NSW Health Has A Full Blown Health IT Failure on Its Hands. As I Predicted in 2006!

The Healthelink Project, which was to provide a prototype for a Shared EHR for NSW has essentially imploded.

Information provided to this blog confidentially confirms both the number of participants in the project and their information transmission activities have both fallen through the floor over the last 12 months! To protect sources I can’t provide much detail concerning the evidence I have seen, but it is clear and dramatic and confirms what I have been saying for a good while. Sadly HealtheLink is such a badly wounded animal that it really now needs to be helped to pass to a much better place!

Visiting the site we find:

Brief News

30th June 2010

103,190 individuals have now been enrolled into Healthelink.

30th April 2010

100,567 individuals have now been enrolled into Healthelink.

31st January 2010

95,136 individuals have now been enrolled into Healthelink.

This shows that despite even the draconian opt out approach very few are getting involved and it is so bad no statistics have been released in six months.

You can explore the project web site here:

http://www.healthelink.nsw.gov.au/

Here are a few selected links from over the years on this debacle.

Tuesday, March 21, 2006

The Slow Demise of Health-E-Link

It’s been another bad day for e-Health In Australia.

Today we learned that the NSW HealthConnect Trial for NSW - the Health-E-Link project is coming apart for the most basic of reasons - the lack of proper involvement and consultation of healthcare providers and consumers.

It seems that NSW Health has been so keen to get the project operational they have altered NSW Health Information Privacy regulations - to the annoyance of many who are interested in the issue - and have also failed to sign up the local doctors before attempting to 'go live'.

The rest is here:

http://aushealthit.blogspot.com/2006/03/slow-demise-of-health-e-link.html

Next

Thursday, October 26, 2006

What is Happening at NSW Health with Healthelink?

“This software is specifically for internal Hospital use and has nothing really directly to do with the Healthelink project which I understand is still battling with the issues raised by the Privacy Foundation and which threatens to become a considerable white elephant.”

Here is the full blog:

http://aushealthit.blogspot.com/2006/10/what-is-happening-at-nsw-health-with.html

Next here:

Sunday, November 26, 2006

Healthelink – Trundling Towards Failure?

“I am afraid this project has all the signs of a project that is on the ropes. I hope not since it has taken so long to get this far. In many ways I am not surprised. As those who have read this blog for a while will know I have always been convinced that the complexities and difficulties associated with shared summary electronic health records have been very underestimated.

Maybe a strategic re-think and revision of the privacy approach can grab victory from the jaws of defeat. I hope so.”

Full article here:

http://aushealthit.blogspot.com/2006/11/healthelink-trundling-towards-failure.html

Second last here:

Wednesday, December 17, 2008

Summary Evaluation Report of NSW HealtheLink Finally Released.

For your reading pleasure the following was pointed out today.

Evaluation

This report presents the results of an evaluation of the Healthelink electronic health record (EHR) pilot. This report was prepared by KPMG. It focuses on the implementation, functioning and performance of the Healthelink EHR pilot from the time of its commencement in March 2006 to September 2008.

An Evaluation of the Healthelink Electronic Health Record Pilot (Summary Report) (272K)

The site is located here:

http://www.healthelink.nsw.gov.au/evaluation

Bit of a pity – yet again – we have a summary report – because citizens are not grown up enough to be allowed the full truth!

Full blog here:

http://aushealthit.blogspot.com/2008/12/summary-evaluation-report-of-nsw.html

Last there is this - and this one which needs to be read in full!

http://aushealthit.blogspot.com/2008/12/secrecy-gone-feral-why-cant-public.html

Depending on who you trust this project has cost between $20 and $40 million, has not saved a single life anyone knows about and is now a dying white elephant.

See here to discover how this has been running since 2001!

http://aushealthit.blogspot.com/2007/07/health-it-in-nsw-can-it-go-much-more.html

The project was a failure, among a very long list, for lack of clinician and public consultation, the lack or usable systems and all round arrogance and secrecy from the NSW Health hierarchy.

Amazingly the NSW Government is apparently going to spend a huge $1.2 million on making this fiasco compatible with the PCEHR and NEHTA Standards. Why bother one asks. It has not worked in 5 years so what will change that now!

From Ms Roxon we have:

“The state governments of the three states will also join this partnership to drive e-health forward in these communities. The Queensland Government has committed $1.2 million of in-kind support to GP Partners. The NSW Government has also committed $1.2 million to support the initiative and will work with the National E-Health Transition Authority to integrate their Healthelink pilot program with the national rollout.”

Full release here:

http://aushealthit.blogspot.com/2010/08/this-looks-like-desperate-pre-election.html

If ever there was a ‘dead parrot’ this is it! First act of the new NSW Health Minister - after the March 2011 election - should be to just put it out of its misery.

The PCEHR will work out worse than this and cost a great deal more in my view - as it is the same incompetent collection of idiots who still run e-Health policy in Australia, and who refuse to learn the lessons of global experience that I try to provide here on the blog.

Watch and wait and see! No good will come of the PCEHR without a radical rethink!

David.

AusHealthIT Poll Number 51 – Results – 03 January, 2011.

The question was:

Will The Planned National Health Reform From the Gillard Government Be Successfully Implemented and Make a Positive Difference?

The answers were as follows:

For Certain

- 2 (10%)

Probably with the Odd Bump in the Road

- 0 (0%)

Maybe but Won't Make Much Real Difference

- 2 (10%)

No - It Does Not Address The Real Issues

- 16 (80%)

Votes : 20

Good to see readers here get what a large collection of smoke and mirrors we are sing with all this!

Again, many thanks to those that voted!

David.

A New Comment From Dr Andrew McIntyre That Was a Bit Big to Post.

Another contribution to the ongoing debate - posted with permission.

The original is here:

http://blog.medical-objects.com.au/?p=81

Australian eHealth still at the Cross Roads!

It’s interesting that there is such a emphasis on xml as the solution when its just an encoding format.

I implemented HL7V2 (classic) <–> HL7V2 (xml) functionality about 7 years ago but have found no real world use cases or demand for it as all it does is bloat the message for little advantage. If xml was the critical factor this should be in demand.

It is the functional models that are important and the encoding of the data should be pushed down to a lower level of the software functionality, and is not a critical factor in success.

CDA gives us a xml document format and easier mechanisms of dealing with hierarchical data. It provides no messaging functionality at all so would need to be encapsulated in HL7V2 messages or a new layer of messaging functionality provided. Hierarchical data can be encoded in HL7V2 and EN13606 archetypes can provide metadata that allows rich functionality wrt hierarchical data that is comparable with CDA. Even without archetypes implementation guides for specific data would work, if they were developed.

Given the funding available I doubt all endpoints can be made capable wrt CDA within 10 years (Given that PIT only systems still exist). Medication management standards in HL7V2 already exist and were even trialled in the “Better Medication Management System” but it appears all this knowledge was lost when HealthConnect Version XX was killed. The current HL7V2 medication standard is more in line with existing implemented medication functionality and supports a rich range of functionality.

Given the expensive failures in the UK and our limited budget the pragmatic solution is enhance what we have and build on existing knowledge. It may not be “trendy” but its probably the smart solution in the face of our limited budget and the fact that we already have widespread V2 support at some level.

We do need compliance programs and in many ways they already exist at a basic level in the form of AHML. Most of the current issues relate to poor compliance with standards.

I agree with Eric that we need a lot more work on Terminology support to achieve semantic interoperability, but we need a sensible overall direction before that can be tackled. What we actually want is stable V2 standards where extensions in functionality are achieved by better use of terminology rather than changes to the standard. This is the basis of decision logic.

The performance of some of our terminological efforts is less than stellar however as AMT is virtually devoid of semantics and will not deliver in its current form. The fact that this is not apparent to people who should know concerns me greatly and suggests that there is no big picture understanding of where we are heading. This concern also applies to CDA based Medication management which appears to support just one transaction: “Deliver script to Pharmacy”. I appreciate this is what people want first, but a brief look at the Medication standard will reveal 76 interactions where only about 10 don’t have a V2 message specified. The scenario of deliver script to pharmacy is just one of the 76 and it is specified.

I think many underestimate the complexity of the task and how well HL7V2 is actually working at the moment and keep asking external experts to solve the problem. After about 2 years of work they usually realise that the problem is huge and not easily soluble with “xml”. The solution requires high quality standards compliant implementations that build on working solutions rather than trying to reinvent the wheel. There is no quick fix and the current 2yr PCEHR program is likely to fail as it fails to build on working solutions, or even a agreed work plan. Its also largely a standards free zone and that should ring alarm bells. The only way to interoperability is a single implementation for all or standards. A single implementation for all is just not going to happen.

I think the evolution of the internet from basic view only type functionality in the early 90’s to rich Web 2.0 functionality in 2010 is the best analogy. HTML and Javascript have not changed much, but the quality and compliance of the browsers and web servers have improved to the point where high level functionality is possible. A similar 10 year for improving quality and compliance of our existing eHealth standards would lead to a similar transformation. CDA may form part of that program, but its not the “solution” and is not the priority at the moment.

It’s interesting that there is such a emphasis on xml as the solution when its just an encoding format.

I implemented HL7V2 (classic) <–> HL7V2 (xml) functionality about 7 years ago but have found no real world use cases or demand for it as all it does is bloat the message for little advantage. If xml was the critical factor this should be in demand.

It is the functional models that are important and the encoding of the data should be pushed down to a lower level of the software functionality, and is not a critical factor in success.

CDA gives us a xml document format and easier mechanisms of dealing with hierarchical data. It provides no messaging functionality at all so would need to be encapsulated in HL7V2 messages or a new layer of messaging functionality provided. Hierarchical data can be encoded in HL7V2 and EN13606 archetypes can provide metadata that allows rich functionality wrt hierarchical data that is comparable with CDA. Even without archetypes implementation guides for specific data would work, if they were developed.

Given the funding available I doubt all endpoints can be made capable wrt CDA within 10 years (Given that PIT only systems still exist). Medication management standards in HL7V2 already exist and were even trialled in the “Better Medication Management System” but it appears all this knowledge was lost when HealthConnect Version XX was killed. The current HL7V2 medication standard is more in line with existing implemented medication functionality and supports a rich range of functionality.

Given the expensive failures in the UK and our limited budget the pragmatic solution is enhance what we have and build on existing knowledge. It may not be “trendy” but its probably the smart solution in the face of our limited budget and the fact that we already have widespread V2 support at some level.

We do need compliance programs and in many ways they already exist at a basic level in the form of AHML. Most of the current issues relate to poor compliance with standards.

I agree with Eric Brown that we need a lot more work on Terminology support to achieve semantic interoperability, but we need a sensible overall direction before that can be tackled. What we actually want is stable V2 standards where extensions in functionality are achieved by better use of terminology rather than changes to the standard. This is the basis of decision logic.

The performance of some of our terminological efforts is less than stellar however as AMT is virtually devoid of semantics and will not deliver in its current form. The fact that this is not apparent to people who should know concerns me greatly and suggests that there is no big picture understanding of where we are heading. This concern also applies to CDA based Medication management which appears to support just one transaction: “Deliver script to Pharmacy”. I appreciate this is what people want first, but a brief look at the Medication standard will reveal 76 interactions where only about 10 don’t have a V2 message specified. The scenario of deliver script to pharmacy is just one of the 76 and it is specified.

I think many underestimate the complexity of the task and how well HL7V2 is actually working at the moment and keep asking external experts to solve the problem. After about 2 years of work they usually realise that the problem is huge and not easily soluble with “xml”. The solution requires high quality standards compliant implementations that build on working solutions rather than trying to reinvent the wheel. There is no quick fix and the current 2yr PCEHR program is likely to fail as it fails to build on working solutions, or even a agreed work plan. Its also largely a standards free zone and that should ring alarm bells. The only way to interoperability is a single implementation for all or standards. A single implementation for all is just not going to happen.

I think the evolution of the internet from basic view only type functionality in the early 90’s to rich Web 2.0 functionality in 2010 is the best analogy. HTML and Javascript have not changed much, but the quality and compliance of the browsers and web servers have improved to the point where high level functionality is possible. A similar 10 year plan for improving quality and compliance of our existing eHealth standards would lead to a similar transformation. CDA may form part of that program, but its not the “solution” and is not the priority at the moment.

Andrew also provides some further useful insights here:

Why CDA is a poor choice for prescribing

There are some who feel that a move to CDA for electronic prescribing is a better option than using HL7 V2 messages. I would contend that this is seriously misguided.

Prescribing is in effect an ordering activity and orders have line items and are not documents in any logical sense. While printed prescriptions may appear to be documents to a casual observer they are in fact a collection of orders and as is usually the case with orders each line item has state that changes in an independent fashion form the other line items. It is not uncommon the cancel an order, or modify the dose or form and this needs to be done at a line item level, not a document level. In effect each line item has methods to change its state, eg from ordered to cancelled or to update it. In a similar fashion the dispenser may substitute one line item for another or decide to cancel one line item. Also they may want to forward one line item to another dispenser, but dispense the others. In effect each drug order is an object with state and methods which supports an extensive array of methods that change its state and allow these state changes to be notified. A brief glance at the HL7 V2 Medication standard produced by Standards Australia with show a vast array of interactions and state changes rather than transfers of simple documents. Supporting these with a document is messy at best as the document is supposed to be static, when in fact every line item is dynamic with a life of its own. To do this with CDA would require adding all the methods as external logic and result in a huge number of new documents, without any good mechanism to identify which line item was changing.

More at the site here:

http://blog.medical-objects.com.au/?p=78

I provide this link since NEHTA has just released a new standards package which some considerable and quite inappropriate pressure is being applied to get approval from Standards Australia volunteers! More evidence of the dysfunctional governance we have in e-Health in OZ.

I don't think NEHTA or DoHA even vaguely understand just how out of their depth they are and how low are their chances of success with their present plans!

Enjoy the holiday reading!

David.

A Piece of Sanity Emerges on New Year’s Eve. Change is Now No Longer Optional - It is Critical!

Good Heavens! It seems there is some sanity in the bureaucracy. Maybe they should act on their anonymous musings!

This was posted a few hours ago, but was so far down among the 32 comments I thought it was worth highlighting!

The original blog is here:

http://aushealthit.blogspot.com/2010/12/it-isnt-only-wikileaks-that-can-cause.html

Anonymous said...

What very very interesting comments by Andrew McIntyre said... Tuesday, December 28, 2010 12:35:00 PM.

Hopefully they will be widely read and hopefully others equally well informed will support or counter these views.

I am not deeply enough involved in the issue to enter the argument but as a senior manager in health and heavily involved in setting directions and strategies for eHealth nationally I have to make my judgment calls on the advice of my 'techo' experts who each have their own biases and differences of opinion.

Having said that as I contemplate Andrew's comments I ask myself (a) will we ever get 'there'? (b) why aren't we drawing more on the expertise of people like Andrew with years of experience at the coalface? (c) how can I rely on the advice I am given by so-called 'experts' in my organisation who are relatively new to the field? (d) how can I better direct the large sums of money available to get better results and outcomes and working interoperable systems in the field?

Questions like these are at the forefront of my mind every day of the week - in short - are we approaching the problem the right way or should we be doing things differently and in what way?

Thank you Andrew for your very interesting comments.

Friday, December 31, 2010 9:12:00 AM

This was in response to this post from Dr Andrew McIntyre.

Andrew McIntyre said...

While it is common for people from other parts of the IT industry to look for an xml solution I am not sure that xml solves much.

HL7V2 predates xml and its very terse and efficient and this can be an advantage wrt storage and latency and the data is much better being machine readable rather than human readable. HL7V2 is at least text and can be read by humans but I almost never do that.

The bigger problem is the modelling required once the encoding issue is dealt with and in reality this is 99% of the problem. HL7V3 was started in 1992 and HL7V3 messaging would have to be called a failure after 18 years of effort with no results. However HL7V2 continues to grow and prosper and can be enhanced to carry high level semantics in a backward compatible way and this is the path I still think is the most likely to succeed.

CDA is xml but offers little advantage over good HL7V2. You may not need to write a xml parser but the advantages mostly finish there and you just get a document and no messaging semantics, so it cannot replace V2 alone!!!

There is nothing that can't be done with HL7V2 done well and I think it’s the tortoise in this race. Its functionality is quite mature in many areas and combining it with Standards based Archetypes leads to a very solid solution that is backward compatible. The issue is that new people tend to read the V3 specs and ignore V2, and then deride it out of ignorance. It’s a solution that keeps growing while V3 is the playground of Ivory Tower Architects with virtually no implementations of V3 messaging that actually work on any scale.

Tuesday, December 28, 2010 12:35:00 PM

And moments ago we had this devastating stuff from a senior ex-NEHTA employee who also sees the need for some pretty radical change:

Eric Browne said...

Anonymous of Friday, December 31 2010 9:12am asks a number of good questions at the forefront of his/her mind every day of the week.

If similar questions are reflective of the e-health management community more broadly, then I would contend that we have the wrong people making such decisions. Such decisions require a deep technical knowledge and considerable engineering knowledge and experience.

I think the principal reason why more isn't made of the experiences and knowledge of the likes of Andrew McIntyre is due to the closed nature of NEHTA. Instead of providing a forum where important technical approaches could be debated and evolve, we have had a situation, initiated under Reinecke, but continued under the present regime, whereby parts of the e-health infrastructure are developed behind closed doors and announced by decree, in the absence of a comprehensive and coherent strategy that can address all the missing pieces. And without a realistic timeframe and strategy for adoption.

There is clearly a shortage of technical skills in e-health in Australia and very little money is going into addressing this skills shortage.

As to the specific issue Andrew raises in support of HL7 v2, I would contend that both v2 and v3 have fundamental shortcomings that inhibit interoperability. In both cases, they rely extensively on external vocabularies to label nearly every data node in message or document. In the Australian messaging standards that have been produced to date, the vocabularies have not been satisfactorily agreed; the vocabularies that have been mandated (e.g. LOINC and SNOMED CT) have major shortcomings; there has been no adequate distribution mechanism established for incorporating and updating these in clinical systems; there has been no adequate conformance and accreditation regime put in place; very little attention has been given to developing agreed clinical models, to the point that there is NO STANDARD way of even representing blood pressure in HL7 v2 or V3.

In short, I think we should be doing things differently. And I, too, would welcome further views on the issues Andrew raises.

Friday, December 31, 2010 10:58:00 AM

So what we have here are bureaucrats being advised by people they don’t trust and who they suspect are pushing very narrow barrows, while the real experts are just sidelined and disempowered.

Great isn’t it?

The present structures will never deliver and need to be changed. Additionally all the bureaucrats who are responsible for e-Health but are being bamboozled by 'techies' need to do something, and quickly, about their sources of advice. The inevitable failure of the PCEHR is not something that would look good on the resume!

Suggestions as to how that may be made to happen welcome.

David.

Postscript:

Look out early in the new year for a blog highlighting the abysmal and now fully documented failure of the NSW HealtheLink project!

D.

Just A Little Note To Blog Spammers

In the last few days there have been all sorts of commercial interests - from medical tourism promoters to mobile phone providers is Pakistan to US EHR merchants trying to get links on this blog to improve their search find success from external users.

Two points:

1. I review and reject all commercial posts of this sort.

2. If users notice a post that has slipped through please tell me so it can be deleted.

Just pathetic!

David.

AusHealthIT Poll Number 50 – Results – 27 December, 2010.

The question was:

Are The Benefits Envisaged As Being Possible for the PCEHR Real?

Obviously Will Come

- 4 (18%)

Might Just Come

- 5 (22%)

Probably Not

- 2 (9%)

It Won't Deliver What is Claimed?

- 11 (50%)

Votes : 22

I think it is fair to say those who read here are of the view that overall there is a question mark over what will actually be delivered in the way of benefits. Only 20% seemed certain it would work as expected!

Again, many thanks to those that voted!

David.

Remember There Is A Big World Out There Getting On With It!

This just popped up. It is probably important. Sadly OZ not actually mentioned.

U.S., Europe Sign Accord to Foster EHR Compatibility

By: Brian T. Horowitz

2010-12-21

European Commission Vice President Neelie Kroes and U.S. HHS Secretary Kathleen Sebelius signed an agreement in Washington to collaborate on EHR interoperability

The United States and the European Commission have signed a memorandum of understanding to work together on compatible formats for EHRs (electronic health records) and to promote education in health care technology.

Vice President of the European Commission Neelie Kroes and U.S. Secretary of Health and Human Services Kathleen Sebelius announced and signed the memorandum on Dec. 17 at the Transatlantic Economic Council, a political organization that fosters economic cooperation between governments.

Interoperability of EHRs is essential for the e-health market to grow globally, according to the Commission.

Under the terms of the memorandum, HHS and the Commission will exchange delegates and specialists to share information on e-health. They'll also set up joint working groups, workshops and conferences to establish shared strategies on EHRs.

Adoption of EHRs is four times higher in the EU than in the United States, the Commission reports.

"Nothing makes more of a difference to people's lives than good health," Kroes said in a statement. "I warmly welcome today's agreement. It is an excellent basis for the Commission and the U.S. authorities to expand our cooperation on promoting the overall benefits of e-health for patients, health systems and companies."

Under the agreement, EU and U.S.companies will have greater potential to do business in e-health on either continent, according to the EC.

The U.S. government is investing $20 billion toward the use of EHRs under the American Recovery and Reinvestment Act.

More here:

http://www.eweek.com/c/a/Health-Care-IT/US-Europe-Sign-Accord-to-Foster-EHR-Compatibility-561574/

Happy Christmas!

David.

Happy Christmas and A Great 2011

Well an amazing year!

Lots of happenings and lots of genuine hopes for sanity and openness seemingly dashed on the twin altars of political expediency and over controlling, obsessive power lust.

I keep hoping 2011 will be better. In the mean time have a great break.

I might pop up some news but otherwise do not plan to be back until mid January 2011.

Stay safe, drive carefully and enjoy the company of those close to you!

David.