Pay for Performance – NHHRC Wants It – Can it Get There and is it a Good Idea?

It seems the National Health and Hospitals Reform Commission (NHHRC) is giving serious consideration to an implementation of so called “Pay for Performance”. This is the idea where a part of a clinicians income is related to undertaking specific clinical activities that are seen as valuable and useful – e.g. various screening actions, vaccination and disease specific clinical monitoring and treatment.

The idea is discussed here:

Performance pay likely for doctors

Adam Cresswell, Health editor | May 06, 2009

Article from: The Australian

LINKING the pay of doctors and nurses to measures of how well they treat their patients, or how quickly they are seen, is likely to emerge as a key plank of the federal Government's health reform push.

The National Health and Hospitals Reform Commission, which is due to deliver its final report by June 30, says the current "fee for service" system of Medicare rebates does little to encourage the most effective treatments, because doctors get paid for each clinical consultation or activity, regardless of whether the patient recovers well or not.

It is likely to recommend other ways of paying medical and allied health staff, such as providing funds for bundles of care.

The NHHRC's chairwoman, Christine Bennett, gave an example of paying for a course of treatments spanning days or weeks for patients with conditions such as type 2 diabetes.

"We have to go beyond that (activity-based payments) to say are we getting the right activity, and are we getting good outcomes for that activity?" she said.

Pay for performance is a controversial issue in the medical profession. Some doctors fear such systems constrain their freedom to choose the best treatment for individual patients. Some GPs have expressed concerns that unscrupulous doctors might seek to maximise their income from new incentives by cherry-picking affected patients and neglecting others. Dr Bennett said allowing certain categories of patients, such as parents of young children and people with chronic and complex needs, to enrol with general practices on a voluntary basis might allow new types of financial support. This might allow the practice to hire additional staff -- an exercise physiologist, podiatrist, cardiac rehabilitation nurse -- depending on the needs of the individual practice's patients.

More here:

http://www.theaustralian.news.com.au/story/0,25197,25436108-23289,00.html

As can be imagined there are a variety of views on the idea.

Doctors split over performance pay

Adam Cresswell, Health editor | May 07, 2009

Article from: The Australian

PLANS by the federal Government's main health reform body to push for a new system of paying health workers for good performance has won backing from some doctors, despite opposition from the profession's peak body.

A number of GPs yesterday spoke out in support of plans by the National Health and Hospitals Reform Commission to pursue new payment systems in preference to the fee-for-service Medicare system, under which doctors are paid irrespective of whether the treatment provided was appropriate or successful.

Inner-west Sydney GP Lydia Kovach said Medicare made doctors into "piece workers" and created incentives to churn patients through the consulting room quickly, rather than work out what was causing complex health problems.

"Anything that moves away from fee for service ... has to be a good idea, because then you are able to look at the patient and not the time," Dr Kovach said.

"Medicare doesn't reward quality so much as quantity."

Yesterday, The Australian reported that the commission planned to pursue and flesh out, in its final report due in June, a previously flagged intention to recommend a shifting scale of payments for doctors, nurses and other health workers based on performance. Commission chairman Christine Bennett said this might be done by various means, such as measuring the proportion of patients with chronic conditions who were given a seasonal flu vaccination, whether patients with heart disease were prescribed beta-blockers or other treatments considered best practice, or how long patients had to wait before receiving treatment.

More here:

http://www.theaustralian.news.com.au/story/0,25197,25440875-23289,00.html

For those who can access Australian Doctor the following long and detailed article is invaluable:

Target practice

28-Apr-2009

Pay-for-performance may be on the cards for Australian GPs. We ask doctors with experience of the UK system: does it improve care or distort clinical priorities? By Heather Ferguson

ON paper, it sounds great: pay GPs a bonus when their patients achieve certain health targets, such as lower hypertension or blood sugar. In theory, everyone wins. Patients are healthier and GPs are better rewarded for their efforts.

That certainly seems to be the view of the National Health and Hospitals Reform Commission (NHHRC). Earlier this year, in its interim report to the Federal Government, the commission recommended that GPs be rewarded for meeting specific targets of disease prevention, chronic illness and avoidable complications.

In another report released last year, the commission had proposed targets around asthma, diabetes management and antibiotic prescribing for URTIs.

For Australian GPs who have worked in the UK recently, it’s all sounding very familiar. Since April 2004 Britain’s GPs have been able to earn bonuses via the Quality and Outcomes Framework (QOF), a list of 76 targets in areas such as coronary heart disease, diabetes, cancer, mental health, and practice organisation.

Each target hit earns a certain number of points: the more points a practice achieves, the more it earns. And the money on offer is staggering. Practices can earn a maximum of about 1000 points each year. That meant that in 2005-06, the average four-GP practice stood to gain up to £130,000 ($A267,000) a year if it met all the targets. In that year, practices collectively raked in an additional one billion pounds in QOF payments.

A wonderful idea, you might think. But it’s all led to some “weird behaviour” says Australian GP Professor Richard Hays, the head of the school of medicine at Keele University in the UK.

For example, practices that want to meet one particular target need to ensure patients can make an appointment within 48 hours. But some practices have simply made it a policy not to make appointments more than 48 hours in advance. The result is a mad scramble by patients each day to try and get an appointment.

.....

WINNERS AND LOSERS

The percentage of heart disease patients with controlled blood pressure jumped from 48% in 1998 to 82% in 2005. The number of patients with controlled cholesterol also leaped, from 17% to 73%.

Pap smear and vaccination rates in deprived areas have moved closer to those in affluent areas.

GPs in deprived areas have done surprisingly well in meeting targets but practices serving deprived populations are unfairly penalised for high morbidity rates.

The QOF cost Britain £3 billion between 2004-07.

To work, QOF needs to be backed by audits, electronic health records and national guidelines.

Some GPs have “gamed” the system to meet targets. For example, a few practices may have “re-coded” patients with heart disease.

Source: National Primary Care Research and Development Centre paper, November 2007

Much more here (subscription required).

http://www.australiandoctor.com.au/articles/8e/0c06018e.asp

The following is also very useful.

Proper incentives key to P4P success: study

By Rebecca Vesely

Posted: May 7, 2009 - 12:00 pm EDT

Pay-for-performance can be effective if physicians get the right incentives, according to a study by Bridges to Excellence published in the American Journal of Managed Care.

The report used statistical data from Bridges to Excellence pay-for-performance programs with more than 13,500 participating physicians in four cities: Albany, N.Y.; Boston; Cincinnati; and Louisville, Ky. The two programs focused on improving patient care while reducing medical errors in medical practices, and improving care for diabetes patients.

More here:

http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20090507/REG/305079966/-1

The full paper is here:

http://www.ajmc.com/media/pdf/AJMC_09May_deBrantes305to310.pdf

The most important things to consider are first does pay for performance work and if it does what is needed for it to be implemented.

It seems the answer to the first question is that well designed and carefully and responsively evaluated programs can influence clinical behaviour. If the incentive goals are developed with an eye to avoidance of all the possible ‘perverse incentives’, and the scale of the incentives is reasonable it is possible to get net improvements in population care and outcomes.

As far as the second question is concerned there is substantial non-obvious complexity that needs to be addressed.

First clinicians and clinical teams have to be well organised and be able to deliver the full spectrum of care for the individual patient over time while both staying in touch with the patient and tracking clinical outcome.

This really means that a ‘medical home’, patient registration or similar arrangement is needed.

Secondly there is a major information management and co-ordination task. This is because any pay for performance program needs to have clear outcome objectives which are not only fully tracked but are also encouraged via point of care decision support that understands the patient context (i.e. diagnoses, current problems, treatments etc). This can only be achieved using quite advanced clinical systems to support the caring clinicians and these systems need to be capable of appropriate coding of the clinical situation so relevant targets and guidelines are provided at the point of care.

Nothing in the NHHRC work to date suggests they understand this or do they seem to realise that without this key information infrastructure any pay for performance program simply won’t work in my view.

Let me be quite clear here. An advanced e-health infrastructure is not important if the pay for performance approach is to be adopted it is mandatory and it cannot work without it. It also cannot be put in place overnight – or even over a year or two. Minister Roxon and the NHHRC need to take careful note!

There is little doubt that quality and safe clinical practice addresses both errors of omission and commission in care delivery, and that if based on appropriate evidence, the use of techniques to obtain clinical consistency can make a positive difference of overall outcomes. What is harder is to ensure the human and technical factors that assist clinicians get care right as often as possible are carefully thought through and sensibly implemented. Pay for performance is a possible part of a holistic approach to reaching that goal.

David.

NSW Health Continues to Grossly Underperform in E-Health.

When do you imagine we can get rid of the team running NSW Health? – to say nothing of the incompetent Government they report to.

Their effort this week as reported locally and by the ABC.

Hospital records system fails twice in one week

Posted Fri May 8, 2009 7:37am AEST

Emergency doctors at Nepean Hospital in Sydney's west are scaling back a new electronic records system because of two failures in the space of four days.

Hospital management says there was a slowdown in the system for two hours on Tuesday, following a widespread outage on Saturday.

Staff at the Nepean Hospital have now stopped using some parts of the system, saying they have lost confidence in it.

Medics will in some cases go back to using pen and paper to record patients' progress.

The chief executive of the Sydney West Area Health Service Professor Steven Boyages has apologised to staff, but says the problems could continue for a year and a half, while the technology is being rolled out.

More here:

http://www.abc.net.au/news/stories/2009/05/08/2564180.htm

and here:

Electronic medical records putting patients at risk – Nepean Hospital

Posted 07/05/2009 at 05:12 PM by StreetCorner

Staff in the Nepean Hospital Emergency Department have banned the use of the new electronic medical records system after it failed for the second time in three days on Tuesday, putting patients at risk, Shadow Minister for Health Jillian Skinner said today. According to Jillian Skinner, medical officers have revealed the latest shut down at the Nepean Hospital ED on Tuesday lasted for two hours, leading to staff deciding on Wednesday they no longer had faith in the new system.

.....

Skinner reported that emergency staff at Nepean Hospital decided yesterday to pull the pin on using electronic records and are now working with pen and paper because they don’t trust electronic medical records system.

Full article here:

http://www.streetcorner.com.au/news/showPost.cfm?bid=10391

What can one say.

The only way you can wind up in a situation like this is to under plan, under scope, under configure to local workflows and need, under test and under train your staff.

The CEO who says that staff might have to put up with being messed around for the next 18 months is clearly in la la land and needs to be replaced at the earliest possible date. The staff will vote with their feet long before then!

Mr Della Bosca (NSW Health Minister) who announced just one week ago that $100M was to be spent on the eMR must be just furious to be let down so badly.

A very bad career move for the CEO to not make sure the basics of Health IT implementation were followed! (Assuming s/he knew them in the first place - Health IT skills are so undervalued there is no certainty that was the case!)

Jinx even! Just amazing, but sadly typical of what seems to be the norm for NSW Health.

David.

e-Health Has Again Been Ignored in the Federal Budget!

The 2009/10 Budget has been released and those concerned with e-Health have again been obfuscated and let down as best I can tell!

Go here and download the .pdf for the details.

http://www.health.gov.au/internet/budget/publishing.nsf/Content/2009-2010_Health_PBS_sup1/$File/Department%20of%20Health%20and%20Ageing%20PBS.pdf

Search for “e-Health” finds really pretty much nothing except some spending in Northern Tasmania. The core material is on Page 271 and a few following pages.

It seems we are to have IHIs (identifiers) implemented by 2012/13 (way later than expected adoption) and that investment in e-Health implementation is to move from $55M to 57M next year. (Page 272)

Amazingly the Program 10.2 (e-Health Implementation) shrinks by 2012/13 from $50M to 30M or so.

The guts of what DoHA is saying is here (Page 281):

“In 2009-10, the Department will develop a legislative and regulatory framework to support the use of identifiers in the delivery of health services, and will support the development of appropriate levels of protection of health information to ensure the privacy of an individual’s health information. This will help to provide consumers with confidence that their personal health information is managed in a secure environment. The Department will work closely with State and Territory Governments, professional groups and consumers to support the development of this infrastructure.

The Department will also support secure messaging services to assist the widespread take-up of electronic referrals, prescribing and discharge summaries, and develop policy parameters for a long-term approach to IEHRs.

The national approach to e-Health has continued through the development of a National E-Health Strategy, supported by all jurisdictions, which provides a structured focus for considering national e-Health implementation. The National E-Health Strategy includes a practical roadmap for further national e-Health development and implementation by the Australian, State and Territory Governments, and allows prioritisation of existing and future investment in national e-Health infrastructure and activities. The Strategy was endorsed by all Health Ministers at the Australian Health Ministers Conference meeting in October 2008. The Government is seeking policy and implementation advice from the Department on e-Health issues to develop its response to the National E-Health Strategy.”

Slightly earlier in the document we find (on Page 222) this rubbish.

“Support for General Practices in Delivering Care

e-Health

To meet the Australian Government’s objectives for this initiative, the Department will introduce a new Practice Incentives program e-Health Incentive in August 2009. The aim for the incentive is to encourage general practices to keep up-to-date with the latest developments in e-Health and will require practices to have secure messaging capability, public key infrastructure certificates, and use electronic clinical resources. This incentive will assist practices to improve administration processes and the quality and safety of patient care. This incentive also lays the foundation for practices to securely exchange information such as discharge summaries, pathology reports and specialist reports electronically, send electronic referrals and pathology orders, and to participate in prescribing electronically as the technology emerges. This incentive has been developed in consultation with the National E-Health Transition Authority (NEHTA), and aligns with the directions set out in the National E-Health strategy. The Department will continue to work closely with NEHTA and Medicare Australia to assist practices to understand and meet the technical requirements of this incentive”

This initiative has and continues to set records for the worst planned and executed in DoHA history!

Overall Translation of Document – We have no clue what to do strategically so we will just provide nonsense words to shut the Minister up on e-Health. Of course there is no funding to implement the National e-Health Strategy I can see.

I am amazed just how often the National E-Health Strategy – that has not been made public – is used to justify what is done. How can we know if it is being followed if we can't see it?. Open Government bah!

Not funding the implementation of the National E-Health Strategy is just an appalling oversight for which all responsible should be condemned. The time has come!

Pathetic and hopeless. Thoughts of this lot's ability in organising a drinking party in a brewery and an inability to do so with unlimited funds flash to mind!

David.

ACT Health Announces A Large e-Health Investment - Is It Credible?

The ACT Budget came down last week. Among a range of initiatives was the following announcement.

ACT budget injects $90m into e-health

Renai LeMay, ZDNet.com.au

The Australian Capital Territory has allocated $90 million as what it described as an "unprecedented level of investment" to electronic health initiatives in its annual budget, including an e-health record for all residents of the territory.

Territory treasurer Katy Gallagher said the investment would fund a suite of initiatives that would put the ACT "at the forefront of e-health technology in Australia" and would give all Canberrans an opportunity for an electronic health record. The funding would help improve safety and quality of care in hospitals, she added, with a focus on improving efficiency across the board.

The news comes as the e-health agenda appears to be gaining speed in Australia, with many states having recently flagged projects to finally dump paper records in favour of e-health systems to store and make patient records available between facilities.

NSW Health Minister John Della Bosca said over the weekend that the state had initiated a $100 million project to digitise no less than 250 hospitals, following on recommendations made in the Garling review of the state health sector in 2008.

More here:

http://www.zdnet.com.au/news/software/soa/ACT-budget-injects-90m-into-e-health/0,130061733,339296293,00.htm

The full press release is found here:

http://www.treasury.act.gov.au/budget/budget_2009/files/press/08_press.pdf

$90 million investment in an e-healthy future

A $90 million investment in e-health capacity and infrastructure will take Canberra’s health care system into the future, ACT Health Minister, Katy Gallagher, said today.

Announcing the funding allocation in the 2009-10 Budget, Ms Gallagher said initiatives like this would ensure our health system was better positioned to meet the needs of the ACT community now and into the next decade.

“We will continue to prioritise health and invest in services to meet growing demand and keep pace with new and innovative ways of delivering health care.”

“Despite the challenging economic times, this Government will not withdraw from our obligations to the community and will continue to invest in health,” Ms Gallagher said.

The benefits of e-health are increased efficiencies, quality, timeliness, safety and productivity of the system overall.

“New information and communication technologies are recognised as being key components in addressing and managing the increase in demand for health services and these initiatives are a significant commitment to meeting these challenges,” Ms Gallagher said.

The Minister said the E-Healthy Future package delivered on a key 2008 election commitment and had four main elements:

Personal electronic health records

“Personal Electronic Health Records (PEHR) will ensure that accurate and trusted personal health information is made available to the right person, at the right time to enable informed care and treatment decisions, which is better for patients and consumers, as well as health professionals and providers.

Digital hospital and healthcare infrastructure

“The ACT Government’s commitment to a $1 billion rebuild of our health system requires next generation digital infrastructure.

“This will require a medical grade secure network to enable safe, timely and reliable exchange of sensitive clinical information by health professionals and provider organisations.

“Remote diagnostic and treatment services to enable care to move seamlessly outside the hospital and clinic environment and into patients’ homes will be achieved through common clinical applications and high availability ICT infrastructure.

Decision support

“Decision support will guide the highly skilled work undertaken by our front line health workers – doctors, nurses and allied health professionals,” Ms Gallagher said.

“This will include electronic medication management (EMM) to ensure safe, accurate and timely prescribing and administration of medication, and online access to clinical protocols, guidelines and new medical research.

Support services

“Support services are the essential infrastructure components of e-health that make decision support, personal electronic health records and the digital environment possible,” Ms Gallagher said.

The Minister said an E-Healthy Future would enable patients to be put at the very centre of the health care system and support General Practitioners through the electronic sharing of patient clinical information between the hospital and the GP to improve patient safety.

“This considerable investment in e-health capacity will also provide patients with a much greater say in how their personal health information can be used to improve access to health care, reduce wasted time associated with current multiple disconnected paper-based and other systems, and above all improve the safety and quality of health care,” she said.

“It will also ensure that our service delivery is safer, more timely and efficient.”

In the capital spend announcement we see the following:

enhancing e-health capacity with An E-Healthy Future $90.2 million

The Budget provides a package of measures designed to build the necessary e‑health capacity and infrastructure, as part of the Government’s $1 billion Your Health Our Priority program to rebuild the public health system.

An E-Healthy Future has four key elements.

1. Personal Electronic Health Records (PEHR) - to ensure that accurate and trusted personal health information is available to enable informed care and treatment decisions.

2. Digital hospital and healthcare infrastructure - to provide the required next generation digital infrastructure, including a medical grade secure network, to enable safe, timely and reliable exchange of sensitive clinical information.

3. Decision support - to guide the highly skilled work undertaken by our front line health workers, including electronic medication management (EMM) to ensure safe, accurate and timely prescribing and dispensing of medications; and instantaneous online access to clinical protocols and research.

4. Support services - to deliver essential infrastructure components of E-Health, including expansion of the ACT Health patient administration system (ACTPAS) to include the Calvary hospital, adoption of an ACT wide staff rostering service, and implementation of a state of the art diet and food management system.

All well and good – although it would be nice to see a few clinical hospital applications and some messaging to and from practitioners included.

But we then look at the recurrent health budget and we find the following:

Program - An E-Healthy Future

2009/10 $350,000

2010/11 $1,381,000

2011/12 $1,061,000

2012/13 $11,050,000.

So no serious expenditure until 2012/13.

Looking back there is also none of the usual $xx Million over x Years.

Looking at the ACT Health Web Site one finds there is an Information Services Branch but no Information Services Plan and no e-Health Plan that can be found (there is a policy on acceptable computer use for staff).

No mention of the branch in the Budget but we do find this:

“Depreciation and Amortisation:

.the decrease of $1.312 million in the 2008-09 estimated outcome from the original budget relates to delayed implementation of major information technology and other capital works projects; and

.the increase of $2.573 million in the 2009-10 Budget from the 2008-09 estimated outcome relates mainly to the completion of major information technology projects. (Page 39 of 44)

Balance Sheet

- cash and cash equivalents: the increase of $16.272 million in the 2008-09 estimated outcome from the original budget relates to a reduction in receivables, receipt of Commonwealth project funds and unspent information technology project funding.

And this

- property, plant and equipment: the decrease of $69.404 million in the 2008-09 estimated outcome from the original budget relates to delays in the Capital Asset Development Plan (CADP).

- intangibles: the increases of $9.380 million in the 2009-10 Budget from the estimated outcome relates to major information technology projects, including those associated with the CADP. (Page 40 of 44)”

We also have to think about the scale of this alleged investment. The ACT population is about 340,000 and that of Australia is 21.7Million.

If you do the proportional arithmetic this is a national capital investment of approximately $5.7Billion!

If you believe this is real you are a keen fan of the tooth fairy! Oh would it were true!

I look forward to the detailed forward plan, investment details etc.

I suspect I will be waiting a long time!

Note: Yet again we seem to have so little understanding of e-Health that one cannot even work out if this notional plan is to fund EHRs, PHRs or both!

David.

What Should Be in the Budget for E-Health? - Vital Read!

The Commonwealth Budget is to be released at 7:30 pm tomorrow. What is to be hoped is that within the document is some substantial boost for the Health Sector given that it has largely been ignored in the first and second stimulus packages.

I do fear we may be disappointed. As the Brain and Mind Institute executive director Professor Ian Hickie wrote in the estimable publication crikey.com.au today:

“At this stage, the Federal Government’s management of the health portfolio has focused largely on managing the politics rather than driving reform.”

I have to say I agree with that broad assessment. I would also suggest that thus far the politics – and the communities frustration with the present state of the Health Sector – has not been all that well managed.

What is needed in e-Health? Essentially the funds to get on with the implementation of the National E-Health Strategy developed by Deloittes. The following comes from a very well informed source.

The recommended funding to implement this Strategy (sadly not released in the summary report made public almost six months ago) are as follows (over 5 and 10 years respectively):

1. Foundational Activities Workstream

E-Health Standards $100M $160M

Unique Health Identifier (UHI) Solution $190M $400M

National Authentication Service for Health (NASH) $80M $200M

Total $370M $760M

2. E-Health Solutions Workstream

National E-Health solutions investment fund $500M $800M

E-Health compliance function $50M $120M

Consumer and Care Provider Health Knowledge Portals $20M $30M

National Prescription Service $60M $90M

Total $630M $1040M

3. E-Health Change and Adoption Workstream

National Awareness Campaigns $60M $100M

Care Provider Incentives $400M $600M

Professional Accreditation and Training Changes $10M $20M

Total $470M $720M

4. E-Health Governance Workstream

National E-Health Entity and Governing Board $20M $40M

National E-Health Regulatory Function $10M $20M

Total $30M $60M

Thus, in summary, the funds required are as follows (quoting the full report):

“The total indicative estimated cost of the implementation of the national E-Health Strategy is A$1.5 billion over five years or A$2.6 billion over ten years. This represents a relatively modest investment program when scaled against total annual recurrent spending on health (approximately A$90 billion) and the total annual recurrent spending on health by all levels of government (approximately A$60 billion).

The major variable component of this figure is the discretionary amount to be allocated to funding high priority E-Health solution developments and providing financial incentives to private sector providers. In both cases the magnitude of these investments should be proportional to the size of projected benefits and should be sufficient to drive meaningful progress towards the achievement of national E-Health outcomes.”

A description of the details of each of the workstreams can be found here:

http://www.nehta.gov.au/component/docman/doc_download/626-national-e-health-strategy-summary-dec08

See pages 10-18.

I would note these costs are remarkably modest when compared with the current and planned investments in the US, UK and Europe.

As a balance to these costs the estimated benefits are cited as follows:

“There are significant challenges associated with attempting to quantify benefits associated with E-Health, not least of which is the paucity of quality data on Australian health care system costs, activities and outcomes. Despite these limitations, it is possible to develop indicative estimates based on analysis of local and international literature. This analysis shows that the tangible benefits associated with implementation of the Australian E-Health Strategy are estimated to be in the order of A$5.7 billion in net present value terms over ten years. The annual savings associated with a fully implemented E-Health Strategy are estimated to be approximately A$2.6 billion in 2008-09 dollar terms.”

What I will be looking for is a commitment to an investment of this sort of scale over some reasonable period to start gathering those benefits. Three hundred million per annum is really small beer in the 90 billion plus of the health budget nationally, especially since some of the early funding is already committed – e.g. a good deal of the Foundational workstream.

The financial information (both costs and benefits) contained in the full Deloittes report has been available within all the State Governments and the Commonwealth for over six months and it is quite wrong in my view that the public does not get a chance to debate the merits of the suggested investments so that some action can be taken if that is the expert and community consensus.

All we have had so far are motherhood statements of support for the suggested directions and then total silence as to how implementation is to be achieved. Given the crucial place of e-Health in any Health Reform Agenda this really is a joke.

If we don’t get some, at least starter funding, to begin investment of this nature and scale then we will all be able to form a view as to the chances of e-Health in Australia ever getting support from this Government.

David.

Useful and Interesting Health IT News from the Last Week – 10/05/2009.

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

First we have:

Getting connected not a priority for seniors

• Dan Harrison
• May 8, 2009

MORE than 15 years after the invention of the World Wide Web, almost half of Australians over 65 have never used the internet.

A report by the Australian Communications and Media Authority, released yesterday, showed 44 per cent of the nation's seniors had never gone online, while only 48 per cent of them had a home internet connection.

Of those older Australians who have never gone online, only 4 per cent said they were likely to in the future.

Asked why, 75 per cent of these said the internet was not relevant to their lifestyle.

In contrast, all respondents aged 14-to-17 had used the internet, and 92 per cent used it at least weekly.

More than half of respondents aged 14 to 49 used the internet daily.

More here:

http://www.theage.com.au/national/getting-connected-not-a-priority-for-seniors-20090507-awt9.html

This is a very important statistic for the NHHRC to take careful notice of. Given the key demographic who will need their proposed Personal EHRs are in this age group, there is clearly a major issue about what to do with the ½ who just are not connected. A clearly discriminatory plan in my view. As I said in my submission the whole proposal needs a major rethink.

Second we have:

Real-time data vital in swine flu fight

Karen Dearne | May 05, 2009

THE lack of a connected health IT infrastructure will hamper Australia's efforts to contain swine flu, e-health experts warn.

Nations with good e-health capacity are analysing vast volumes of patient data taken from providers' systems in near real-time, but federal and state health planners are forced to rely on fragmented and poorly resourced data sharing networks.

"If there is an e-health infrastructure, we have the potential to deal with disease outbreaks before they become pandemics. The technology is already available," iSoft chief operating officer Andrea Fiumicelli said.

"Time is of the essence. In the past, the spread of diseases was measured in months, today it is a matter of hours because of the rapid movement of goods and people around the world.

"Information technology is the only way to meet the time challenge in collecting and sharing information in a pandemic."

Once doctors, hospitals, labs and researchers are all using e-health software, it becomes possible to automatically analyse patient records or medical processes to identify risks, flag alerts and speed up diagnostic or treatment responses.

More here:

http://www.australianit.news.com.au/story/0,25197,25429057-15306,00.html

There are good examples of really well developed e-Health surveillance system – especially in the UK with the EMIS based system. We have yet to get seriously close to that situation here which is a significant worry. It seems to me we may not have seen the last of this virus.

Third we have:

Plans to keep business ticking over in pandemic

Karen Dearne | May 05, 2009

BUSINESSES are considering workplace strategies to protect staff and keep critical systems running in the event of a mass influenza outbreak.

Gartner research director Steve Bittinger says most companies are prepared, having learned the lessons of the SARS and avian flu epidemics in 2003-04.

But they expect a large proportion of the workforce to be absent for a week or more due to the new virus, while the policy of social distancing -- which encourages people to minimise contact with others -- will keep many others out of cities and off public transport.

"The number one response to the pandemic is to just stay home, have some food in the cupboard and if you do have to go out, be careful," he said.

"Fortunately, a substantial amount of IT work can be done from home these days, and most people already have those arrangements in place."

In situations where people needed to remain onsite it was generally possible to reduce staff numbers to small teams.

"You have a team who come in and work a shift together, then all go off together," Mr Bittinger said. "Then the next shift comes in -- there's no overlap ... If one group gets sick you haven't lost your entire workforce."

More here:

http://www.australianit.news.com.au/story/0,24897,25429058-15319,00.html

Good to see companies are being prudent.

Fourth we have:

IBA Health (ASX:IBA) Changes Its Name to iSOFT Group Limited (ASX:ISF)

Sydney, May 5, 2009 (ABN Newswire) - IBA Health Group Limited (ASX:IBA)(PINK:IBATF) - Australia's biggest listed health IT company today announced that shareholders voted in favour of changing the company's name to iSOFT Group Limited (ASX:ISF) to build on the goodwill associated with one of the world's leading health IT brands, iSOFT.

The company's shares will trade as iSOFT Group on the Australian Securities Exchange, under the new ASX code ISF, from 8 May. The decision will align the company's name with its major brand and embrace a common identity among shareholders, customers and employees, IBA's Executive Chairman and CEO Gary Cohen told investors at the company's headquarters in Sydney today.

"The time is right for the company's name to reflect this powerful brand and leverage our footprint across 38 countries," Cohen said. "We have already implemented the iSOFT name among all our strategic products, and have relationships with some 13,000 customers."

More here:

http://www.abnnewswire.net/press/en/60599/IBA_Health_ASX:IBA_Changes_Its_Name_to_iSOFT_Group_Limited_ASX:ISF.html

Worth just noting the change has now formally occurred.

Fifth we have:

e-Health, Dr Strangelove style

Tuesday, 05 May 2009 | Julian Bajkowski

Actual article is here:

http://www.misaustralia.com/viewer.aspx?EDP://1241491501933&section=blogs&xmlSource=/blog/feed.xml&title=e-Health%2C+Dr+Strangelove+style

It describes a 1961 EHR initiative from IBM. Reminds us all how long we have been at this!

See the video here:

http://www.youtube.com/watch?v=t-aiKlIc6uk

For other Youtube material on EHRs go here:

http://aushealthit.blogspot.com/2007/12/youtube-and-electronic-health-record.html

Sixth we have:

Roxon rebuff strains national network ROI

Telco industry to lobby Rudd on key issues

Darren Pauli 08 May, 2009 00:01

Tags: nbn

Federal Health Minister Nicola Roxon has ignored calls from the telecommunications industry to integrate hospitals and healthcare networks into the National Broadband Network (NBN).

The industry's leading experts say government could lose millions unless disparate and costly fibre network contracts are integrated into the $43 billion NBN.

Roxon refused to attend a recent meeting with the Digital Economy Industry Workgroup, which includes experts from telecommunications, health and energy sectors, to discuss network exit plans for hospitals and other health agencies.

The workgroup, setup earlier this year, argues millions could be saved by allowing agencies to scrap existing network contracts and standardise on NBN services.

Telecommunications analyst and workgroup member Paul Budde said Roxon must address the issue within her department to ensure agencies are ready to move to the NBN as it is phased in.

More here:

http://www.computerworld.com.au/article/302413/roxon_rebuff_strains_national_network_roi?eid=-255

It seems to me we all have a problem with the way the Health Agencies nationwide a managing the use of technology. Some serious leadership is really required here:

Seventh we have:

MBS penalties mooted for e-health avoidance

Andrew Bracey - Friday, 8 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 (NHHRC).

The new proposals – released in a supplementary paper last week – recommend that public and private benefits for health and aged care services be tied to the provision of personal e-health records for all patients. GPs would have until January 2013 to comply.

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

“It may not be possible for a GP to meet those requirements, and in those cases, patients would not be able to claim rebates from them,” he said. “It would prevent patients claiming rebates that the existing system gives them. We would certainly not be in favour of this.”

NHHRC member and National E-Health Transition Authority clinical lead Dr Mukesh Haikerwal said the requirements would need to be matched by IT infrastructure grants or incentives for health care providers.

More here:

http://www.medicalobserver.com.au/News/0,1734,4476,08200905.aspx

I am surprised there has not been a more furious pushback from the profession. They seem to be sleepwalking into a real ambush in my view. The proposal is almost as intrusive as the plan from Senator Ludwig to have bureaucrats review patient clinical information as discussed a week or so ago. See here:

http://aushealthit.blogspot.com/2009/04/why-are-ministers-roxon-and-ludwig.html

Eighth we have:

Auditor-General to review NBN tender

Mitchell Bingemann | May 06, 2009

THE Auditor-General will conduct a preliminary review of the Government's terminated national broadband network tender following concerns raised by the Opposition.

On April 7, Prime Minister Kevin Rudd aborted the original NBN request for proposals after finding none of the proponents - included Optus, Acacia and Axia - offered sufficient bids.

Instead the federal Government announced it would form a state-owned enterprise to build a $43 billion fibre to the home network in combination with private suppliers.

But concerns about the legal validity of the RFP termination, raised by Opposition Communications spokesperson Nick Minchin, have prompted Auditor-General Ian McPhee to initiate a preliminary review of the original tender process.

“The Rudd Government wasted almost 18 months and $20 million on a tender which was based on totally unrealistic key objectives, which the bidders themselves confirmed could not be met,” Senator Minchin said.

Lots more here:

http://www.australianit.news.com.au/story/0,24897,25438890-15306,00.html

This seems like a very good plan. The public and the providers will both be interested in knowing just how we wound up with such a failed process.

Lastly the slightly more software orientated article for the week:

OpenOffice.org 3.1 arrives, improves user interface

New features benefit collaborative document editing

Rodney Gedda 08 May, 2009 14:25

Tags: open source, open office, openoffice

The first major release of the 3.0 series of open source office suite OpenOffice.org, version 3.1, is now available with big improvements in usability and the user interface.

OpenOffice.org now has anti-aliasing making graphics look “smoother” on screen and dragging objects now displays a “shadow” of the object, rather of a dotted outline.

General text formatting improvements include “overlining” in addition to regular underlining, subtle highlighting of background text and better grammar checker integration.

More here:

http://www.computerworld.com.au/article/302542/openoffice_org_3_1_arrives_improves_user_interface?eid=-6787

This is really getting to the stage when paying for MS Office is becoming optional – especially for home and small business use. There are certainly the MS Office ‘ribbon haters’ who will be thrilled with this release!

In case anyone missed it the Windows 7 Release Candidate is now available for download. See the following article for instructions:

http://www.smh.com.au/articles/2009/05/04/1241289106407.html

Windows 7: It's Vista done right

David Flynn

May 5, 2009

David Flynn gets hands-on with the latest version of Microsoft's operating system - and explains how to score a free copy to test for yourself.

More next week.

David.

Report Watch – Week of 4 May, 2009

Just an occasional post when I come upon a few interesting reports that are worth a download or browse. This week we have a few.

First we have:

Getting Health IT Right under ARRA

Markle Foundation announces broad agreement on principles for Getting Health IT Right under the American Recovery and Reinvestment Act (ARRA).

Read Achieving the Health Objectives under ARRA (PDF, 453K)

Read the news release.

The Report links are found here:

http://markle.org/

Markle are serious contributors and their report will be worth a close read. Australia – instead of the mindless e-PIP program should be having a similar debate about how to foster e-Health here!

Second we have:

Wednesday, January 28, 2009

ROI of Personalized Medicine for Key Stakeholders Examined

A new report by the Deloitte Center for Health Solutions finds significant opportunities for the adoption of personalized medicine to produce a positive return on investment for key stakeholders in the U.S. healthcare system. The report also finds that consumers stand to gain the most significant ROI within the shortest time period.

The report, titled “The ROI for Targeted Therapies: A Strategic Perspective,” provides an analysis of personalized medicine’s economic value proposition. It examines the importance of ROI for multiple stakeholders--consumers, diagnostic companies, pharmaceutical and biotechnology companies, and payers.

More here

http://www.hfma.org/hfmanews/PermaLink,guid,9dd8115d-29a3-4118-bd13-0cbdc8fc80fd.aspx

Read the report.

This is an important area of future medical care that is very technology intensive.

Third we have:

Report: Change EHR Priorities

April 24, 2009

Hospitals should consider changing their priorities when implementing electronic health records, automating documentation of physicians’ notes earlier in the game, a new report suggests.

The change in priorities would help hospitals provide adequate data for “core measures” that many payers demand, according to a new white paper from Computer Sciences Corp., a Falls Church, Va.-based consulting firm. The Centers for Medicare & Medicaid Services, other payers and some states often require hospitals to use a set of national quality performance measures for pay-for-performance programs and other projects.

More here:

http://www.healthdatamanagement.com/news/EHR-28100-1.html

To view the full report, “Core Measures: All About the Data,” visit csc.com.

An interesting perspective from CSC.

Fourth we have:

Effect of an Electronic Medication Reconciliation Application and Process Redesign on Potential Adverse Drug Events

A Cluster-Randomized Trial

Jeffrey L. Schnipper, MD, MPH; Claus Hamann, MD, MS; Chima D. Ndumele, MPH; Catherine L. Liang, MPH; Marcy G. Carty, MD, MPH; Andrew S. Karson, MD, MPH; Ishir Bhan, MD; Christopher M. Coley, MD; Eric Poon, MD, MPH; Alexander Turchin, MD, MS; Stephanie A. Labonville, PharmD, BCPS; Ellen K. Diedrichsen, PharmD; Stuart Lipsitz, ScD; Carol A. Broverman, PhD; Patricia McCarthy, PA, MHA; Tejal K. Gandhi, MD, MPH

Arch Intern Med. 2009;169(8):771-780.

More here:

http://archinte.ama-assn.org/cgi/content/abstract/169/8/771?etoc

and this article:

An Electronic Health Record–Based Intervention to Improve Tobacco Treatment in Primary Care

A Cluster-Randomized Controlled Trial

Jeffrey A. Linder, MD, MPH; Nancy A. Rigotti, MD; Louise I. Schneider, MD; Jennifer H. K. Kelley, MA; Phyllis Brawarsky, MPH; Jennifer S. Haas, MD, MSPH

Arch Intern Med. 2009;169(8):781-787.

More here:

http://archinte.ama-assn.org/cgi/content/abstract/169/8/781?etoc

Two interesting trials with full abstracts available on the site.

Additional reporting is found here:

http://www.healthday.com/Article.asp?AID=626483

Medication Errors Could Be Cut: Experts
Two reports show promise of computers, pharmacists for proper prescribing

By Steven Reinberg

HealthDay Reporter

Fifth we have:

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/

Very important material given what the NHHRC is proposing here in Australia – needs a close read.

Last we have:

The Doctor of the Future

By Chuck Salter

In March, President Obama identified "the biggest threat to our nation's balance sheet." Not major banks on the brink of insolvency. Not paralyzed credit markets. Not a bailout tab in the trillions. The biggest threat, he warned, "by a wide margin," is "the skyrocketing price of health care."

Health care accounts for $1 in every $6 spent in the United States -- and costs are climbing at twice the rate of inflation. Every year, an estimated 1.5 million families lose their homes because of medical bills. Although we have the world's most expensive health-care system, 24 countries have a longer life expectancy and 34 have a lower infant-mortality rate, according to the latest United Nations report.

But some physicians and surgeons have been quietly rethinking and reinventing medicine for the 21st century. Often collaborating with innovative companies, these pioneers are experimenting with cutting-edge technologies, from software to robots, that have the power to revolutionize the medical landscape -- producing better outcomes, lower costs, broader access, and greater convenience. And advances on a far greater scale could emerge from the stimulus package and the $634 billion the Obama administration proposes to invest in health-care reform; the much-discussed expansion of electronic medical records (see Why Electronic Health Records Are Worth the Hype--and the Price [0]) is just the beginning. As these breakthroughs come together, they will change the world for patients, doctors, insurers, regulators -- all of us.

The doctor of the future will see you. Now.

Vastly more here:

http://www.fastcompany.com/node/1266043/print

Interesting perspectives!

So much to read – so little time – have fun!

David.