New Zealand Health Informatics Forum Doing Well!

This really good message arrived today.

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A message to all members of Health Informatics Discussion Forum

We now have over 1000 members on the Health Informatics Discussion Forum!

The forum area is getting busy with questions, so if you would like to join the discussion visit:

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We still need your help to grow further so please invite your friends to join too:

http://www.healthinformaticsforum.com/invite

If you have a blog, please post a note to tell people about the forum - the more members we get, the more useful the forum becomes.

Best wishes,

Dr Chris Paton BMBS BMedSci

Administrator

Health Informatics Discussion Forum

http://www.healthinformaticsforum.com/

Visit Health Informatics Discussion Forum at: http://www.healthinformaticsforum.com

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Since I seem to have a blog – a plug seems like a good idea.

Go have a look and encourage this Antipodean Health IT initiative.

David.

NEHTA Continues on its own Clueless Way.

We had the release of another ‘bodice ripper’ from NEHTA last week. I describe it thus because of the breathless enthusiasm it offers on an unproven and untried concept – just like those with intact bodices (just like those who were consulted) must feel - when confronted with a similarly unfamiliar, badly considered “proposal”.

NEHTA Consultation Report

• Identifier: NEHTA 0296:2008
• Published: 14/10/2008
• Hits: 57
• Filesize 813.1 KB
• Filetype pdf (Mime Type: application/pdf)
• Reference: NEHTA Consultation Report

Description:

This report provides a summary of feedback and discussion following an extensive consultation period conducted by NEHTA on benefits and drivers for an Individual Electronic Health Record (IEHR).

NEHTA conducted two Clinician and Consumer Roundtable sessions in June 2008. One in Brisbane (5 & 6 June) with an urban focus and one in Alice Springs (11 & 12 June) discussing issues relating to a rural and remote context. A Peak Body Summit was also held in Canberra (18 June). The aim of the Summit was to present and validate the key recommendations from the Roundtables in Brisbane and Alice Springs. In total, over 150 people attended the sessions. The objectives of the sessions were to consult with Clinicians and Consumers on the benefits, drivers and acceptance of e-Health, specifically, the:

· Purpose and benefits of unique consumer and provider identification;

· Purpose and benefits of the IEHR;

· Privacy of information held within the Unique Healthcare Identifier (UHI) Service and IEHR service;

· Type of information held within a IEHR (including clinician and consumer views on sensitive information);

· Access to and participation in the UHI Service and IEHR service;

· Governance of the IEHR Service;

· Consent arrangements to establish and authorise access to the UHI Service and IEHR Service; and

· Secondary uses of the UHI and IEHR information.

The report can be downloaded from here:

http://www.nehta.gov.au/index.php?option=com_docman&task=doc_details&gid=569&Itemid=139&catid=130

A report from ZD-Net is also available:

Hurry it up: Public tells NEHTA

Suzanne Tindal, ZDNet.com.au

15 October 2008 03:50 PM

Clinicians and consumers have told Australia's peak e-health body to stop conducting pilots and speed up the roll out of a national electronic health record project, according to a report released yesterday.

The report collated of issues discussed at recent round-table sessions in Brisbane, Alice Springs and Canberra, where over 150 people gathered to pass on their thoughts on electronic health records to the National E-Health Transition Authority (NEHTA).

NEHTA's level of community engagement was criticised last year in an independent review by the Boston Consulting Group.

The e-health group is the key central figure attempting to coordinate disparate state and federal government and private sector initiatives which are currently seeing billions of dollars ploughed into building e-health systems around Australia.

Round-table participants proposed a model where records with minimum information were rolled out — for example a health summary for involved individuals including immunisations, allergies, medications, problems, organ donor status, next of kin and contact details — until trust had been built up, when functionality could be increased.

"We really firmly believe — well, I certainly firmly believe that we have to have this in as soon as possible, and just suggested that yes, we won't get a perfect system up and running straight away, so let's get something up and running, and develop it as it goes," one consumer said.

His comments were echoed by a clinician. "I agree with the fact that we need to start, sort of, shallow and we need to get this out there now. The longer we wait, the more likely we are to have lots of little projects going on that are never going to talk to this project, so we need to get it out there," they said.

However, despite enthusiasm to get the show on the road, round-table participants wanted a high level of support along with the roll out, with concerns that parts of the health sector were not ready for implementation.

More here:

http://www.zdnet.com.au/news/software/soa/Hurry-it-up-Public-tells-NEHTA/0,130061733,339292662,00.htm

Just a few short comments.

First we have a 60 page report. How much is actual consultation report? By my count all of 9 pages of excited quotes from anonymous consumers, clinicians etc. The rest was all padding, attendance lists and so on. (Remember we had all these people flown to Alice Springs and elsewhere at some vast cost for 9 pages!)

Second each of the three gatherings was richly populated by NEHTA staff (about 10-15% of the attendance). I wonder why when what was wanted was non NEHTA staff consultation? I wonder where they there to make sure no hard questions were asked?

Third there is still no clarity about just what the proposed IEHR is and how it will relate to GPs, Specialists, Service Providers (Path, Radiology etc), Hospitals, Public Health and the like.

Fourth where we the non-NEHTA technical people who could ask the technical questions about the practicality and feasibility of the IEHR – not a one I could see.

Fifth, why does it take 5 months to write and publish up a nine page report when an organisation has over 100 staff and 20 who attended the sessions. The meetings were mid June and it is now mid October. (The document was done by Mid September according to the .pdf) I wonder is this release all about failing to be funded by COAG?

Sixth and very important is that without a real technical and functional design of the planned IEHR we can have no confidence as to what is actually proposed here.

Seventh and also important are all those who were not consulted. The hospital sector seems to have been especially ignored.

Eighth it would be fair to say there is no real implementation plan etc. A ¾ page next steps section hardly cuts it!

Last we are still to see all the privacy and security assessments – and to consult without clarity on those matters is really a waste of time and money!

All in all another shocker from a worryingly out of touch organisation that has no clue about e-Health and how it should be done.

David.

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.