International News Extras For the Week (04/05/2009).

Again there has been just a heap of stuff arrive this week.

First we have:

Pressure mounts on NHS patient e-records

By Nicholas Timmins, Public Policy Editor

Published: April 27 2009 23:20 | Last updated: April 27 2009 23:20

Main suppliers to the stalled £12.7bn National Health Service’s programme to ­create an electronic record of patients have been given until the end of November to demonstrate real progress in installing the systems in big acute ­hospitals.

If the seven-month deadline is not met, “we will look at alternative approaches”, Christine Connelly, the Department of Health’s chief information officer, told the Financial Times.

Asked whether that could involve termination of the billions of pounds’ worth of important contracts held by BT, CSC, Cerner and Isoft, she said: “At this point, we are not ruling anything out.”

She stressed, however, that “it is in all our interests to make the systems and solutions we currently have a success”.

Her comments came as she outlined the latest plan to get back on track the troubled records programme, which is running at least four years late. Under the plan, she said:

● All hospitals will be given greater freedom to configure the system to their local needs.

● A “library” of such adaptations will be built, so trusts can choose which version is closest to their requirements and then, if need be, adapt it further.

Much more here (Subscription required):

http://www.ft.com/cms/s/0/bae2ae52-3358-11de-8f1b-00144feabdc0.html

It seems we are getting towards the end game in terms of Cerner and iSoft delivering real working implementations. Can’t be much fun for those in the middle.

There is more reporting on the issue here:

Connelly sets a November deadline for suppliers

28 Apr 2009

Christine Connelly has given the main suppliers to the National Programme for IT in the NHS seven months to demonstrate "significant progress" in delivering information systems to the acute sector.

In a keynote speech to the Healthcare Computing conference in Harrogate, the newly styled Director General for Informatics said “we will look at alternative approaches” if the November deadline is not met.

More here:

http://www.ehiprimarycare.com/news/4790/connelly_sets_a_november_deadline_for_suppliers

Hard to be much clearer than this! Except maybe here.

U.K. Imposes Deadline To Fix Sick E-Health Program

The CIO of Britain's Department of Health says outsourcers working on the long-delayed project have seven months to get it right -- or they may have to get out.

By Paul McDougall, InformationWeek

April 28, 2009

URL: http://www.informationweek.com/story/showArticle.jhtml?articleID=217200451

Second we have:

London trusts in chaos as NHS IT system 'loses' waiting lists

Details of thousands of patients waiting for treatment have been lost, investigation reveals

• Simon Bowers
• guardian.co.uk, Tuesday 28 April 2009 00.05 BST

Thousands of patients' details have been discovered on "lost" waiting lists at hospitals in London, as they struggle with a controversial new computer system installed as part of the government's troubled £12.7bn overhaul of NHS IT, an investigation has revealed.

The discovery has embroiled several trusts in a crisis which has already cost tens of millions of pounds in lost revenues and mounting bills for remedial work. It has also reduced the number of patients treated by hospitals. Trusts have been forced to put on additional clinics in a push to clear the backlog and have drafted in a legion of IT troubleshooters to fix the waiting list mess.

The Barts and the London trust has launched a "serious untoward incident" investigation - an NHS procedure reserved for crises that could cause serious harm or attract public concern - though officials insist no patients have come to clinical harm.

A joint investigation by the Guardian and Computer Weekly has found Barts and the London is now so overwhelmed by patient record confusion that it has stopped providing monthly data to the Department of Health on the government's key waiting list target, conceding it does not have reliable figures. IT mayhem at Barts and the London has also caused several neighbouring primary care trusts to miss their waiting list targets, with some urgently looking at alternative destinations for patients requiring hospital treatment.

Much more here:

http://www.guardian.co.uk/society/2009/apr/28/nhs-it-cerner-computers-hospitals

Continuing issues with the NPfIT that have doubtless prompted the first article tomorrow.

Third we have:

New electronic records would open VA care to all veterans

April 24, 2009 - 11:55 AM

Tom Philpott

Special to the Sun Journal

President Obama's ambitious plan to establish a lifetime electronic record for service members and veterans will improve delivery of benefits, speed processing of claims and, over time, open VA health care to any veteran, regardless of their medical condition or income level.

VA Secretary Eric Shinseki first raised the idea of a more sophisticated electronic record system, and linked it to automatic enrollment by all veterans in the VA health system, during a House hearing in February.

This week, through a press spokeswoman, Shinseki confirmed that universal access to VA health care is integral to the administration's plan to develop as quickly as possible a 21st Century electronic record system.

"Secretary Shinseki and the whole (VA) team believe that ‘uniform registration' " in the VA health system "is an essential part of the lifetime virtual record," said Katie Roberts, his press secretary, in an e-mail.

Shinseki and Defense Secretary Robert Gates were with the president April 9 in the Old Executive Office Building when Obama announced to an audience of veterans a "huge step toward modernizing the way VA health care is delivered and (VA) benefits are administered."

Obama described a comprehensive electronic record system, to be developed and used jointly by the Department of Defense and VA, which would hold all service-related documents, administrative and medical, on individuals from the time they enter service until "they are laid to rest."

Reporting continues here:

http://www.newbernsj.com/articles/electronic_45103___article.html/shinseki_record.html

This is a very interesting initiative given the scale and importance of the VA Health System in the US and its history of Health IT innovation.

Fourth we have:

Piecing Together Medication Administration

Howard J. Anderson, Executive Editor
Health Data Management, May 1, 2009

This is part two of a three-part series on patient safety. Part three, on clinical decision support for physician group practices, will appear in the October issue.

When it comes to using information technology to support medication administration, there’s no tried-and-true recipe for success. Many hospital executives agree that a handful of technologies can play key roles in improving medication safety. But creating a “closed loop” process to automate all the steps from the ordering to the distribution of medications is a remarkably complex undertaking.

There’s no consensus on what comes first, second or third in automating all the steps involved. And technology won’t solve anything unless it’s paired with changes in doctors’ and nurses’ workflows.

Computerized physician order entry certainly can play a critical role in improving medication administration. But only about 8 percent of hospitals have the costly technology in place so far (see January 2009 issue, page 18). That could change, however, as a result of looming extra payments from Medicare and Medicaid to hospitals under the federal economic stimulus package. Hospitals that use qualifying electronic health records systems that enable physicians to place orders electronically stand to gain extra payments.

Other technologies that can help improve medication safety include electronic medication administration records, which often, but not always, are subsets of broader electronic health records; automated medication dispensing cabinets; pharmacy information systems; and bar codes on medications and patient wristbands. In addition, some hospitals are devising ways to automate the medication reconciliation process, keeping more accurate records of all the drugs patients take before, during and after a hospital stay (see sidebar, page 28.)

Pioneering organizations and analysts alike say that it’s difficult to measure the success of medication administration automation efforts because it’s tough to pinpoint errors that are avoided and near-misses. And many hospitals lack meaningful data on error rates.

A great deal more here:

http://www.healthdatamanagement.com/issues/2009_65/-28110-1.html

This is a useful discussion of the place of ‘full cycle’ medication management and what the components are that make it up.

Fifth we have:

Here’s a “Meaningful Use” Tip

April 24, 2009

Hospitals that want to make an educated guess on how the federal government will define “meaningful use” of electronic health records under the economic stimulus package can use an existing benchmark, one expert says. They can refer to the qualifications for earning Stage 4 on the seven-level rating system of hospital EHR functionality from HIMSS Analytics, a Chicago-based research firm.

Jerri Hiniker, program manager at Stratis Health, a Bloomington, Minn.-based quality improvement organization, predicts the federal government likely will set standards for meaningful use of EHRs that align with HIMSS Analytics’ Stage 4. That stage calls for the use of both clinical decision support and computerized physician order entry, among other functionality.

More here:

http://www.healthdatamanagement.com/news/EHRs-28101-1.html

For more information on the HIMSS Analytics standards, visit himssanalytics.org.

This is a very live debate after the term was used in the Health IT stimulus legislation. All sorts of groups are contributing to the debate.

More here:

http://www.healthdatamanagement.com/news/stimulus-28127-1.html?ET=healthdatamanagement:e855:100325a:&st=email&channel=electronic_health_records

HIMSS Defines 'Meaningful Use' of EHRs

April 28, 2009

And here:

http://govhealthit.com/articles/2009/04/28/blumenthal-health-it-agenda.aspx

'Meaningful use' definition will shape health IT agenda, Blumenthal says

• By Mary Mosquera
• Apr 28, 2009

The forthcoming definition of the “meaningful use” of health information technology will set the direction of the Obama administration’s strategy for health IT adoption, said David Blumenthal, the new national coordinator for health IT.

And here:

http://www.modernhealthcare.com/article/20090429/REG/304299995

‘Meaningful use’ hearing provides broad HIT dialogue

By Joseph Conn / HITS staff writer

Posted: April 29, 2009 - 10:00 am EDT

The idea Tuesday was to have the National Committee on Vital and Health Statistics hold the first of two days of hearings on the “meaningful use” of electronic health-record systems.

The NCVHS got a lot more to chew on—a daylong discourse on the ills of the nation’s healthcare system and a broad overview of what role health information technology might play in healthcare reform.

In the 785-page American Recovery and Reinvestment Act of 2009, terms relating to “meaningful use” appear 108 times in the sections on Medicare and Medicaid incentives and penalties for using or not using health IT. According to a Congressional Budget Office estimate, the stimulus act will funnel as much as $34 billion into the IT subsidy program. (lots more follows).

And here:

http://industry.bnet.com/healthcare/1000595/lets-limit-meaningful-use-of-ehrs-to-what-really-works/

Let's Limit 'Meaningful Use' of EHRs to What Really Works

By Ken Terry | April 29th, 2009 @ 2:54 pm

And here:

http://www.healthdatamanagement.com/news/EHRs-28137-1.html?ET=healthdatamanagement:e858:100325a:&st=email&channel=electronic_health_records

Physicians Weigh In on Stimulus Terms

April 29, 2009

And last here:

http://www.healthdatamanagement.com/news/EHRs-28136-1.html?ET=healthdatamanagement:e858:100325a:&st=email&channel=policies_regulation

AHIMA: Focus on Results

April 29, 2009

Sixth we have:

AHRQ Readies E-Prescribing Tool

April 24, 2009

The Agency for Healthcare Research and Quality has contracted with the Rand Corporation, Santa Monica, Calif., to develop a toolset for implementing electronic prescribing systems.

The toolset will be a "how to" guide for implementing e-prescribing across various provider settings, according to a notice AHRQ published April 24 in the Federal Register.

Despite efforts of Medicare to encourage e-prescribing, adoption remains limited, the agency notes. "On the surface, e-prescribing involves getting a prescription from point A to point B," according to the notice. "In reality, the complexity of e-prescribing reflects all aspects of the process from appropriate prescribing, through dispensing, to correct patient use."

More here:

http://www.healthdatamanagement.com/news/e-prescribing-28098-1.html

Good to see some positive action in providing help in moving e-prescribing forward. Link provided in article.

Seventh we have:

Vt. ban on marketing use of Rx data remains intact

A federal judge in Vermont rejected a challenge to a state law that blocks the use of prescriber-identifiable data for marketing. U.S. District Judge J. Garvan Murtha wrote that the prescribing information represents protected speech under the First Amendment but can be appropriately limited to advance a substantial government interest, granting deference to the Vermont Legislature’s conclusion that it has one. The decision consolidates two lawsuits, one filed by a group of data vendors and another by the Pharmaceutical Research and Manufacturers of America, which sought an injunction blocking a provision of the law compelling drug companies to pay a fee to support an “evidence-based education” program.

More here:

http://www.modernhealthcare.com/article/20090427/REG/304279935

I have never understood why this data should be used for marketing. It is a noxious business that, in my view, should indeed be illegal. Good one the more enlightened States in making the move.

Eighth we have:

5 Myths on Health Care's Electronic Fix-It

By Tevi Troy

Sunday, April 26, 2009

Are electronic health records the panacea for all our health-care ills? Congress seems to think so: With strong cheerleading from President Obama, it has approved $20 billion for EHRs as part of the stimulus package. Health information technology undeniably holds a lot of promise, but it's still in its infancy. Is it worth a stimulus now? A look at some health IT myths:

1. Electronic health records will cure our health system.

EHRs will potentially provide a lot of benefits, most notably by reducing medical errors -- e.g., doctors prescribing medications to patients with an allergy to them -- that kill as many as 98,000 Americans each year. A much-cited 2005 Rand Corp. study of EHRs found that they could save $77 billion annually and potentially eliminate 200,000 adverse drug reactions. Yet a more recent analysis, by Stephen Parente and Jeffrey McCullough in Health Affairs, found that "the evidence base is not yet sufficient" to show that EHRs would improve outcomes.

Implementing EHRs to improve billing -- which would be the simplest and least creative way to spend Congress's money -- is not enough. EHRs can improve our system and help achieve the assumed cost savings only if they bring about changes in the way we practice medicine. Doctors have extremely limited time with their patients. EHRs would help by giving them access to the patients' documents, including all previous tests and conditions, in advance, and by allowing patients to communicate with physicians via e-mail. With the right kind of EHRs, doctors could obtain real-time guidance on the best care for a specific patient from databases containing all the latest diagnostic and therapeutic guidelines.

But this technology is evolving rapidly, and implementing systems in the right way will require thoughtfulness and creativity. As pediatrician and health IT expert Kenneth Mandl, who co-wrote a skeptical analysis of subsidizing EHRs for the New England Journal of Medicine, told the New York Times, "If the government's money goes to cement the current technology in place, we will have a very hard time innovating in health care reform."

Full article here:

http://www.washingtonpost.com/wp-dyn/content/article/2009/04/23/AR2009042303943.html

Read about the other 4 “myths” at the web-site. Comments welcome.

Ninth we have:

Making the Business Case for HIT

Carrie Vaughan, for HealthLeaders Media, April 28, 2009

Chief information officers are not always a member of the CEO's inner circle. In fact, only a quarter (25.23%) of CEOs listed a CIO as members of their senior executive team, according to the 2009 HealthLeaders Media Industry Survey. But the passage of the American Recovery and Reinvestment Act of 2009 may have just elevated their position. The federal government's $36 billion incentive package to install electronic health records means that more CIOs will report directly to the CEO and help set the strategy of the organization.

The role of the CIO has been evolving during the past several years beyond a position that focuses solely on technology and is viewed as the "keeper of information resources." In the April issue of HealthLeaders magazine ("Not Just Techies Anymore"), we examine how that role has evolved during the past several years. Now more than ever, CIOs are helping drive the operational strategy for the organization, says Asif Ahmad, vice president for diagnostic services and CIO for Duke University Health System and Duke University Medical Center. "If you look at the for-profit sector, most of the time the person who is running operations is also responsible for making sure the technology works," he says. "Healthcare needs to follow in those footsteps."

Much more here:

http://www.healthleadersmedia.com/content/232195/topic/WS_HLM2_TEC/Making-the-Business-Case-for-HIT.html

It is interesting to see how the role of the CIO is evolving as there is increasing recognition of the importance of the role in the health system and its sustainability

Tenth we have:

Microsoft Launches Amalga for Life Sciences

April 28, 2009

Microsoft Corp. has introduced a version of its Amalga data aggregation and reporting software for the life sciences industry.

More here:

http://www.healthdatamanagement.com/news/research-28126-1.html?ET=healthdatamanagement:e855:100325a:&st=email&channel=systems_integration

More information is available at microsoft.com/amalga.

More evidence of the Microsoft interest in the health sector.

Eleventh for the week we have:

Bill would boost open-source EHRs for rural use

By Joseph Conn / HITS staff writer

Posted: April 28, 2009 - 10:00 am EDT

West Virginia, a small, mostly rural state, is the adopted home of Democratic Sen. Jay Rockefeller, and, arguably, also where open-source healthcare information technology has been most widely adopted.

It is in keeping, then, that Rockefeller, past chairman and current member of the Senate Veterans Affairs Committee, and current chairman of the health subcommittee of the Senate Finance Committee, announced last week that he was introducing legislation to “facilitate nationwide adoption of electronic health records, particularly among small, rural providers.”

The Rockefeller bill seeks to do so by creating a public utility software system based on the clinical IT systems developed at taxpayer expense by the VA and the Indian Health Service, according to a news release and Rockefeller’s testimony in the Congressional Record.

The senator’s Health Information Technology Public Utility Act of 2009 would, according to a news release, “build upon the successful use of open-source electronic health records” by the VA, related software developed by the Indian Health Service and the federal health information exchange software released as open source earlier this month.

More here (registration required):

http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20090428/REG/304289994

It will be interesting to see how the balance between proprietary and open source plays out over the next few years.

Twelfth we have:

In final remarks, Casscells touts informatics, SOA, small vendors

• By Peter Buxbaum
• Apr 27, 2009

Health informatics is key to Defense Department efforts to reduce costs and improve quality as well as to the future shape of the national health care system.

That was one of the conclusions of a symposium that brought together government and private health care officials to discuss health reform, health care costs and the role of information technology in future health care systems. The conference took place on Friday at the National Defense University in Washington.

“We’re trying to get the new administration off to a good start,” said Dr. Ward Casscells, the assistant secretary of Defense for Health Affairs, speaking at a press wrap-up at the conclusion of the conference. “Secretary [Robert] Gates has asked us to do what we can to control costs while improving ease of access to health care and not jeopardizing quality. The president has set the same goals for the country as a whole.”

Lots more here:

http://govhealthit.com/articles/2009/04/27/cascells-farewell-remarks.aspx?s=GHIT_280409

These comments certainly define what is hoped for out of the planned Health IT investments.

Thirteenth we have:

Utah rolls out first U.S. open-source disease tracker

• By John Moore
• Apr 23, 2009

Public health agencies in Utah have deployed what the state calls the first open-source, Web-based infectious disease tracking and management system in the U.S.

The rollout of the open-sourced CSI TriSano disease tracker began with two local health departments in January and has since expanded to a total of 12 local agencies as well as the Utah Department of Health.

The state originally planned to acquire a commercial disease-tracking system. But the systems under consideration cost as much as $2 million before customization, according to David Jackson, product manager with the Utah Department of Health.

Instead, the state pursued an open-source development project, partnering with the Collaborative Software Initiative, a Portland-based software company.

CSI TriSano was built to replace a number of siloed systems in use at state and local health departments, noted Jackson.

Much more here:

http://govhealthit.com/articles/2009/04/23/utah-open-source-disease-tracker.aspx?s=GHIT_280409

Definitely topical work as we watch the potential pandemic emerge!

Fourteenth we have:

Hampshire rejects SCR for HHR

28 Apr 2009

The largest primary care trust in England has decided not to implement the Summary Care Record in the next 12 months and to expand its own shared care record system instead.

The Hampshire Health Record (HHR) already covers 65% of the Hampshire population and NHS Hampshire plans to roll it out to 90% of residents by the end of March next year.

It also covers Southampton City PCT, where 80% of residents have records, and Portsmouth City PCT, where 35% of residents have records.

NHS Hampshire said the HHR contains more information than the SCR currently holds and already accepts feeds from all GP systems. It also argued that promoting both the SCR and HHR could be confusing.

However, it said it was actively looking at how patients might be able to access the HHR through the national secure health portal, HealthSpace.

In a statement issued to EHI Primary Care, Jenny Nash, chief information officer for NHS Hampshire said: “Since the HHR project began, the national NHS Summary Care Record service has started.

Much more here :

http://www.ehiprimarycare.com/news/4792/hampshire_rejects_scr_for_hhr

One really has to wonder just how sensible this is. However with all the problems in the NPfIT it might turn out to be pretty smart!

Fifteenth we have:

At least four southern trusts plan for Lorenzo

28 Apr 2009

At least four hospitals in the south of England intend to implement CSC’s Lorenzo, according to informatics plans, with community and mental health trusts taking systems from both TPP and CSE-Servelec.

In South Central SHA several hospital trusts that have yet to receive a system under the National Programme for IT appear to be planning for a move to Lorenzo.

The informatics plan from NHS Hampshire , obtained by GP Dr Neil Bhatia under the Freedom of Information Act, reveals that Portsmouth Hospitals NHS Trust plans to implement Lorenzo in 2010/11 “if [it] provides required functionality”. Frimley Park Hospital NHS Foundation Trust is renewing its patient administration system contract for three years but will also implement Lorenzo “once tried and test and delivering benefits.”

More here:

http://www.ehiprimarycare.com/news/4791/at_least_four_southern_trusts_plan_for_lorenzo

A little good news I suspect if things work out – especially after the dire reporting in the top article in this collection!

Sixteenth we have:

Using Data to Change Processes

By Howard J. Anderson, Executive Editor May 1, 2009

Data mining can be the foundation for meaningful changes in the practice of medicine. Inova Health System has evidence that proves this is far more than just a hypothesis. The Falls Church, Va.-based system, which owns five hospitals, is using the information pinpointed by data mining to help devise new clinical processes. Then it's using its electronic health records system to guide clinicians on how to follow those processes, providing rules and alerts to steer them on the right path.

The result? Serious safety events-those that cause serious harm or even death-declined by 60% from May 2005 to February 2009 at Inova's hospitals. Hospital-acquired infections declined 60% during the same period. And the mortality rate has substantially declined.

Inova is using Web-based data mining software called Quality Manager from Premier Inc., a Charlotte, N.C.-based purchasing alliance. It's a participant in Premier's Quest, a quality improvement benchmarking project. The alliance recently announced that it will expand the project beyond the original 166 hospitals.

Very much more here:

http://www.healthdatamanagement.com/issues/2009_65/-28117-1.html

Just more news about the utility of Health IT once you get started. A good article!

Fourth last we have:

Recession puts the squeeze on hospital IT projects

April 27, 2009 | Bernie Monegain, Editor

WASHINGTON – The recession has forced more than half the nation's hospitals to either scale back information technology projects already in progress or postpone them, according to a new survey from the American Hospital Association.

The findings are based on 1,078 responses that the AHA calls "broadly representative of the universe of hospitals."

The survey shows that 28 percent scaled back IT projects already in progress, while 27 percent decided not to move forward on planned projects. Six percent halted IT projects that were already under way.

Hospitals also reported scaling back or eliminating clinical technology plans, with 34 percent deciding to not move forward on their plans and 32 percent scaling back. Six percent stopped clinical technology projects already in the works.

Hospitals are finding themselves financially squeezed in other ways, too.

More here (with slides):

http://www.healthcareitnews.com/news/recession-puts-squeeze-hospital-it-projects

Hardly a surprise!

Third last we have:

HIT Policy, Standards Committees Official

April 29, 2009

In notices published on April 29 in the Federal Register, David Blumenthal, M.D., the national coordinator for health information technology, has established the HIT Policy Committee and the HIT Standards Committee.

Both committees are mandated under the American Recovery and Reinvestment Act. The HIT Policy Committee will advise Blumenthal on a range of issues related to implementation of a national health information network. The HIT Standards Committee will advise Blumenthal on standards, implementation specifications and certification criteria for the electronic exchange and use of health information.

More here (with links):

http://www.healthdatamanagement.com/news/economy-28130-1.html?ET=healthdatamanagement:e856:100325a:&st=email&portal=hospitals

Clearly no plan to waste time getting rolling!

Second last for the week we have:

Following Swine Flu Online

Tracking and communications could play a key role in combating a pandemic.

By Michael Day

The World Health Organization (WHO) admitted on Tuesday that it's too late to contain swine flu, and experts say that it is now vital to track the spread of the virus in order to mitigate its effects. Vaccines and antivirals will be crucial to the effort, but tracking and communications technologies could also play a key role in monitoring the virus, distributing accurate health information, and quelling outbreaks.

Bloggers and social-networking sites were among the first to follow the outbreak's rapid spread from its epicenter in Mexico--where swine flu has been linked to more than 150 deaths--to cities across the United States and on to Europe, Israel, and New Zealand.

The need for fast information has seen the Centers for Disease Control and Prevention (CDC) build up a large following on Twitter. Groups ranging from fellow federal institutions, such as the National Institute for Occupational Safety and Health, to local Red Cross divisions, as well as many regular Twitter users, are employing the service to receive updates. Some experts, however, warn that Twitter can just as easily spread misinformation and panic. According to data from the medical tracking site Nielson, conversations related to swine flu reached 2 percent of all messages on Twitter over the weekend. By contrast, Google's Flu Trends, a site that aims to spot flu outbreaks by monitoring search queries related to flu symptoms and treatment, has shown little increase in activity in recent days.

Much more here:

http://www.technologyreview.com/web/22554/?nlid=1986

This is a good summary of the various e-Health approaches being used.

This provides some rich information on the same topic.

http://mashable.com/2009/05/01/swine-flu-cdc/

Swine Flu: The Official CDC Social Media Toolkit

May 1st, 2009 | by Jennifer Van Grove

Last for this week we have:

EHR Implementations: Success Lies Beyond the Build

Rob Drewniak for HealthLeaders Media, April 28, 2009

When the uninitiated think of electronic health record implementations, they focus on build and rollout. Most likely, the implementation is considered an "IT project," and the communication machine starts rolling just before staff members are affected. However, the initiated know that EHR implementations—successful ones, that is—are process, workflow, and operational in nature. They are considered operational improvement projects with a healthy dose of change management, and communication begins when the decision to move to an EHR is made.

With the American Recovery and Reinvestment Act's HITECH incentives, healthcare organizations are being urged to roll out EHRs and use them in a "meaningful" way. The following are three areas that often get the short shrift during an EHR implementation, but they are as critical to success as the functionality itself.

Communication. One of the first steps in an EHR implementation is to carefully create a communication plan that focuses on all classes of end users. The message should address the benefits of the new system's functionality, as well as, the changes that will occur post-implementation to people's everyday workflow. From implementation experience at academic medical centers, ambulatory facilities, and community hospitals, my colleagues and I have identified the need to better prepare end users for the effects on their daily processes.

The learning and change process begins with these early communications. In addition to the "training" concept inherent in it, early adoption questions can surface that may alter the build and the training program. In addition to end users, leadership and the project team require early and frequent knowledge. You can use e-demos and training materials based on actual scenarios to help assimilate everyone involved to the new environment.

Much more here:

http://www.healthleadersmedia.com/content/232196/topic/WS_HLM2_TEC/EHR-Implementations-Success-Lies-Beyond-the-Build.html

This is very much the best being held back to last. Excellent set of points on how to improve the chances for success.

There is an amazing amount happening. Enjoy!

David.

NHHRC E-Health Submission - Due Tomorrow - Comments Welcome!

Submission to National Health and Hospitals Commission

From

Dr David G. More

7^th May, 2009

Background:

The NHHRC issued a press release entitled “NHHRC Backs Person-controlled Electronic Health Records” on 30 April, 2009.

This may be accessed here:

http://www.nhhrc.org.au/internet/nhhrc/publishing.nsf/Content/mediaRelease300409

In summary the report made 7 recommendations which were summarised as follows:

“The Commission has made seven recommendations to make person-controlled electronic health records a reality. These include:

• By 2012, every Australian should be able to have a personal electronic health record that will at all times be owned and controlled by that person;
• The Commonwealth Government must legislate to ensure the privacy of a person’s electronic health data, while enabling secure access to the data by the person’s authorised health providers;
• The Commonwealth Government must introduce unique personal identifiers for health care by 1 July 2010;
• The Commonwealth Government must develop and implement an appropriate national social marketing strategy to inform consumers and health professionals about the significant benefits and safeguards of the proposed e-health approach; and
• The Commonwealth Government must mandate that the payment of public and private benefits for all health and aged care services be dependent upon the provision of data to patients, their authorised carers, and their authorised health providers, in a format that can be integrated into a personal electronic health record.”

Qualifications to Provide Comment:

I am a consultant in the e-Health domain and have been so for over 20 years. I have provided professional advice for both public and private sector organisations including DoHA, NEHTA, SA Health, NSW Health (where I acted as CIO for a period), IBM, Ramsay Healthcare etc.

My qualifications include medical and science degrees, a PhD in Medicine, 2 clinical fellowships in Anaesthesia and Intensive Care and a Fellowship of the Australian College of Health Informatics.

Key Comments:

I have the four major criticisms of the document as it was released.

First the evidence base on which is supports the deployment of the Person-Controlled Electronic Health Record (PEHR) has been assembled in what can only be termed a fraudulent and deceptive fashion. For reasons best known to the authors of the paper evidence for the use , by healthcare providers, of electronic health records (EHRs) has been appropriated and it is claimed this evidence supports the adoption of PEHRs which is simply does not.

To date I am not aware of any major studies validating the value of PEHRs (or PHRs as the rest of the world describes these records).

Indeed a major review published as late as December 2008 stated the following.

“We spend nearly $2 trillion annually in healthcare in the US with a high cost per person and an unacceptable variability in the quality of care. It is clear that PHRs have the potential, if designed appropriately and adopted widely, to reduce costs and simultaneously improve quality and safety of care. This potential has led to enormous public enthusiasm for PHRs and large investment. However, the existing knowledge base that underpins this work is surprisingly limited and most of the fundamental issues remain unresolved. For PHRs to realize their future potential, additional research is essential, but it is unlikely to be performed unless substantial additional financial support is committed to PHR research and evaluation, especially from federal and commercial sources. If these additional investments are not made, much time and money may be wasted and the potential value of PHRs will remain unrealized.”

See the following for the full article.

http://www.jamia.org/cgi/content/full/15/6/729

Similar sentiments are expressed here in a slightly earlier paper when discussing benefits:

“Benefits of Personal Health Records

For consumers, PHRs have a wide variety of potential benefits. One of the most important PHR benefits is greater patient access to a wide array of credible health information, data, and knowledge. Patients can leverage that access to improve their health and manage their diseases. Such information can be highly customized to make PHRs more useful. Patients with chronic illnesses will be able to track their diseases in conjunction with their providers, promoting earlier interventions when they encounter a deviation or problem. Collaborative disease tracking has the potential to lower communication barriers between patients and caregivers. Improved communication will make it easier for patients and caregivers to ask questions, to set up appointments, to request refills and referrals, and to report problems. For example, communication barriers are responsible for many adverse drug events in the outpatient setting.¹¹ In addition, PHRs should make it easier for caregivers (proxies for the patients) to care for patients, which is difficult today. A critical benefit of PHRs is that they provide an ongoing connection between patient and physician, which changes encounters from episodic to continuous, thus substantially shortening the time to address problems that may arise.

To date, there is limited evidence supporting these hypothetical benefits; however, many consumers have high satisfaction levels with existing early versions of PHRs.^3,7,12,13 In particular, consumers place value on easy access to test results and better communication with clinicians.

The PHR can benefit clinicians in many ways. First, patients entering data into their health records can elect to submit the data into their clinicians' EHRs. Having more data helps clinicians to make better decisions. The PHR may also become a conduit for improved sharing of medical records. Patients who are more engaged in their health are more active participants in the therapeutic alliance, for example, when patients with chronic conditions collaboratively manage their illnesses with clinicians to reduce pain, improve functional outcomes, and improve medication adherence. Finally, asynchronous, PHR-mediated electronic communication between patients and members of their health care teams can free clinicians from the limitations of telephone and face-to-face communication or improve the efficiency of such personal contacts. Notably, all the advantages of PHRs for providers depend on the PHR being integrated with the provider's EHR.

Potential benefits of PHRs to payers and purchasers of health care include lower chronic disease management costs, lower medication costs, and lower wellness program costs, although none of these has been well studied. The greatest area of benefit relates to the chronic disease management, where costs are typically high.^14”

Full paper here:

http://www.jamia.org/cgi/content/full/13/2/121

Note there is “limited evidence supporting these hypothetical benefits”.

On the other hand there are many studies identifying the benefits of provider used EHRs. This evidence can be best accessed at the Health IT page of the US Agency for Health Care Research and Quality. See here:

http://healthit.ahrq.gov/portal/server.pt?open=512&objID=650&PageID=0&parentname=ObjMgr&parentid=106&mode=2&dummy=t

There seems little point in rehearsing this information again in this short submission

My second criticism is that by having the NHHRC publish this apparent plan – the fuller scope and much more fully thought out National E-Health Strategy developed by Deloittes for AHMAC – is very likely to be sidelined and not supported for implementation. The NHHRC document does not address a legion of issues regarding the development of e-Health in Australia and its support of Health Reform and this is a deeply concerning. At best the NHHRC document should be seen as being adjunctive to the work undertaken by Deloittes and Booz and Co on behalf of the NHHRC.

My third criticism is that even if the recommendations found on pages two and three of the PEHR document were to be implemented, and this seems to be highly unlikely, the document totally fails to address provider costs and compliance as well as overarching national e-Health governance. The benefits for the cost, sustainabilty and quality and health care in Australia would be dramatically less than that which may be achieved by implementation of the Deloittes plan.

Lastly I am deeply suspicious of the NHHRC motives in the formulation of this proposal. On page 11 we read “While we support this overall vision for e-health, we have long debated the most cost-effective means of enabling and encouraging the development of personal electronic health records.” I take this to be inferring that the NHHRC has cast around for a low cost way of seeming to be doing something in e-Health, has ignored the need to provide provider e-Health solutions and is hoping that by offering a voluntary PHR that the issue will go away – as the PHR will be made available cost free, or at low cost, by the likes of Microsoft or Google.

Let me be quite clear – a PEHR does not in any way replace the need for provider systems and networks and to think this proposal provides reform enabling e-Health for the NHHRC and the country is just utterly fanciful.

There are two things I also need to make it clear. First I am totally convinced of the necessity of an appropriate, funded e-Health plan as part of the overall NHHRC final report. Second I need to disclose I was an unpaid advisor to the consulting team who developed the Deloittes plan and that I have also made unpaid contributions to the work undertaken by Booz and Co.

It is my belief the NHHRC should issue a clarifying press release placing this document in its proper context as a discussion document for PHR directions in the overall context of the Deloittes National E-Health Strategy. The NHHRC then needs to say that it endorses the Deloittes work fully or explain how it will actually develop an implementable replacement that fully addresses the e-Health needs of all the stakeholders in the Australian Health System.

Only NSW Health Could Mess Up Like This!

I know it seems to be a little unfair to make critical comments two days in a row but this really is a ripper.

Power failure lasting 36 hours cripples hospital care

• Kate Benson Medical Reporter
• May 6, 2009

DOCTORS at more than 100 hospitals in the state could not access patient records or vital test results for up to 36 hours last weekend after a power failure crippled NSW Health's computerised database.

Some records were lost, X-ray and pathology results could not be accessed and staff were forced to use whiteboards to keep track of emergency patients after the main server shut down at 9am on Saturday because of a faulty circuit-breaker.

Back-up power from the Cumberland Data Centre, which provides computer access to the Greater Western, Greater Southern and Sydney West area health services also failed, plunging some of the busiest hospitals in the state into chaos.

Thousands of patients were affected, with doctors and nurses forced to take notes on paper and go to other parts of the hospital to collect hard copies of results, extending treatment times and adding to the confusion.

Some staff, who did not want to be named, said the weekend was chaotic and a shambles. One surgeon said it was fortunate no lives were lost.

.....

A spokesman for Mr Della Bosca said workers doing routine maintenance at the data centre had triggered the outage. No patients had reported problems connected to the blackout but a full investigation would be launched. "If necessary changes will be implemented to prevent a recurrence," he said.

with Louise Hall

BLACKED OUT

Hospitals at Westmead, Auburn, Blacktown, Nepean, Lithgow, Mount Druitt, Cumberland, Blue Mountains, Dubbo, Bathurst, Orange, Mudgee, Parkes, Bourke, Albury, Queanbeyan and Goulburn were affected.

Full article here:

http://www.smh.com.au/national/power-failure-lasting-36-hours-cripples-hospital-care-20090505-au1s.html

Further coverage is here:

Patients weren't at risk during hospital power failure: Della Bosca

LiveNews | Francis Keany and Richard Maxton

“There are no reports of adverse patient outcomes related to the temporary power outage.”

NSW Health Minister John Della Bosca

The health system is in damage control again after revelations wide-sweeping blackouts meant doctors at more than 100 hospitals couldn't access patients records or test results for 36 hours.

The power failure last weekend crippled the health database impacting on more than 100 hospitals.

Some records were lost and doctors were unable to access x-ray and pathology results.

.....

However surgeons and the NSW Opposition claim the power loss indicated a serious failure.

NSW Shadow Health Minister Jillian Skinner has told 2GB's Alan Jones the failure of the back up system is extremely concerning.

"The Minister's response is almost, 'Oh well, don't worry about it, no one's lives were at risk'. The same with the Health administrators that spoke out yesterday.

"I joined doctors in saying this is a real worry. We've got to get guarantees this will never happen."

More here:

http://www.livenews.com.au/news/patients-werent-at-risk-during-hospital-power-failure-della-bosca/2009/5/6/205376

There are a few things to be said here:

First the Health Minister would not have a clue and has no way of knowing if any patient was harmed or put at risk. The oppositions comments are more than reasonable I believe.

Second the fact that problems lasted for more than an hour or two suggests total incompetence at both a planning and operational level. Everyone recognises that there can be single point failures that can take a little while to sort out – but 36 hours! Just who was the clueless person who designed the fail safe systems that it took this long to become operational again. Management of the shared services environment should be held accountable and it would be more than reasonable to conduct a short formal PUBLIC enquiry to properly apportion blame and put appropriate remedies in place. I bet that does not happen!

Third, this enquiry should also examine how the manual back-up system worked so the whole Health Sector can learn any lessons that may be available. From the reported comments of staff it does not seem the manual systems coped all that well.

Fourth, I wonder why, if this happened at the weekend, why it has taken until Wednesday for the issue to be reported? Could it be that staff are a bit nervous about speaking out – Mr Garlig SC did suggest there was a little problem with bullying etc in NSW Health?

Fifth incidents like this need to be seen to be effectively handled so we don’t create undue anxiety regarding EHR initiatives. Just hiding the issue under the carpet does not help!

On a positive note this incident should prompt a risk review of all contingency and continuity plans state wide – and testing of them fully to ensure they actually work as intended. 36 hours is just way to long as further automation occurs. I bet that if done, the resulting document would never make it into the public domain as it should!

David.

NSW Health IT – Has Much Changed over the Years?

The following press release appeared over the weekend (always a suspicious time!).

02 May 2009

Patient care and safety enters the digital age

NSW Minister for Health, John Della Bosca, announced today that the State Government had started rolling out new electronic medical records (eMR)s technology into public hospitals across the State to help improve patient care and safety.

The Minister said the new technology would also make it easier for doctors and nurses to track the condition of patients through the health system as hospital information would be linked between facilities via eMRs.

“The $100 million project will be rolled out to 188 hospitals across the State by the end of 2010,” Mr Della Bosca said.

“The new eMR replaces many existing paper records and makes secure patient information available to authorised clinicians from computer workstations across the hospital.

“A major benefit of the eMR program is the completeness of patient data and information on medical orders.

“Prior to the introduction of eMR, some requests for medical imaging and pathology could require referral back to the requesting clinician due to incomplete or illegible hand-written records.

“This technology will improve the efficiency of hospital care and free up doctors and nurses to focus on patients and not paperwork which will further improve patient safety,” he said.

The benefits for patients include:

• Decreased delays in retrieving clinical information;
• Timely availability of integrated patient information, including results of tests and patient scheduling;
• Reduced duplication of orders for diagnostic tests; and
• A reduction in the potential for errors.

The benefits for doctors, nurses and allied health professionals is that eMR will allow them to:

• Record patient care where and when it is delivered
• Review progress and order treatment or diagnostic tests from any workstation within the health facility
• Be prompted with alerts and allergies at the time of ordering
• Continually review results and outcomes as well as alter care as required.

“In his Special Commission of Inquiry into Acute Care Services in NSW Public Hospitals, Peter Garling SC recommended the implementation of the eMR into NSW hospitals as a way of improving the sharing of information and communication among medical teams,” Mr Della Bosca said.

“Results from the initial trials and roll-out reveal a positive take up of the new technology by clinicians, demonstrated by the use of electronic medical orders to request blood tests and x-rays.

“The eMR is one of the cornerstone projects of NSW Health’s Information and Communication Technology Strategy, which is modernising the way health services are supported in NSW.

“Delivering a statewide eMR will help provide consistent delivery of quality healthcare for patients in both rural and metropolitan hospitals across the State,” he added.

For a range of health information, go online to www.health.nsw.gov.au

The release is found here:

http://www.health.nsw.gov.au/news/2009/20090502_01.html

The SMH followed up thus

Paper patients' notes out, digital records in

• Louise Hall Health Reporter
• May 2, 2009

BY THE end of next year, every public hospital in NSW will move from paper patient notes to electronic medical records that can be accessed by any health worker, the Government has announced.

The Minister for Health, John Della Bosca, said the $100 million project to digitise 250 hospitals will save money by eliminating duplicate diagnostic tests and imaging. It will also improve patient safety by alerting staff to a deteriorating patient and reduce the likelihood of errors.

Mr Della Bosca said doctors, nurses, allied health and social workers will be able to access a centralised repository of a patient's medical chart, laboratory results, prescriptions and referrals, no matter where the patient enters the health system.

Peter Garling, SC, recommended an urgent roll-out of electronic medical records (eMR) in his special commission of inquiry into acute care services, which found NSW's record-keeping system is "a relic of the pre-computer age" that puts patient safety at risk.

.....

The next step will link hospital-based records to primary care providers, such as GPs, by way of an electronic discharge summary.

.....

NSW Health has admitted that two previous attempts to implement electronic medical records in 1991 and 1999 had failed, at a cost of $12 million and $30 million respectively.

The National Health and Hospitals Reform Commission has recommended an individual patient-controlled electronic health record owned by the patient who decides which health care providers can access it.

Full article here:

http://www.smh.com.au/national/paper-patients-notes-out-digital-records-in-20090501-aq6k.html

The NSW AMA reaction is here:

AMA casts doubt on hospital paper scrap plan

Posted 1 hour 14 minutes ago

The Australian Medical Association (AMA) has cast doubt on plans for all of New South Wales' public hospitals to scrap paper records by the end of the year.

The association's state president, Dr Brian Morton, has welcomed the State Government's $100 million project to move to electronic medical records.

.....

"I think there must be extreme cynicism as to the ability of NSW Health and the State Government to actually respond in implementing change and to actually allow independent audit of the process, so that we can see as a community that change has occurred and that quality of care really is improving," he said.

Full report here:

http://www.abc.net.au/news/stories/2009/05/03/2559261.htm

Quite telling is this report from Computerworld.

http://www.computerworld.com.au/article/301824/nsw_health_spend_100m_electronic_medical_records?eid=-6787

NSW Health to spend $100m on electronic medical records

Patient information to be shared between health facilities

Rodney Gedda 04 May, 2009 14:32

After many promises and trials, NSW Health has committed $100 million over the next two years to replace existing paper-based health records in public hospitals with a state-wide electronic system aimed at improving patient care.

NSW Health anticipates the new electronic medical record (eMR) technology will make it easier for doctors and nurses to track the condition of patients through the health system as hospital information will be linked between facilities electronically.

Minister for Health, John Della Bosca, said the $100 million project will be rolled out to 188 hospitals across the state by the end of 2010.

“The new eMR replaces many existing paper records and makes secure patient information available to authorised clinicians from computer workstations across the hospital,” Della Bosca said.

“A major benefit of the eMR program is the completeness of patient data and information on medical orders.”

A similar system is the NSW Healthelink project, which began about five years ago and was well received by clinicians.

Healthelink now claims 70,000 subscribers.

Della Bosca said prior to the introduction of eMR, some requests for medical imaging and pathology could require referral back to the requesting clinician due to incomplete or illegible hand-written records.

More here:

http://www.computerworld.com.au/article/301824/nsw_health_spend_100m_electronic_medical_records?eid=-6787

The scepticism that anything has changed is pretty obvious.

The recent release should maybe compared to this one:

30 May 2005

Patients to benefit from online access to medical records

Public hospital patients across NSW will have access to state of the art Electronic Medical Record (EMR) technology after the NSW Government today announced a call for tenders to expand the roll out of the EMR system, Health Minister Morris Iemma said today.

"The Electronic Medical Record is a foundation stone of our vision for how we will harness technology to improve patient care," Mr Iemma said.

"The Electronic Medical Record system will give clinicians online access to diagnostic tests for their patient carried out in hospital, regardless of whether as inpatient, outpatient or in emergency.

"From this base we aim to build a network that will ultimately allow consolidated test results to be accessed online from any authorised PC location across the state.

"So if a patient is admitted to Prince of Wales Hospital Emergency Department, their clinician will be able to access diagnostic test results done previously at Nepean Hospital or even Wagga Base Hospital.

"Improved access to clinical information can help reduce delays and give medical professionals the information they need to deliver the best possible care to patients," Mr Iemma said.

"This will be a significant boost for frontline health services delivering better access to a patient's clinical information wherever they are in the health system," Mr Iemma said.

"The system will also allow electronic charting making it easier for treating clinicians to detect trends in diagnostic results."

"NSW Health is looking to secure state-wide EMR coverage, and to do this it is seeking a second provider for point-of-care clinical system to those Areas that currently have not had a provider appointed," Mr Iemma said.

Mr Iemma said that online results reporting is already being used by Sydney West, Sydney South West, the Children's Hospital at Westmead and Central Coast and would be extended to Northern Sydney and Greater Western Area Health Services by early 2006.

This second call for tenders will see this technology rolled out to the remaining Area Health Services.

The Minister said that privacy and security will be assured as each clinician is given a unique identification and password to access the system.

Preserving system integrity and patient privacy are critically important aspects of the project and NSW Health will take all necessary steps to ensure patient confidentiality is maintained.

Roll out of the software will be managed through HealthTechnology, the new shared IT services agency established as part of the restructure of the state health information management and technology function.

For a range of health information, go online to www.health.nsw.gov.au

The release is found here:

http://www.health.nsw.gov.au/news/2005/20050530_04.html

Of course that didn’t quite go as planned!

09 February 2006

Electronic Medical Record Tender Closes with no vendor meeting all requirements

NSW Health today announced that it would review its options for its second Electronic Medical Record (EMR) solution after concluding that no single product presented in the tender could meet the defined requirements to a satisfactory level.

NSW Health's Chief Information Officer, Michael Rillstone, said that while he was sympathetic to vendors, who had put in a significant effort, it was important that NSW Health move forward with its EMR program with confidence that the needs of Area Health Services would be met with minimal disruption to front line health services.

"A number of the clinical information systems presented were currently under development and while these may yet meet NSW Health's requirements in the future, at present they represented too high a risk on a number of fronts.

"We only have one chance to get this right. Health is a complex environment, and that does not mix well with high-risk software implementations, as we have seen in the past.

"Nine responses were received. A comprehensive evaluation found that no single product could meet to tender requirements to a satisfactory level," said Mr Rillstone.

The EMR is aimed at providing an information system that will enhance the health care of people attending NSW public hospitals. It will allow statewide coverage of clinical information systems with the goal of making comprehensive information available to treating clinicians, no matter where a patient enters our health system.

Mr Rillstone said that key modules of the EMR strategy have already been rolled out over the past three years into two Area Health Services and the Children's Hospital at Westmead.

The selection of a second vendor was preferred because it provided a more competitive environment with alternate product options. However, this approach represents no advantage if it comes with significantly higher implementation risks.

"Sound health care and clinical decision-making is enhanced by timely access to quality information.

"For example, having the test results of a patient in hospital quickly integrated into their treatment notes so that treating clinicians can consider the results in the context of the patient's overall condition and current therapies to make timely decisions," Mr Rillstone said.

The Chief Information Officer said it was important to understand that NSW Health remained committed to delivering an EMR and that improving the quality and timeliness of patient care and providing support to busy clinicians as they care for their patients was a priority.

While the current second EMR tender outcome is a setback, work has begun immediately on reviewing the options for moving forward aimed at minimising any delay.

The release is here:

http://www.health.nsw.gov.au/news/2006/20060209_02.html

The bottom line is that unless something has changed dramatically, this is just a joke. I wonder will we get a new announcement of essentially the same thing a further four years (an one or two ministers) hence.

The AMA and Computerworld are perfectly justified in being sceptical! A review of the news releases from NSW Health since 1999 shows at least 2 other seeming starts down the e-Health path that don’t seem to have gone far.

This one, from February, 2001, is my favourite:

Electronic Health Records - Better Care, Your Choice

A SYSTEM of linked electronic health records (EHRs) will significantly improve patient care in NSW hospital patients within two years, the Minister for Health, Craig Knowles, said today.

The full release is here:

http://www.health.nsw.gov.au/archive/news/2001/February/02-02-01.html

Just how focussed efforts are on this newly announced initiative becomes a little clearer when one goes here:

http://www.emr.health.nsw.gov.au/

The information on the eMR page says it was last updated 26th Sep 2008! Only eight months ago!

Funny how EHR has become EMR and then become eMR – I wonder what all that means?

Time will tell I guess if this is serious or not. I, for one, will not be holding my breath.

David.

The NHHRC Gets E-Health Very Badly Wrong at the First Go!

The following is going to form the basis of my submission regarding the e-Health plan proposed by the National Health and Hospital Reform Commission (NHHRC).

First some press reaction to last week’s announcement.

Quickly of the mark we have the Australian IT Section.

Patients may have to foot e-health bill

Karen Dearne | April 30, 2009

PATIENTS may have to pay for their own electronic health records, with the key healthcare reform body urging the federal Government to mandate "person-controlled" systems commercially available from providers like Microsoft and Google.

"We believe that the rapid development of new IT applications required across the health sector to give people the opportunity to have an electronic health record is best undertaken by commercial IT developers in an open competitive market," the National Health and Hospitals Reform Commission (NHHRC) said in a supplementary paper released today.

While tech-savvy patients are increasingly keen to manage their own medical records, public agencies worldwide have opted to maintain control over health information-sharing systems to ensure confidentiality, technical security and data quality.

But in an unexpected turnaround, the NHHRC said "every Australian should be able to choose where and how their personal e-health record will be stored, backed-up and retrieved", and that the record should be "at all times owned and controlled by that person".

Instead of providing a national health IT infrastructure, the Government's role should be "to regulate privacy and technical standards", and allow the market to come up with products that suit both consumers and healthcare providers

"By 2012, every Australian should be able to have a personal e-health record," said NHHRC chair Christine Bennett. "The Government must legislate to ensure the privacy of a person's e-health data, while enabling secure access to the data by the person's authorised health providers."

To thwart likely objections from doctors over sharing information contained in their patients' records, the NHHRC wants the payment of public and private benefits to health and aged care services "to be dependent upon the provision of data to patients, their authorised carers and other health providers, in a format that can be integrated into a personal e-health record".

Microsoft has previously told the NHHRC it was feasible to establish an affordable, consumer-controlled e-health record nationwide within one year. Its HealthVault web-based platform has been designed to allow people to collect, store and share their own medical information with doctors and family members.

The commission's interim blueprint, released late last year, has been criticised for its failure to put information technologies at the heart of planned health sector reform.

While today's paper said the nationwide adoption of individual e-health records would return between $7-$9 billion in economic benefits from increased productivity and reduced adverse events over 10 years, the federal and state governments have baulked at providing the necessary funding.

More here:

http://www.australianit.news.com.au/story/0,25197,25409711-15306,00.html

Second we have the professional press

GPs face MBS restrictions under proposed e-health agenda

Friday, 1 May 2009

GPs who do not sign up to the Government’s e-health agenda could find their access to the MBS restricted, under radical new proposals touted by the National Health and Hospitals Reform Commission.

The new proposals – released yesterday – recommend public and private benefits for health and aged care services be tied to the provision of personal electronic health records to all patients. GPs would have until January 2013 to comply.

However, AMA e-health committee chair Dr Peter Garcia-Webb criticised the proposal, claiming it could greatly disadvantage patients.

http://www.medicalobserver.com.au/News/0%2C1734%2C4453%2C01200905.aspx

And here:

Push for e-health records by 2012

1-May-2009

Doctors should lose funding if they fail to integrate referrals, discharge and patient information into a national system of e-health records, the Federal Governments main advisory group has said.

Yesterday the National Health and Hospital Reform Commission released a series of recommendations designed to kick start the development of national e-health records.

Its key message is that Federal Government should guarantee every Australian can “own and control” their own e-health record by 2012.

But as part of that process it also said the government should make funding to health providers dependent on their ability to send and receive information in a way that is compliant with the e-health record system.

That includes GPs, medical and non medical specialists, pharmacists and health and aged care providers being able to transmit key health data – including referrals, discharge information, prescriptions and synopses of diagnosis and treatments - in a format that can be “integrated into a personal electronic health record” by January 2013.

The commission said hospitals would also face loss of funding unless they were able to provide referral and discharge information under a national e-health system by 1 July 2012. And the same deadline has been suggested for pathology and diagnostic imaging providers.

More here (if access available):

http://www.australiandoctor.com.au/articles/ec/0c0607ec.asp

And finally the mainstream press health section

Push for electronic health records

Adam Cresswell, Health editor | May 01, 2009

Article from: The Australian

THE federal Government's main health reform advisory body has set a target date of 2012 by which it says every Australian should be able to have their own electronic health record.

In one of its most definitive statements, the National Health and Hospitals Reform Commission said yesterday that any electronic health record should be under the control of individual patients, instead of doctors.

It also called on the federal Government to take steps to enable health records to be introduced. These steps include introducing unique personal health identifiers - code numbers for each individual - by July next year. Medicare numbers are not suitable for this purpose because entire families can be included on one Medicare card.

More here:

http://www.theaustralian.news.com.au/story/0,25197,25411894-23289,00.html

Interestingly, in parallel we have this paper appear.

Acceptability of a Personally Controlled Health Record in a Community-Based Setting: Implications for Policy and Design

Elissa R Weitzman^1,2,4, ScD, MSc; Liljana Kaci¹, BA; Kenneth D Mandl^1,3,4, MD, MPH

¹Children’s Hospital Informatics Program at the Harvard-MIT Division of Health Sciences and Technology, Children’s Hospital Boston, Boston, MA, USA

²Division of Adolescent Medicine, Children’s Hospital Boston, Boston, MA, USA

³Division of Emergency Medicine, Children’s Hospital Boston, Boston, MA, USA

⁴Department of Pediatrics, Harvard Medical School, Boston, MA, USA

Corresponding Author:

Elissa R Weitzman, ScD, MSc

Children’s Hospital Informatics Program

One Autumn Street, Room 541

Boston, MA 02215

USA

Phone: +1 617 355 3538

Fax: +1 617 730 0267

Email: elissa.weitzman [at] childrens.harvard.edu

ABSTRACT

Background: Consumer-centered health information systems that address problems related to fragmented health records and disengaged and disempowered patients are needed, as are information systems that support public health monitoring and research. Personally controlled health records (PCHRs) represent one response to these needs. PCHRs are a special class of personal health records (PHRs) distinguished by the extent to which users control record access and contents. Recently launched PCHR platforms include Google Health, Microsoft’s HealthVault, and the Dossia platform, based on Indivo.

Objective: To understand the acceptability, early impacts, policy, and design requirements of PCHRs in a community-based setting.

Methods: Observational and narrative data relating to acceptability, adoption, and use of a personally controlled health record were collected and analyzed within a formative evaluation of a PCHR demonstration. Subjects were affiliates of a managed care organization run by an urban university in the northeastern United States. Data were collected using focus groups, semi-structured individual interviews, and content review of email communications. Subjects included: n = 20 administrators, clinicians, and institutional stakeholders who participated in pre-deployment group or individual interviews; n = 52 community members who participated in usability testing and/or pre-deployment piloting; and n = 250 subjects who participated in the full demonstration of which n = 81 initiated email communications to troubleshoot problems or provide feedback. All data were formatted as narrative text and coded thematically by two independent analysts using a shared rubric of a priori defined major codes. Sub-themes were identified by analysts using an iterative inductive process. Themes were reviewed within and across research activities (ie, focus group, usability testing, email content review) and triangulated to identify patterns.

Results: Low levels of familiarity with PCHRs were found as were high expectations for capabilities of nascent systems. Perceived value for PCHRs was highest around abilities to co-locate, view, update, and share health information with providers. Expectations were lowest for opportunities to participate in research. Early adopters perceived that PCHR benefits outweighed perceived risks, including those related to inadvertent or intentional information disclosure. Barriers and facilitators at institutional, interpersonal, and individual levels were identified. Endorsement of a dynamic platform model PCHR was evidenced by preferences for embedded searching, linking, and messaging capabilities in PCHRs; by high expectations for within-system tailored communications; and by expectation of linkages between self-report and clinical data.

Conclusions: Low levels of awareness/preparedness and high expectations for PCHRs exist as a potentially problematic pairing. Educational and technical assistance for lay users and providers are critical to meet challenges related to: access to PCHRs, especially among older cohorts; workflow demands and resistance to change among providers; inadequate health and technology literacy; clarification of boundaries and responsibility for ensuring accuracy and integrity of health information across distributed data systems; and understanding confidentiality and privacy risks. Continued demonstration and evaluation of PCHRs is essential to advancing their use.

(J Med Internet Res 2009;11(2):e14)
doi:10.2196/jmir.1187

KEYWORDS

Medical records; medical records systems, computerized; personally controlled health records (PCHR); personal health records; electronic health record; human factors; research design; user-centered design; public health informatics

Full paper is here:

http://www.jmir.org/2009/2/e14/

My initial response (associated with the announcement of the plan) is found here:

http://aushealthit.blogspot.com/2009/04/important-e-health-release-from.html

With the advantage of a few days of thinking and reading around this topic I can only say that, while I am entirely happy with what I said last week I now believe I was not sufficiently condemnatory of the vast number of weaknesses contained in this proposal.

My purpose here is not to say we should in any way slow or constrain the overall development of e-Health in Australia but that we should be doing it is a balanced, co-ordinated, consultative way.

It is simply absurd to propose a national deployment of Personal Health Records without addressing a range of other critical issues.

These critical issues in the e-Health domain include governance, funding, leadership, communication, professional and provider education and consumer involvement. I believe the necessary balance was properly and consultatively achieved in the National E-Health Strategy which was developed last year and which I am deeply concerned may not receive the attention and funding it is due because of the release of this new document.

The NHHRC needs to absorb two key pieces of information is seems to be ignoring.

First it needs to recognise there is no established benefits case for PHRs (they are essentially too new for the work to have been done) so investment in this area is speculative and not evidence based at preset. (see paper cited above)

Second it must be clear that when it has been talking of EHRs it has been – to date – talking of provider maintained and used EHRs – for which there is a much longer history of use and an overwhelming benefits case – including work done by organisations as diverse as the RAND Corporation and NEHTA.

No-one, just no one, has asked to public if they want their own personal health record to which their health professionals will be financially compelled to contribute. This is a nonsense of a just staggering magnitude.

The new NHHRC document is essentially a semantic and definitional con job as it takes evidence of value and success from ‘real’ electronic health records and just assumes the same can be said about PHRs. This is just not true!

Balance and leadership is critical here and what I am seeing are a range of vested interests subverting what should be a quite simple staged strategic implementation.

The drivers are the Commonwealth wanting to minimise expenditure on e-Health but needing to be seen to doing something, NEHTA recognising the real Shared EHRs are complex and slow to implement and fundamentally require quality provider systems in which they have essentially no expertise and various health software providers seeing PHRs as something they have already done and can easily bring to our market at a very good profit. The NHHRC also does not seem to have the depth of understanding in e-Health that can really help it optimise overall health sector outcomes through the use of e-Health. If it had this expertise e-Health would not have been left to being an afterthought.

It is also important to recognise that with Internet access being nowhere near universal there is significant policy discrimination against the poor, the older and the IT illiterate who will miss out on access to PHRs.

Overall the NHHRC has two reasonable ways forward.

The first is to make it clear that the present paper is adjunctive to the already developed National E-Health Strategy and formally recommend that this strategy be funded and implemented.

The second is to develop a new balanced National E-Health Strategy and insist it be funded and implemented.

Given the NHHRC does not have the time to do the latter the first is the only way forward. I see any other outcome as deeply flawed.

In passing the NHHRC has to recognise that he medical profession is presently being battered by all sorts of regulatory changes, PIP vagueness and uncertainty, probity reviews, challenges to professional autonomy and a threat to its vital role in the health system.

This shift seems to many of them to be part of a pattern. As a result many are finding the professional practice of medicine dramatically less attractive and fulfilling.

Love or hate them the medical profession is key to any success in e-Health and alienating them will sink any progress before it even starts. This sort of jackboot compulsion to supply information for patient systems at their cost will spark a backlash the like of which I can only imagine - once they realise what is going on.

Lots of issues also remain in this NHHRC proposal such as the data quality and reliability of PHRs. Care should never be based on untrustworthy information and this proposal encourages that deeply flawed approach.

David.