

http://www.theaustralian.news.com.au/story/0,25197,24437561-23289,00.html

We have also had recently

Data privacy concerns remain as Google PHR grows

By: Rebecca Vesely/ HITS staff writer

Story posted: September 29, 2008 - 5:59 am EDT

About two years ago, lightning struck for SafeMed, a healthcare analytics software firm, when representatives from Google strolled by the fledgling company’s booth at a trade show.

“That initiated some discussions,” says Richard Noffsinger, chief executive officer of SafeMed. The San Diego-based company signed on as one of Google Health’s first partners, sprouting more growth and new clients.

“The partnership has helped us in all areas,” Noffsinger says, including lending financial stability. SafeMed also benefited from its collaboration with Google’s engineers so it could meet expected growing demand from the millions of Google users. “Having a customer of the stature of Google is incredible.”

Google Health, launched in May to much fanfare, allows users to store, organize and manage their personal health records and other information online. The concept is that the approach puts individuals in charge of their own health data and allows them to access that data when they switch providers, visit an emergency room or search for relevant health information.

The jury is still out on whether people will use Google Health or another consumer-driven online PHR, and Google has declined to release any numbers to date.

To make the product attractive to consumers and to ensure personal medical information is relevant, Google Health is relying extensively on third parties. Google is deploying the so-called “long tail” model, in which a large number of unique products or services are offered to a wide range of people with the expectation that freedom of choice will drive participation.

In applying that model to healthcare, Google Health, along with Microsoft Corp., which offers a competing product called HealthVault, are rapidly shaping the health information sphere. HealthVault, launched in fall 2007, is a formidable competitor, with more than 100 partners, including leaders in the health information technology field such as Kaiser Permanente.

Much more here:

http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20080929/REG/309299997/1029/FREE

And then we have the results of two recent surveys

Americans say EHRs worth the privacy risks

Dec. 4, 2007 —A majority of polled Americans believe EHRs have the potential to improve U.S. healthcare and that the benefits outweigh privacy risks, based on a Wall Street Journal (WSJ) Online/Harris Interactive poll.

According to poll results published in The WSJ, three-quarters of the 2,153 survey respondents agreed that patients could receive better care if doctors and researchers were able to share information using electronic systems and 63 percent agreed such record sharing could decrease errors.

Also, 55 percent agreed the transition could reduce healthcare costs, compared with 15 percent who disagree. However, about one-quarter of those polled remained unsure whether EHRs can provide these benefits.

More here:

http://www.healthimaging.com/index.php?option=com_articles&task=view&id=8917&division=hiit

and here

Few Americans confident in privacy of EHRs

By: Rebecca Vesely/ HITS staff writer

Posted: October 9, 2008 - 5:59 am EDT

Many Americans want electronic health records, and say they would access their personal health information online, but the majority are concerned about confidentiality issues, according to a survey by the Employee Benefit Research Institute, a not-for-profit, nonpartisan organization.

Fifty-five percent of those surveyed said it is extremely or very important for providers to use electronic or computer-based health records instead of paper ones. Another 25% said it is somewhat important, while 7% said it is not too important and 9% said it is not important at all. Those results are statistically unchanged from when the question was asked in 2005.

More here:

http://modernhealthcare.com/apps/pbcs.dll/article?AID=/20081009/REG/310099994

What one needs to do with all this is drill down to the next layer and talk to individuals and understand what they want and fear. The answers are a little different from what surveys tell you.

First it is true most people think electronic patient records are a good idea and should be used, especially if security and privacy can be pretty much assured.

Second most people understand that data leaks and disclosure is possible occasionally and so….

Third how worried you are about information leak depends on individual circumstances – if you have a potentially stigmatizing medical history (HIV/AIDS, Hepatitis C, Mental Illness, severe genetic risk etc) you are much more worried and might even try to keep such information secret etc – with a risk to all.

For this reason surveys that don’t deeply explore the reasons for anxieties and concerns and work out ways to address them don’t get us all that far.

I look forward to the details of the Nous Group Study.

David.

Useful and Interesting Health IT Links from the Last Week – 12/10/2008

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

These include first:

NSW hospital statistics on patients 'worth nothing'

Mike Steketee, National affairs editor | October 11, 2008

THE NSW Government has an explanation for why some public hospitals are failing to see most of their urgent patients on time -- it does not believe its own health figures.

According to the data, in January only 36 per cent of patients with an imminently life-threatening condition were seen within the required 10 minutes of arriving at the emergency department of the Royal Prince Alfred Hospital, in inner Sydney.

But the NSW Health Department says this figure and those for Westmead Hospital are wrong because of problems with collecting data, even though they are included in the performance indicators it publishes to enable people to compare hospitals.

Asked by The Weekend Australian why the Government had published incorrect figures, a spokesman for NSW Health Minister John Della Bosca said it was important to publish the information for the sake of transparency.

"Although some of the data might reflect poorly on these hospitals, we are prepared to wear that while we try to fix the teething problems," he said.

The revelations add a bizarre twist to the string of claims about fudged figures on hospital performance in NSW and Victoria.

Mostly the allegations are that data is being massaged to meet performance benchmarks. But in this case, the NSW Government claims the figures understate the true situation.

State governments have responded to dissatisfaction with public hospitals by releasing data on their performances, available on health department websites.

According to former Victorian and NSW premier's department head Ken Baxter, whose consultancy prepared a report on the funding of public hospitals earlier this year, the figures, particularly in NSW, "are not worth the paper they were written on".

There were serious doubts about the veracity of the data fed into them from hospitals. Nor were they necessarily the best indicators of performance.

"For example, waiting times for elective surgery can be manipulated for what you want out of them," Mr Baxter said.

The report by TFG International, of which Mr Baxter is chairman, found hospital data was "inconsistent, patchy and not readily comparable on a state-by-state basis".

Although the states had spent more than $2billion on information technology and data collection systems, this money had "largely been wasted".

Much more here:

http://www.theaustralian.news.com.au/story/0,,24478368-2702,00.html

This is a very worrying report and goes to the question of just how well the funds for IT in hospitals has been spent – but more importantly just how well the investments have been managed. It seems a national audit of e-Health capability and data quality should be on the agenda sooner rather than later.

Second we have:

VicRoads admits to selling database information

The Victorian roads authority has confirmed it sells information from its licence database to 190 organisations, but defended the practice as perfectly legal.

Dylan Bushell-Embling 07/10/2008 12:52:00

The Victorian roads authority, VicRoads, has admitted it sells personal information to 190 outside organisations, but has refused to name any of its customers.

The Herald Sun yesterday published the details of a secret deal, whereby companies such as Connex and Yarra Trams paid for special access to information from the VicRoads licence database.

More here:

http://www.computerworld.com.au/index.php?id=651912288&eid=-6787

Other coverage is here:

VicRoads cashes in on personal information

Article from Herald Sun

Ashley Gardiner

October 09, 2008 12:00am

VICROADS raked in $6.4 million in one year by selling the personal information on its licence and registration databases.

The Herald Sun can also reveal that Connex ticket inspectors use a verbal password for database access, a process described as "only 95 per cent secure".

VicRoads has admitted instances of inappropriate use of its databases by outside organisations.

Registration and licensing operations director Chris McNally confirmed VicRoads raised revenue through the databases.

"(This) goes towards offsetting the more than $100 million cost of running VicRoads' registration and licensing business," Mr McNally said.

Since the late 1990s, there had been a small number of incidents in relation to external access of the databases, Mr McNally said.

"One involved the inadvertent release of information to an external party and one involved the inappropriate disclosure of information," he said. "The person concerned in this case is no longer with the agency."

VicRoads now requires external agencies to provide a quarterly compliance report and an independent audit.

More here:

http://www.news.com.au/heraldsun/story/0,,24467932-5006922,00.html

This is an absolute disgrace. Trade in personal identification information is quite unacceptable and in such a pathetically insecure way as this it is just dreadful. VicRoads is to be condemned – running a license system is core business for such an entity – not a cost to be offset!

Third we have:

Just what the doctors ordered

Karen Dearne | October 07, 2008

case study | SA Heart Centres
CARDIOLOGISTS in South Australia have said goodbye to costly commercial broadband services by building a private high-speed microwave network to link their Adelaide clinics.

Dr Bill Heddle, chairman of SA Health Centres, says the practice was hampered by slow connections and he was unimpressed by the premiums charged for high-speed fixed-line links when the operation moved to electronic patient records and images.

"In the early days, we often had problems using dial-up broadband.

"The computer kept crashing and it took 20 minutes to log on," he says.

"In that time, you need to have seen at least one patient or you get behind on your appointments."

SA Heart Centres is Australia's largest cardiology group, with 17 specialists operating in six large clinics in suburban Adelaide, plus smaller clinics at Mt Gambier, Port Lincoln and in the Riverland.

"We looked for solutions to this big problem of being able to have reliable and rapid access to patient information wherever we were seeing them," Heddle says.

More here:

http://www.australianit.news.com.au/story/0,24897,24454724-24171,00.html

This story makes one wonder if the National Broadband Network – as planned – will be fast enough in 2-3 years when it finally gets built. I think 100 Mbs should be the minimum for the NBN at the end-user level.

Fourth we have:

Canberra plans unified privacy principles

Karen Dearne | October 07, 2008

SPECIAL Minister of State John Faulkner has proposed a set of unified privacy principles and protections for credit reporting and health information, following a revamp of the Privacy Act.

Senator Faulkner will also tackle abuses of data capture and usage made possible by small, cheap and versatile devices that record and transfer sound, images and data.

"Privacy is not about what we voluntarily - however unwisely - disclose of ourselves," he told a symposium at the University of NSW Cyberspace Law and Policy Centre last week.

"Privacy is our right to make that decision for ourselves.

"But new developments, whether it be the internet, the camera-phone, radio-frequency ID tags or CCTV in public places, have made it incredibly easy for others to make that decision for us."

More here:

http://www.australianit.news.com.au/story/0,24897,24456243-15319,00.html

This is good – as it seems the Senator Faulkner ‘gets it’. He is dead right – the decision about where out information goes is the one that matters and is what most worries people about e-Health proposals.

There is also good coverage here:

Privacy lags in technology rush

http://www.smh.com.au/news/technology/privacy-lags-in-technology-rush/2008/10/07/1223145356191.html

Fifth we have:

Identity fraud 'fastest-growing crime'

October 6, 2008 - 7:52PM

With identity fraud becoming the nation's fastest-growing crime, Crime Stoppers has urged Australians to stop throwing personal information into rubbish bins.

Identity fraud has claimed half-a-million victims in the last 12 months at an estimated cost of $1 billion to the national economy, says the Australian Bureau of Statistics (ABS).

And professional women in their 20s and 30s are most at risk.

Despite the danger, a Newspoll survey shows nearly 70 per cent of people throw away bank and credit card statements, social security and tax file number details, utility bills and other personal information.

Ahead of national identity fraud awareness week, Crime Stoppers has urged Australians to shred their statements and personal information, as well as digital information held on CDs, before throwing it away.

More here:

http://www.computerworld.com.au/index.php?id=293044380&eid=-255

The relevance of this report for the e-Health Domain relates to the personal identity systems and identifiers planned by NEHTA. We need to be sure these credentials are managed in such a way that they have no value to the criminal identity fraudsters. As I see it the only way this can be achieved is by having major penalties for the use of NEHTA identifiers as part of the information that can be used to establish identity for any purpose other than the expected healthcare roles. I know this has been mooted but I would like to see the actual law enacted before becoming involved in these schemes.

More information here:

No names: inside the fake identity racket

Conrad Walters

October 7, 2008

WANT to buy enough information about a stranger's credit card to steal their money? All it takes is one email and a transfer of funds through Western Union.

The Herald found it was remarkably easy to unearth the online locations where hackers conduct a global trade in stolen credit card information.

If you want the data from a standard Australian credit card, it will cost you just $US1.50 ($1.80). Rather rob from a gold card holder? That'll be $2.50, thanks.

For accounts in Britain and the United States, the salesmen claim even to be able to bypass some of the latest anti-fraud protection, including Verified by Visa. And if your needs are great, bulk deals are available.

Full investigative article is here:

http://www.smh.com.au/news/national/no-names-inside-the-fake-identity-racket/2008/10/06/1223145261821.html

and here:

http://www.smh.com.au/news/national/the-great-credit-card-swindle/2008/10/06/1223145261818.html

and here:

http://www.smh.com.au/news/technology/security-you-can-bank-on-still-elusive/2008/10/06/1223145261878.html

Last we have the slightly more technical article for the week:

Are international standards organisations no longer incorruptible?

The fight over OOXML and ODF seems to have taken another twist as the bodies continue to pile up in their wake.

Carl Jongsma 08/10/2008 12:55:00

For the last several months Microsoft has been pushing for their Office Open XML (OOXML) office suite file specification to be accepted as an international standard by ISO, presumably to help them gain traction for future government contracts (look, this file specification is an ISO standard, it must be good).

As far as ISO/IEC DIS 29500 is concerned, it continues its steady progress towards standardship, however it seems that Microsoft's push towards this goal hasn't been without its bodycount. While the ISO site lists 29500 as a deleted standard, complementary reporting shows the process is still ongoing and OOXML will soon become ISO/IEC IS 29500.

In an ideal world, standards bodies would be incorruptible and lead to the publication and adoption of consistent standards across the user communities. Anyone who has followed the OOXML progress through ISO would think otherwise. The ongoing stoush regarding Microsoft's effort to get the ODF-killer that has yet to be properly implemented through the standards body has claimed some high profile casualties, with the national Standards body of Norway effectively self-destructing after 13 of 23 members of the technical committee resigned in disgust.

More here:

http://www.computerworld.com.au/index.php?id=43917536&eid=-6787

It is amazing that we see this sort of goings on in international standardisation. There needs to be trust in these international processes if the benefits are to be achieved. Having Microsoft apparently distorting processes like this – as seems to be the case – is really not good news at all.

More information is here:

More OOXML trouble as Norwegians quit

Over half of Norway's ISO body, Standard Norway, have resigned over the country's approval for OOXML, citing Microsoft influence.

John E. Dunn (Techworld) 07/10/2008 10:03:00

Full article here:

http://www.linuxworld.com.au/index.php/id;1521592002;fp;;fpid;;pf;1

Another minor bit of news for Win XP users.

Microsoft grants Windows XP yet another reprieve

New timeline will make it possible for users to purchase XP-powered PCs through next July, just months before Microsoft plans to roll out Windows 7.

Gregg Keizer (Computerworld (US)) 07/10/2008 08:03:00

See article here:

http://www.computerworld.com.au/index.php?id=293044380&eid=-255

Finally – a small comment on the Financial Crisis – If our banks are so safe why not a time limited guarantee on all bank deposits and a guarantee of interbank cash flows so commerce can work – at least in Australia as seems to be happening all over the advanced world?

More next week.

David.

Obama and McCain on Health IT.

With less than a month to go until the US general election iHealthBeat has published a useful summary of what we can expect from each of the candidates.

Modernizing Health Care With President Obama or President McCain

by David Merritt

With only 35 days left until the presidential election, Americans have an important decision to make regarding the future of health care. With the perpetual problems of rising costs, poor quality and the uninsured, Americans must decide which candidate is better suited to help build a 21st century intelligent health system that saves lives and money for all Americans.

A critical part of any solution will be the rapid deployment of health IT. Both Sens. Barack Obama (D-Ill.) and John McCain (R-Ariz.) know the importance of modernizing our system through IT, and while some may condemn one or the other as someone who “doesn’t get it,” one point needs to be clarified: health IT is not a bipartisan issue -- it is a nonpartisan issue. Everyone agrees on its necessity. Everyone agrees on the goals we should work toward.

Where many advocates and policymakers disagree is how best to accomplish these shared objectives.

I believe that a President Obama or a President McCain will make health reform, and thus health IT, a top priority. It is just too important an issue to ignore.

So what would each man do to advance health IT specifically? Yes, we can look at their promises from the stump and read their health care plans for a general sense of how each man would advance health IT, but the reality is that campaign politics do not allow for intricate or exhaustive policy proposals, nor should the campaign trail be the place for this kind of policy development.

Much more here:

http://www.ihealthbeat.org/Perspectives/2008/Modernizing-Health-Care-With-President-Obama-or-President-McCain.aspx

At the end of the article there are relevant links.

More On The Web

• McCain’s Health IT statement
• Obama’s Health IT statement
• Center for Health Transformation

There is also a summary of the more general policy positions of the two on health in general here:

Health plans pit low-cost vs. public coverage

By TONY LEYS

leys@dmreg.com

November's presidential election offers a dramatic choice on how to attack America's health care problems.

Should the country try to hold down costs by encouraging consumers to shop for inexpensive coverage? That's what Republican John McCain proposes.

Or should the government build on the current system by offering more public insurance plans and subsidies to uninsured people, as Democrat Barack Obama wants to do?

Iowans heard a lot about the issue during last winter's caucus campaigns, in which each party's candidates quibbled with each other over relatively small variations in their health care proposals. But now, with two general-election candidates whose differences are stark, the discussion has taken a back seat to worries about the overall economy.

More here:

http://www.desmoinesregister.com/apps/pbcs.dll/article?AID=/20080929/NEWS09/809290326/-1/LIFE04

The most comprehensive analysis of the differences between the two I have so far seen is provided by the Commonwealth Fund. This is found here:

http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=707948

While it is clearly a good thing that both the candidates have expressed a view on the topic of Health IT, I must say the prospect of real money is attractive.

On page 2 of the main health policy document from Brack Obama we have:

(1) INVEST IN ELECTRONIC HEALTH INFORMATION TECHNOLOGY SYSTEMS. Most medical records are still stored on paper, which makes them difficult to use to coordinate care, measure quality, or reduce medical errors. Processing paper claims also costs twice as much as processing electronic claims. Barack Obama and Joe Biden will invest $10 billion a year over the next five years to move the U.S. health care system to broad adoption of standards-based electronic health information systems, including electronic health records. They will also phase in requirements for full implementation of health IT and commit the necessary federal resources

to make it happen. Barack Obama and Joe Biden will ensure that these systems are developed in coordination with providers and frontline workers, including those in rural and underserved areas. Barack Obama and Joe Biden will ensure that patients’ privacy is protected. A study by the Rand Corporation found that if most hospitals and doctors offices adopted electronic health records, up to $77 billion of savings would be realized each year through improvements such as reduced hospital stays, avoidance of duplicative and unnecessary testing, more appropriate drug utilization, and other efficiencies.

John McCain has the following:

INFORMATION TECHNOLOGY: Greater Use Of Information Technology To Reduce Costs. We should promote the rapid deployment of 21st century information systems and technology that allows doctors to practice across state lines.

I am afraid if I had a vote I would have to lean to the Democrats!

David.