This Is Sure To Get a Lot of Coverage. This is The Sort of Research That Often Confuses and Makes Headlines.

The following paper appeared a little while ago.

http://www.ajmc.com/supplement/managed-care/2010/AJMC_10dec_HIT/AJMC_10decHIT_Jones_SP64to71

Electronic Health Record Adoption and Quality Improvement in US Hospitals

Spencer S. Jones, PhD; John L. Adams, PhD; Eric C. Schneider, MD; Jeanne S. Ringel, PhD; and Elizabeth A. McGlynn, PhD

Published Online: December 22, 2010 - 12:00:43 AM (EST)

Objective: To estimate the relationship between quality improvement and electronic health record (EHR) adoption in US hospitals.

Study Design: National cohort study based on primary survey data about hospital EHR capability collected in 2003 and 2006 and on publicly reported hospital quality data for 2004 and 2007.

Methods: Difference-in-differences regression analysis to assess the relationship between EHR adoption and quality improvement for acute myocardial infarction, heart failure, and pneumonia care.

Results: Availability of a basic EHR was associated with a significant increase in quality improvement for heart failure (additional improvement, 2.6%; 95% confidence interval [CI], 1.0%-4.1%). However, adoption of advanced EHR capabilities was associated with significant decreases in quality improvement for acute myocardial infarction and heart failure. We observed 0.9% (95% CI, -1.7% to -0.1%) less improvement for acute myocardial infarction quality scores and 3.0% (95% CI, -5.2% to -0.8%) less improvement for heart failure quality scores among hospitals that newly adopted an advanced EHR, and 1.2% (95% CI, -2.0% to -0.3%) less improvement for acute myocardial infarction quality scores and 2.8% (95% CI, -5.4% to -0.3%) less improvement for heart failure quality scores among hospitals that upgraded their basic EHR.

Conclusions: Mixed results suggest that current practices for implementation and use of EHRs have had a limited effect on quality improvement in US hospitals. However, potential "ceiling effects" limit the ability of existing measures to assess the effect that EHRs have had on hospital quality. In addition to the development of standard criteria for EHR functionality and use, standard measures of the effect of EHRs on quality are needed.

(Am J Manag Care. 2010;16(12 Spec No.):SP64-SP71)

The paper is here:

http://www.ajmc.com/supplement/managed-care/2010/AJMC_10dec_HIT/AJMC_10decHIT_Jones_SP64to71

In passing it is worth noting this paper was one of a number on Health IT. A full list is here:

http://www.ajmc.com/supplement/managed-care/2010/AJMC_10dec_HIT

The paper caused a number of responses.

An early one is here:

Sunday, December 26, 2010

Study highlights 'lurking question' of measuring EHR effectiveness: The science in Medical Informatics is dead

The science in Medical Informatics is dead.

I'm not going to even use academic fabric softener in my assertion, e.g., "may be", "appears to be", or "is it?" (as a question) dead.

It's dead.

When HIT experts recommend changing the study goalposts when existing studies don't give results they'd like to see, rather than first and foremost critically and rigorously examining why we're seeing unexpected results, science is dead.

http://www.healthcareitnews.com/news/study-highlights-lurking-question-measuring-ehr-effectiveness

Study highlights 'lurking question' of measuring EHR effectiveness

December 22, 2010 | Molly Merrill, Associate Editor

WASHINGTON – Hospitals' use of electronic health records has had just a limited effect on improving the quality of medical care nationwide, according to a study by the nonprofit RAND Corporation.

The study, published online by the American Journal of Managed Care, is part of a growing body of evidence suggesting that new methods should be developed to measure the impact of health information technology on the quality of hospital care.

[In other words, we're not getting the results we thought and hoped we'd get with "Clinical IT 1.0", so let's alter the study methodologies and endpoints --- rather than using the results we have to identify the causes and improve the technology to see if we can do better with "Clinical IT 2.0."

Further, it's not as if there's no other data on why health IT might not work as hoped - ed.]

Most of the current knowledge about the relationship between health IT and quality comes from a few hospitals that may not be representative, such as large teaching hospitals or medical centers that were among the first to adopt electronic health records.
[This implies "other" "representative" hospitals are either not doing it right, or the technology is ill suited for them and may never work. Which is it? We really need to know before we proceed with hundreds of billions more in this "Grand Experiment" - ed.]

The RAND study is one of the first to look at a broad set of hospitals to examine the impact that adopting electronic health records has had on the quality of care.

The research included 2,021 hospitals – about half the non-federal acute care hospitals nationally. Researchers determined whether each hospital had EHRs and then examined performance across 17 measures of quality for three common illnesses – heart failure, heart attack and pneumonia. The period studied spanned from 2003 to 2007.

The number of hospitals using either a basic or advanced electronic health records rose sharply during the period, from 24 percent in 2003 to nearly 38 percent in 2006.

[How many billions of dollars diverted from patient care needs does that represent? - ed.]

Researchers found that the quality of care provided for the three illnesses generally improved among all types of hospitals studied from 2004 to 2007. The largest increase in quality was seen among patients treated for heart failure at hospitals that maintained basic electronic health records throughout the study period.

However, quality scores improved no faster at hospitals that had newly adopted a basic electronic health record than in hospitals that did not adopt the technology.

[In other words, the improvements or lack thereof had little to do with electronic vs. paper record keeping - ed.]

…..

Carl Sagan wrote that science is a candle in the dark in a demon haunted world.

It seems the demons are winning.

-- SS

Lots more here:

http://hcrenewal.blogspot.com/2010/12/science-in-medical-informatics-is-dead.html

Coverage also appeared here:

EHR upgrades no sure quality boost: RAND

By Joseph Conn

Posted: December 23, 2010 - 12:00 pm ET

Hospitals upgrading their electronic health-record systems might not see quality improvements as dramatic as expected, according to a newly released report on research funded through the RAND Corp.

The RAND researchers compared the levels of adoption of hospital EHR systems between 2003 and 2006 with their scores on selected clinical quality process measures for acute myocardial infarction, heart failure and pneumonia for those information technology-enabled hospitals and those without IT systems. The study period covered 2003 to 2007.

They concluded that availability of what the researchers defined as a basic EHR was associated with “a significant increase in quality improvement for heart failure” but conversely, adoption of an “advanced” EHR was associated with “significant decreases in quality improvement for acute myocardial infarction and heart failure,” according to a 16-page report, Electronic Health Record Adoption and Quality Improvement in U.S. Hospitals, based on research by the RAND Corp., published in the December issue of the American Journal of Managed Care.

“During the study period, the quality of care for AMI, heart failure and pneumonia was broadly improving,” the researchers said. “Heart failure quality scores improved significantly more among hospitals that maintained a basic EHR than among hospitals with no EHR.”

But, according to their research, “We did not observe a similar effect on AMI or pneumonia quality scores, nor did we find that adopting or upgrading an EHR accelerated quality improvement. Instead, our results indicate that new adoption or upgrade to an advanced EHR was associated with smaller gains in AMI and heart failure quality scores.”

Full paper here:

http://www.modernhealthcare.com/article/20101223/NEWS/312239996/

and here:

Study: The better care no guarantee with e-health

According to a recent U.S. study, hospitals that upgrade to electronic medical records may not necessarily have higher-quality medical care. The study was in the latest online issue of the American Journal of Managed Care that focused on a range of U.S. hospitals.

The 2,021 hospitals in the study represented half of the non-federal, acute-care hospitals in the U.S., researchers examining performance across 17 measures for three common illnesses such as heart failure, heart attack and pneumonia.

Spencer Jones, an information scientist at RAND, a non-profit research organization, and his co-authors reported that they had found significantly better care for patients treated for heart failure than the other two conditions.

Quality scores for heart attack improved no faster at hospitals, which used basic electronic health records compared to those that didn’t after reviewing data from 2003 to 2007.

The scientists reported numerous explanations for the mixed results, such as how adopting the technology may divert staff from other ways of improving quality, or how existing hospital quality measures may rise to a ceiling level and no higher.

Full article here:

http://shortcutgeek.com/study-the-better-care-no-guarantee-with-e-health/223825/

And last here:

EHR Effectiveness for Hospital Care Questioned

Cheryl Clark, for HealthLeaders Media , December 29, 2010

A large RAND study of nearly half the acute care hospitals in the U.S. calls into question the value of electronic medical records, saying that except for basic systems used to treat congestive heart failure patients, EHRs are not improving process of care measures for many large hospitals that have them.

"The lurking question has been whether we are examining the right measures to truly test the effectiveness of health information technology," says Spencer S. Jones, a RAND scientist and lead author for the report. "Our existing tools are probably not the ones we need going forward to adequately track the nation's investment in health information technology."

Jones and authors write that their "results should temper expectations for the pace and magnitude of the effects of the Health Information Technology for Economic and Clinical Health (HITECH) legislation. The challenges and unintended consequences of EHR adoption are well documented."

Federal aid amounting to $30 billion is stimulating a national push to adopt EHR in healthcare settings, but Jones' report says that data demonstrating that the technology improves quality comes from a few large teaching hospitals and may not be representative of hospitals at large.

The study looks at 17 process measures for three common illnesses, heart failure, heart attack, and pneumonia between 2003 and 2007. Also, the number of hospitals using basic or advanced EHR grew from 24% to nearly 38% during that period.

Those 17 process measures included whether clinicians gave aspirin to patients who arrived in the hospital with an acute myocardial infarction, an ACE inhibitor or ARB for left ventricular systolic dysfunction to patients with heart failure and an oxygenation assessment to patients admitted with pneumonia. The measures did not include any outcomes.

Quality of care at all hospitals improved overall regardless of whether they had EHR over this time, but with the exception of patients with CHF, it did not improve faster at hospitals with EHR than at hospitals without it.

"Adoption of advanced EHR capabilities was associated with significant decreases in quality improvement for acute myocardial infarction and heart failure," the authors write.

RAND used Health Information Management Systems Society survey data, which includes 90% of U.S. hospitals and includes clinical IT application implementation status, excluding hospitals that didn't disclose their software vendor. Hospital process measures were taken from Medicare's Hospital Compare.

Lots more here:

http://www.healthleadersmedia.com/print/TEC-260743/EHR-Effectiveness-for-Hospital-Care-Questioned

I suggest that people read the .pdf file which makes the tables much easier to understand and the whole paper easier to grasp.

For me, I worry about studies melding a large number of hospitals with varying systems being lumped together retrospectively to try and form conclusions based on information that is a few years out of date.

I am more comfortable assessing the outcomes when known systems are deployed in Randomised Controlled Trial like situations or similar as more trust can be placed on both the outcomes and the analysis. Not to say such work should not be done but it needs to be assessed very carefully.

Just how hard it can be to draw useful information from broad studies can be very hard. This recent paper highlights the issue.

Shahian DM et al. Variability in the measurement of hospital-wide mortality rates. N Engl J Med 2010 Dec 23; 363:2530.

The results, as reported, are interesting and do need careful analysis and ideally testing.

David.

Weekly Australian Health IT Links – 04 January, 2011.

Here are a few I found since the last post.

Note: Each link is followed by a title and a paragraph or two. For the full article click on the link above title of the article. Note also that full access to some links may require site registration or subscription payment.

General Comment:

Well I am not sure you missed much while you were away. Except for all the discussion on the overall directions for e-Health into the future - 30+ comments so far.

All are well worth a careful read, as are the follow-up posts and threads.

All the best to all for 2011!

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http://www.thepunch.com.au/articles/myhospitals-mychoice/

MyHospitals, MyChoice?

by

Tory Shepherd

Governments treat their employers (us) with such contempt.

They genuinely think we can’t handle the truth, that they need to control the information flow so our little heads don’t explode, or our little worlds implode.

No - not the Wikileaks saga. The MyHospitals debacle.

The Federal Government site is but a shell, a skeletal frame of information that will neither help consumers make decisions nor spark underperformers into action - let alone highlight where they’re underfunding.

What people want to know when going to hospital (assuming they’re in a fit state to wonder) is how long it will take to be seen, how good the care is, and what the risks are.

The current website tells them none of that. Sure, it’s good to be able to compare elective and emergency waiting times to a national average; that is, it’s good for us media types to see who’s falling behind.

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http://nehta.gov.au/e-communications-in-practice/emedication-management

e-Medication Management

Through e-Medication Management prescriptions may be securely transmitted direct from the GP's desktop to the dispensing pharmacy. Medication information is then securely available in a wide range of healthcare settings from hospitals to community health centres and pharmacies. This will result in an improved use of medicines and a reduction of the number of adverse medication events.

New Documents Published in the last week or so. See NEHTA site.

Also IHE has published new material in the same are in the last few days.

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http://www.itnews.com.au/News/242288,tender-released-for-electronic-health-record-system.aspx

Tender released for electronic health record system

By John Hilvert on Dec 20, 2010 9:33 AM

Filed under Strategy

Government seeks advice on benefits, trends.

The Australian Government has released a tender for consulting work prior to the roll-out of a personally-controlled electronic health record (PCEHR) system.

Issued as part of the Government's $466.7 million eHealth investment, the Request for Tender for the PCEHR system (RFT 217/1011) was welcomed by the Minister for Health and Ageing, Nicola Roxon.

"The successful tenderer will put in place the analytical and evaluation framework that will underpin the development of e-health records," Roxon said.

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http://www.computerworld.com.au/article/372068/sa_health_prescribes_cancer_information_system/?eid=-6787&uid=25465

SA Health prescribes cancer information system

The system is to replace multiple systems in a bid to save patients

• Hamish Barwick (Computerworld)
• 22 December, 2010 11:36

In an effort to improve patient safety, South Australia Health is looking to purchase a cancer information system (CIS) to be used in 13 hospitals.

Department documents state that cancer management within SA hospitals is performed through numerous disparate systems ranging from local patient admission systems to manual paper based record keeping.

“Drugs are ordered and formulated manually and the complex process of following standard treatment protocols is presenting a tangible risk to patient safety," the documents read. "A CIS has been proven with other hospitals to increase patient safety and improve operating efficiency."

-----

http://www.theaustralian.com.au/australian-it/government/ibm-health-ink-109m-ict-outsourcing-deal/story-fn4htb9o-1225975551096

IBM, Health ink $109m ICT outsourcing deal

• UPDATED Fran Foo
• From: Australian IT
• December 23, 2010 4:45PM

THE federal Health Department has extended its technology services agreement with IBM to the tune of $109 million.

The value includes a modification to the last 12 months of the existing contract.

The contract renewal is further proof that Health and IBM are joined at the hip -- no other IT company was invited to tender for the business, a procurement process dubbed direct sourcing.

Health was especially concerned new vendor agreements could have an adverse impact on the Gillard government's health reforms.

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http://www.smh.com.au/national/timing-change-will-fix-health-problem-20101220-1935r.html

Timing change will 'fix' health problem

Julie Robotham HEALTH EDITOR

December 21, 2010

EMERGENCY doctors will clock the time between patients arriving in an ambulance and the hospital taking over their care, in a move expected to put a more favourable gloss on the politically sensitive measure before the state election.

The so-called off-stretcher time, which varies greatly between hospitals, reflects how crowded emergency departments are because paramedic crews must stay with patients until they are triaged or treatment is begun.

Under a new system beginning early next year, hospital staff will record the time the patient is transferred to a treatment bay. This will replace the current system, which records the time the ambulance crew report they are ready to respond to another call, and means average off-stretcher time will be shorter.

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http://www.e-health-insider.com/news/6521/isoft_makes_move_on_life_sciences

ISoft makes move on life sciences

21 Dec 2010

ISoft has signed a marketing agreement with US company, CliniWorks, to market its AccelFind software to organisation and hospitals across the world.

The companies say the software enables users to extract and de-identify medical knowledge from any type of data, including free text notes, discharge summaries or structured data such as those stored in electronic records or lab systems.

The agreement will see iSoft provide AccelFind as part of its Life Sciences solution, under the ‘Powered by CliniWorks’ banner.

ISoft’s director for life sciences, Dr Joerg Kraenzlein, said: “This is a tremendous opportunity to accelerate clinical research in a so far unprecedented way.

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http://www.e-health-insider.com/news/6530/isoft7_reach_%C2%A325m_agreement

ISoft7 reach £25m agreement

23 Dec 2010

The seven “out of cluster” trusts in London and the South of England that signed a deal with CSC and iSoft to keep their patient administration systems have reached an agreement to continue with their contracts.

Letters of intent from the trusts - known as the iSoft7 - have been received by both CSC and iSoft. They confirm the trusts’ plans to continue running iSoft’s iPM out of CSC’s datacentre until 2016.

The trusts that have iCM will also have their licences and maintenance extended to a similar timescale.

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http://www.e-health-insider.com/news/6524/morecambe:_lorenzo_starting_to_stabilise

Morecambe: Lorenzo starting to stabilise

22 Dec 2010

The director of service and commercial development at University Hospitals of Morecambe Bay NHS Foundation Trust has said Lorenzo is “starting to stabilise” seven months after go-live.

Patrick McGahon told E-Health Insider in a statement that more than 180 fixes to key functionality have taken place over the past six weeks and that fixes would continue until spring 2011.

“Staff who use Lorenzo have seen improvements in general usability across the various areas. The system is now starting to stabilise and improvements are continuing to be seen.”

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http://www.theage.com.au/technology/technology-news/price-shock-looms-for-some-on-nbn-20101220-1937l.html

Price shock looms for some on NBN

Clancy Yeates

December 21, 2010

SOME households could be forced to pay more for a basic internet service when they are compulsorily switched over to the $36 billion national broadband network, according to the business plan released yesterday by NBN Co.

The long-awaited plan predicted that households will have to pay between $53 and $58 a month for the most basic entry-level offering - compared with today's ''naked ADSL'' plans that start at about $30.

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http://www.heraldsun.com.au/ipad-application/state-government-looks-to-scrap-troubled-myki-smartcard/story-fn6bfkm6-1225976850649

State Government looks to scrap troubled myki smartcard

• Ashley Gardiner
• From: Herald Sun
• December 28, 2010 12:00AM

THE State Government has frozen the expansion of myki as it considers whether to scrap the troubled smartcard.

The Herald Sun can reveal the new Government has put the brakes on the planned introduction of myki to V/Line regional services.

It has also ordered the abandonment of plans to switch off the existing Metcard by Easter.

A system for commuters to top up their accounts through bus drivers has also been halted.

The Government has commissioned a major accounting firm to conduct a broad audit of the troubled $1.35 billion smartcard.

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http://www.computerworld.com.au/article/371841/government_releases_nbn_business_plan/?eid=-6787&uid=25465

Government releases NBN business plan

A basic feed from the NBN will cost telecommunications wholesalers $24 a month, the federal government has revealed.

• AAP (AAP)
• 20 December, 2010 13:12

A basic feed from the National Broadband Network (NBN) will cost telecommunications wholesalers $24 a month, the federal government has revealed.

Communications Minister Stephen Conroy released the long-awaited NBN business plan in Canberra today.

The basic plan will offer download speeds of 12 megabits per second and upload speeds of one megabit per second.

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http://www.computerworld.com.au/article/371838/nbn_viable_says_gillard/?eid=-6787&uid=25465

NBN is viable, says Gillard

Prime Minister Julia Gillard says the business plan for the NBN proves that it will be both viable and affordable.

• AAP (AAP)
• 20 December, 2010 12:57

Prime Minister Julia Gillard says the business plan for the national broadband network (NBN) proves that it will be both viable and affordable.

The federal government released the long-awaited business plan today, which has been with Communications Minister Stephen Conroy since early November.

Gillard said the plan confirms the NBN will be delivered at a smaller cost than originally thought.

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http://www.smh.com.au/business/broadband-network-business-plan-to-be-released-in-full-20101219-191yk.html

Broadband network business plan to be released in full

Lucy Battersby

December 20, 2010

THE government is expected to release the full business plan for the $36 billion national broadband network today.

The plan will outline assumptions about the network's viability, how many people are expected to use it, and how profitable it will be.

A cut-down 35-page version of the plan was released last month to help secure votes from independent senators for new telecommunications legislation, but it failed to impress both investors and the federal opposition.

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http://www.theage.com.au/world/youve-seen-the-movie-now-try-the-gadget-20110101-19cle.html

You've seen the movie, now try the gadget

January 2, 2011

Times are changing and Hollywood sci-fi dreams are becoming a technological reality. Stephen Cauchi finds out which big screen fantasies are now fact.

BLADE Runner, a film set in 2019, features flying cars zipping over a dystopian Los Angeles. Sometime between now and 2029, according to the Terminator films, artificially intelligent robots will battle humans for world supremacy. And in 2054, according to Stephen Spielberg's hit Minority Report, police will be able to predict crimes before they happen.

These scenarios are unlikely to be realised, at least in the timeframe suggested by the films. But a review of this year's technological achievements show that at least some gadgets that were once the sole preserve of a sci-fi writer's imagination are becoming reality.

Great fun!

-----

Enjoy!

David.

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.