Health IT in NSW – Can it Go Much More Slowly?

Health IT in NSW has a long a proud tradition of glacial progress that extends all the way back to the 1980’s. Rather than run through all that history – which will be grist for another article in the future maybe – we should just consider the last few years.

Ministerial press releases make a fun retrospective! The circularity and repetition (a colleague would call it “Brownian Motion”) is just hilarious.

Let’s start in 2001. (My comments in italics)

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

Electronic health records - better care, your choice

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

The Minister today released a report into the privacy implications of the proposed system - Panacea or Placebo? Linked Electronic Health Records and Improvements in Health Outcomes - from the NSW Ministerial Advisory Committee on Privacy and Health Information, chaired by NSW Privacy Commissioner Chris Puplick.

The report explores the scope of electronic health records and how they can be implemented with an assurance of security and confidentiality. Following its release the public is being asked to comment on the recommendations.

NSW is leading the nation in its development of the electronic health record system.
Only patients who actively agree will have an electronic health record.

Mr Knowles said there were many advantages for patients who wanted this service.

"If you need to have multiple admissions to hospital it will be much easier for the treating doctors to have access to your records. This will greatly reduce the burden of repeating information many times and the risk of mistakes about, for example, which drugs a patient is taking, allergies or pre-existing medical conditions which could affect current illness or treatment," Mr Knowles said.

"Health record privacy is our top priority. A unique identifier system will help ensure access is strictly limited to authorised medical staff only.

""Of course, patients will have ultimate control. They can ask for the service, they can stop the service. To ensure the integrity of the system, patients will be able to get information about who has accessed their health records and when," Mr Knowles said.

The first stage of the electronic health record system is expected to start later this year.”

This was the first manifestation of Healthelink. Now six years later it is still in trial in two small areas and all the work done to decide the approach to privacy was overturned in 2005 as I recall. This was announced by the (Health Minister -4) (i.e. the fourth most recent Health Minister).

In late 2001 we had the release of the point-of-care clinical system (PoCCS) which was planned to support the clinical care process by enabling the doctor, nurse or allied health professional to:

· Record care where and when it is delivered

· Review progress and order treatment or tests from any workstation

· Continually review results and outcomes and alter care as required

· Be prompted with alerts and allergies at time of ordering

· Generate a clinical pathway or care plan to prescribe care for the patient's length of stay in hospital

· Monitor progress on the clinical pathway and record variances to analyse outcomes

· Utilise decision support at the time of ordering and on review of clinical outcomes

· Measure patient acuity to determine the intensity and complexity of care required and given

· Generate discharge referrals with automatic population of data from relevant systems e.g. radiology, pathology

The tender closed in February 2002 and after evaluation (which took a while) a selection was made (Cerner) and some implementations were begun in 2003 I understand.

Flashing forward to late 2002 it was all obviously getting too hard – so the retreat was made to paper.

Health Information - For The Record

Wednesday December 4, 2002

Health Minister Craig Knowles today launched the 'My Health Record' scheme, an initiative encouraging people to condense their medical information in one location to avoid confusion, time and expense when seeking medical treatment, and to increase the chances of a faster recovery.

An Australian first, the comprehensive 'My Health Record' booklet is being made available to more than 20,000 people in New South Wales who suffer chronic illnesses such as heart disease, respiratory disease and cancer.

Over the next 12 months, copies will be widely available to all people who frequently receive medical attention.

A centrepiece of the governments $45 million dollar Chronic Illness program, 'My Health Record' is available from local Doctors, hospitals and health centres for free. It includes pages and plastic sleeves where patients can voluntarily record dates and times of GP and hospital visits, diagnostic test results, procedures, medications taken, allergies and emergency contact numbers.

"For the first time we have a far-reaching scheme encouraging people to track their medical history and have the information at hands reach," Mr Knowles said.

"This is invaluable for better health outcomes, especially for people who seek treatment from multiple providers including doctors, hospitals and pharmacists on an ad hoc basis."

Chair of the NSW Chronic Illness Program, Professor Ron Penny, said the scheme was designed to ensure patients receive the most appropriate management of their condition at all times.

"It's about 'getting it right' early and ensuring patients are provided with continuity of care," Prof Penny said.

"It's an example of how we can reduce pressures on the health system by ensuring patients avoid unnecessary admissions and benefit from coordinated health care.

"Importantly, patients will no longer need to repeat their medical history over and over."

Mr. Knowles said almost one in five people admitted to NSW public hospitals (in 1999/2000) suffered chronic conditions including cancer, heart disease, asthma, arthritis, stroke and diabetes.

The admissions equate to 36% of total public hospital bed days, and cost $1.1 billion.

"'My Health Record' is a simple, cost effective program focussing on managing illness before it develops into a crisis," Mr Knowles said.

Obviously handling the information electronically was just too hard so this seemed like the next best option. Time moves on and suddenly we see Healthelink re-launched! (3 years later)

Minister launches Healthelink to put health records online

16 May 2004

NSW patients and parents of children in medical care will soon be able to log on to the internet and view their comprehensive medical histories following the signing of a contract to establish two pilots for an electronic health record system for NSW.

Minister for Health Morris Iemma, today announced the commencement of the groundbreaking $19.4 million program to put patients' medical records online.

The Health e-link will for the first time in NSW give GP's, specialists, emergency department clinicians and allied health workers online access to their patients' detailed medical histories and to the most up to date information on their treatment and medication.

"The Health e-link system will make our health system safer and more efficient, by making sure that clinicians all have access to the same information about their patients' medical histories," Mr Iemma said.

"Tests won't have to be repeated unless absolutely needed, nor will patients and carers have to recall from memory all aspects of care they received in the past.

"This new system means that whenever a patient visits the local doctor, the emergency department or a specialist all members of the health care team will have access to the same records.

"Illegible and incomplete hand written medical records can lead to mistakes being made and these are removed in Health e-link," Mr Iemma said.

The Minister said the system, which will be piloted at the Children's Hospital at Westmead and at Maitland and Raymond Terrace in the Hunter, will also provide patients with unprecedented access to their own medical records.

The electronic health record will include information on:

• Family history
• Allergies and alerts
• Medical and surgical history
• Procedures performed (pathology and radiology)
• Diagnostic results
• Multidisciplinary care plans

"In our health system, care is often not delivered by a single clinician," Mr Iemma said.

"Currently medical records are mainly stored physically in separate systems across hospitals, emergency departments, GP clinics, community health and outpatient clinics, diagnostic units and specialists' rooms," Mr Iemma said.

"So a clinician only has access to medical records that are physically stored in their own rooms and access for patients is extremely limited.

"The Health e-link system will allow clinicians and patients to log on and see all of their medical records, ranging from GP visits, prescriptions issued, blood test results, x-rays and hospital discharge notes," Mr Iemma said.

The Health e-link will likely result in:

• Greatly enhanced co-ordination and timeliness of care
• Less likelihood of adverse drug reactions due to unknown allergies
• Fewer diagnostic tests being unnecessarily repeated

Mr Iemma said that a consortium led by LogicaCMG, and including Orion International and Healthlink, had been selected to work with NSW Health to commence the pilot with a view to deliver a state-wide electronic health record system.

The first groups to participate in the pilot are

• Children aged 0 -15 accessing the public health system in the South Western Sydney, Wentworth and Western Sydney Area Health Services
• Chronic disease patients in Maitland and Raymond Terrace

Mr Iemma stressed that Health e-link has in-built security systems to ensure patient privacy and confidentiality.

Information will be password protected and each patient will have a unique patient number, individuals would only be able to access their own personal information.

Participation in the pilot will be voluntary.

The NSW Health e-link project is also a trial site for the national electronic health record system, HealthConnect, along with Tasmania, Queensland, South Australia and the Northern Territory.

Mr Iemma called on the Federal Government to make a genuine commitment to funding this program in NSW, citing the fact that Tasmania and South Australia have received generous grants as a result of Medicare Plus negotiations in the Senate, but not NSW or other states.”

Of course, as is well known, somehow the consent rules changed and rather than opt-in an opt-out approach was adopted. Of course, after another two years and now up to Health Minister – 2 the trial gets announced again – now five years after the initial launch!

Trial of Electronic Health Records

23 March 2006

Healthelink, the first NSW pilot of a revolutionary electronic health records system to improve patient care and speed up treatment, begins in the Hunter today.

NSW Minister for Health, John Hatzistergos, said the project will involve the secure collection and storage of eligible patients’ health information from Maitland Hospital, John Hunter Hospital, East Maitland and Raymond Terrace community health centres.

"Electronic health record systems will provide health care professionals with the medical patient information they need, when they need it,” Mr Hatzistergos said.

“This will make a big difference for patients and health-care staff - providing instant access to a patient’s records without having to contact their GP or wait for paper records to be retrieved.

“The Electronic Health Record has exciting potential: to unclog delays in the system and improve safety for patients.

“The information will be displayed in an electronic health record accessible by the patient and participating healthcare providers.

“That means, for example, that an emergency department specialist could quickly access a patient’s care details from other public hospitals or community health centres – giving them more information to provide better care.

“It also means that when the patient later visits their GP, the doctor can access vital information from the hospital about their treatment and condition. Hospital discharge summaries and patient test results will also be accessible through the system,” Mr Hatzistergos said.

“This is the first stage of the trial, in the next stage GPs will also be able to enter patient information into the system as well as being able to view records from hospitals.

Healthelink will initially be available for people aged 65 years and over living in the Maitland and Raymond Terrace areas – postcodes 2320 to 2324.

"Privacy and security have been a key focus during the development of the system and will continue to be our highest priority in the trial.

“All patient information will be held in a secure password-protected environment and in accordance with health privacy laws.

“This Healthelink pilot is completely voluntary, anybody who does not wish to take part will be able to opt out easily.

"The revolutionary pilot will test how well the Electronic Health Record will assist doctors and nurses in real-life healthcare situations, and we hope to learn from its use here in the Hunter,” Mr Hatzistergos said.

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

Well that is a far as the Healthelink saga goes so far – the trial has been underway for 15 months and tenders have been called to evaluate what we got for the $19.5 million. (This is to be completed by the end of 2007) Of course in the mean time HealthConnect has largely vanished and broad implementation of Shared Electronic Health Records – under NEHTA’s guidance – is not seemingly proceeding apace with a business case not due until 2008 or 2009.

Moving back in time just 10 months we note that despite the 2002 PoCCS tender there have been some delays and problems. To fix this a new tender was released. The background is as follows

“In February 2002, the Department issued a Request for Tender (RFT) for a Point-of-Care Clinical System (RFT IT-135). As a result of this tender, Cerner Corporation’s Millennium software was made available to Area Health Services (Area(s)) via a period purchasing deed of agreement. A number of Areas are currently implementing the Cerner Millennium product.

The purpose of this tender process (RFT IT-190) is to evaluate current market offerings with a view to selecting a second EMR solution in order to provide remaining Areas with an alternative EMR product thereby providing a competitive environment.

The Department is conducting this tender process (RFT IT-190) to evaluate Tenderers capable of supplying the required EMR, that are willing to enter into a period contract with the NSW Department of Health for the implementation of an EMR in a number of the NSW Area Health Services in line with the requirements of this RFT.

Potentially four Areas could be seeking EMR implementations through the period contract arrangements resulting from this RFT. These are South Eastern Sydney Illawarra, Hunter New England, Greater Southern and Justice Health” (Quoted from 2005 Tender).

Here is the press release

Patients to benefit from online access to medical records

30 May 2005

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

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

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

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

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

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

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

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

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

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

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

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

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

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

As we now know the second tender got nowhere!

Electronic Medical Record Tender Closes with no vendor meeting all requirements

09 February 2006

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

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

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

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

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

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

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

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

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

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

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

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

And to come full circle we now have an article in the Financial Review telling us the following – and revealing just how long it has taken to work out what to do after the failed tender:

http://www.misaustralia.com/viewer.aspx?EDP://20070720000019155824&magsection=news-headlines&portal=_mis&title=NSW+e-health+system+to+log+on+in+2008

NSW e-health system to log on in 2008

Renai LeMay

The Australian Financial Review | 20 Jul 2007 | Information

The NSW government's $40 million computer project to eliminate paper patient records in public hospitals is gathering speed.

NSW Health's area divisions are currently ramping up preparations for the project, with implementation of US health giant Cerner's technology scheduled to take place from early next year.

The project, in the works since 2002, will give NSW's 84,000 medical staff electronic access to millions of patient clinical records and test results across more than 180 public hospitals.

It is one component of the $300 million that NSW has allocated to public e-health until 2009.

The South-Eastern Sydney & Illawarra Area Health Service (SESIHS) will be one of the first divisions within NSW Health to try the technology. The division's chief information officer, Jean Evans, told The Australian Financial Review that St George Hospital in the Sydney suburb of Kogarah would be the first to receive the new systems in March next year.

Sutherland Hospital will follow soon after, with the division to implement the new computer systems within all of its 19 hospitals by the end of 2008.

"We're not the only area, but we're the first one to go with the full functionality," Ms Evans said. The entire state-wide system is due to be completed in 2009.

….. (see the full article at URL above)

I think it is fair to say that the progress in all this can only be characterised as glacial and essentially incompetent. It simply should not take this long to get reasonable Health IT Support into our major hospitals.

I really wonder how all these slow-coaches sleep at night considering the number of preventable clinical errors and deaths they are failing to prevent by moving at their present snail’s pace!

David.

Useful and Interesting Health IT Links from the Last Week – 22/07/2007

Again, in the last week, I have come across a few reports and news items which are worth passing on. This week it seems to be, at least in part, to be follow-ups of last weeks finds

These include first:

The news that IBA seems to have been ‘pipped at the post’ in its purchase of iSoft. The best coverage I could find of the new plans comes from Forbes Magazine in the US.

http://www.forbes.com/markets/2007/07/20/isoft-compugroup-nhs-markets-equity-cx_po_0720markets19.html

An iSoft Landing For The NHS
Parmy Olson, 07.20.07, 2:02 PM ET

LONDON - Though often a slow and lumbering affair, Britain's National Health Service prides itself on offering free health care to anyone who needs it. A noble sentiment, but keeping the institution running is agonizingly complicated, and software companies like iSoft have been commissioned to help grease the wheels.

Isoft (other-otc: ISFGF - news - people )has been key to a £6.2 billion ($12.8 billion) upgrade of the NHS computer system, but it has fallen foul of investors in the past few years thanks to accounting indiscretions in 2004 and 2005. Last year, the British software firm, which makes hardware and software systems for hospitals, booked a £344 million ($707.5 million) loss.

Now it's just been swallowed up by a German software company that is paying a 18.9% premium over another offer by an Australian suitor. So enamored is iSoft with the bid by Koblenz, Germany-based CompuGroup that its chairman and acting chief executive, John Weston, said the company had "no hesitation" in recommending the 66 pence per share ($1.36), £160 million ($329 million) all-cash offer.

Shares in iSoft jumped 10.25 pence (21 cents), or 18.7%, to 65 pence ($1.34) in Friday afternoon trading in London, just below the bid price, suggesting that investors don't see a counterbid on the horizon. The deal is roughly two times iSoft's revenues, which is about average for health care software deals. IDX, another struggling software company contracted by the NHS, was acquired by General Electric (nyse: GE - news - people ) subsidiary GE Medical in 2006 for $1.2 billion, or twice revenue.

…..( see the URL above for full article)

As regular readers will know I hold a few IBA shares and was slightly surprised to see the share price rise almost 3% in the absence of any news or announcement from IBA on this to the Australian Stock Exchange on Friday.

Information appeared in the UK press late in the afternoon (16:53 July 20, 2007) that this new offer had been made and with Sydney being nine hours ahead of the UK at present was available early Saturday morning here. Certainly the breaking news section of the Sydney Morning Herald had it at 8:15 am on Saturday. It seems the information might just have leaked a little earlier to some market insiders. We will never know I guess. Of course the rise could also relate to UBS buying a greater than 5% stake in IBA the day before (19 July).

It will be interesting to see how all this plays out – given that the IBA offer has already been approved by iSoft shareholders. We will just have to wait and watch!

Late news is that the deal will result in IBA collecting a £1.3m break fee ($A3.00M) but iSoft shareholders are likely to conclude that it is money well spent says another piece of commentary that can be found here:

http://business.timesonline.co.uk/tol/business/industry_sectors/technology/article2110792.ece

It will be very interesting to see what is announced before the ASX opens tomorrow at 10am.

Still $3.0M should help defray some of the costs of the bid!

Second we have:

http://www.cio.com.au/index.php?id=1320293134&eid=-601

E-Health Starts with The Patient

The best way to implement an e-health project is to involve users from the start, and to make the patient the centre of things, says a former Saudi CIO soon to visit Australia.

Sue Bushell 19 July, 2007 10:48:49

The best way to implement an e-health project is to involve users from the start, and to make the patient the centre of things, says a former Saudi CIO soon to visit Australia.

Bassam A Al-Kharashi, deputy director general sales, marketing & business development for the Sultan Bin Abdulaziz Medical & Educational Telecommunications Program says making patients the priority has been key to the success of a major business process transformation effort underway at the 220-bed King Khaled Eye Specialist Hospital.

"(In starting this project) we looked at our customer, which is the patient, and we asked ourselves why the patient comes to hospital, comes to see a doctor. The doctor has to provide health-care, provides services to the patient.

"So we need to start with these two entities, the patient systems, and human resources because the physician is part of the human resources system. And from there we move into the other systems - the finance - and we go through the cycle of the patient - why the patient comes, and then what kind of services that help them. It makes a big difference," Al-Kharashi says.

…..( see the URL above for full article)

An interesting article showing two things. First that it is a sound approach in implementing Health IT to implement systems in a way that is optimised to support the hospital’s business processes and second just how the Saudi Health System has been improved taking advantage of all those oil dollars.

Third we have:

http://www.misweb.com/magarticle.asp?doc_id=24882&rgid=2&listed_months=0

A health-e start
By Claire Doble • Published: Monday, 1 August 2005

The vast potential benefits of IT in health care are matched only by the challenges of implementing technology in such a complex environment. Claire Doble examines Australia's burgeoning e-health sector.

One day, your mobile phone will tell you to go and see a doctor. When you arrive at the medical centre, a nurse will usher you into a sensor room that checks your temperature, heart rate, blood pressure, and other vital signs.

By the time you get to see Dr Jones, all the information just collected, as well as pertinent medical data from throughout your life, will be at her fingertips - wirelessly transmitted from a national database, your phone and the sensor room into her PC.

You may need to provide a DNA sample so that she can access the confidential parts of your file, but it will all be available. Dr Jones may not even be in the room with you, she may be treating you through a virtual patient care unit that has screens and sensors to give her all the information she would have if she was standing right there.

It turns out you need minor, keyhole surgery, so she does it straight away, with the aid of lasers and a virtual simulator at her end. When it's all over, you walk away, slightly tender, with a prescription and an extra application loaded on your mobile to monitor your post-op condition, which will electronically alert you, Dr Jones and the clinic if anything seems to be going awry.

The above scenario may still sound like science fiction, but some of it should become a reality in the next few years, and the virtual patient care concept is already in practice today. Electronic health, or e-health, is one of the next frontiers of ICT innovation.

The shift to e-health encompasses all the potential business benefits that made ICT solutions so crucial to the enterprise - it will save money, reduce errors, get results, speed delivery of critical units, and free skilled workers from menial tasks so they can concentrate on doing the important things better.

…..( see the URL above for full article)

This is a fascinating browse to see the optimism of virtually two years ago in terms of what was hoped for from NEHTA and e-Health. I leave it as an exercise for the reader to browse and consider how far we have actually come in the last two years.

Fourth we have:

Last week I pointed out this article.

http://archinte.ama-assn.org/cgi/content/short/167/13/1400

Electronic Health Record Use and the Quality of Ambulatory Care in the United States

Jeffrey A. Linder, MD, MPH; Jun Ma, MD, RD, PhD; David W. Bates, MD, MSc; Blackford Middleton, MD, MPH, MSc; Randall S. Stafford, MD, PhD

Arch Intern Med. 2007;167:1400-1405.

Interestingly we now have a article reviewing all sorts of comments on the real meaning of the report:

http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20070718/FREE/70718003/1029/FREE

Vendors dispute EHR, ambulatory-care report

By: Andis Robeznieks / HITS staff writer

Story posted: July 18, 2007 - 10:54 am EDT

A report detailing how the use of electronic health records does not necessarily lead to an increase in the quality of care may be misinterpreted by some as proof that EHRs aren’t useful. EHR vendors, consequently, are concerned.

"It's caused quite a bit of discussion in our industry—to say the least," said Hugh Zettel, director of government and industry relations for GE Healthcare. "We don't believe the reporting on it has been accurate relative to the findings of that paper."

The report, Electronic Health Record Use and the Quality of Ambulatory Care in the United States, appeared in the July 9 edition of the Archives of Internal Medicine, and concluded quite bluntly that: "As implemented, EHRs were not associated with better quality ambulatory care."

Written by prominent health information technology figures from Harvard Medical School and Stanford University, the study examined records of 50,574 patient visits collected as part of the National Ambulatory Medical Care Survey in 2003 and 2004, and compared how physicians with and without EHRs did on 17 quality measures. The researchers concluded that EHR-using physicians had significantly better scores on only two quality indicators, had no significant difference on 14, and did significantly worse performance on one.

…..( see the URL above for full article)

The article provides some interesting perspectives on the negative findings of the study. My feeling is that without real detail as to the capabilities and methods of deployment of the systems being assessed it is very hard to draw any firm conclusions. Some well planned and executed studies are needed in the real world – given the data from leading users at advanced centres is quite clear regarding benefit.

The impact of implementation of advanced systems in a “real world” environment really needs to be settled once and all.

Fifth we have:

http://www.hhnmag.com/hhnmag_app/jsp/articledisplay.jsp?dcrpath=HHNMAG/Article/data/07JUL2007/0707HHN_CoverStory&domain=HHNMAG

Cover 2007 Most Wired

Ten Lessons from the Top 100
By Alden Solovy

One thing is certain: Technology is part of the process of improving care

The nation’s 100 Most Wired Hospitals and Health Systems have better outcomes than other hospitals on four key measures: mortality rates, the Agency for Healthcare Research and Quality’s patient safety measures, the Joint Commission’s Core Measures and average length of stay. This is the strongest evidence in the nine-year history of the survey of an association between the implementation and adoption of information technology and the quality and cost of patient care.

Although the analysis is compelling, chief information officers and researchers are quick to point out the limitations. The research shows that, in general, hospitals with good quality results are also dedicated to information technology. It does not show that IT caused those benefits.

“These initiatives are a combination of people, process and technology, not just technology alone,” says Mike Alverson, acting CIO, Texas Health Resources, Arlington, which makes its eighth appearance on the Most Wired list in 2007 and is an Innovator Award finalist. “Health care IT is a team sport.”

Analysts point out two general caveats to the outcomes research. First, information technology is one of many tools for achieving process improvements that lead to better outcomes. It must be used in conjunction with other tools and techniques to have an effect on care. Second, the analysis shows an association between IT adoption and key quality measures, but association is not causality. (See sidebar, “A Higher Standard”)

One thing is certain: like much of health care, CIOs and other senior executives at the nation’s Most Wired hospitals use technology as part of the process of improving care. They have measured the benefits of these changes. Disentangling the gains from using high-tech tools from the value of a skilled staff and better processes isn’t even of interest.

How are the Most Wired achieving their results? What are they doing to make technology part of their process improvement plans? Here are 10 lessons from this year’s benchmark group of top hospitals.

…..( see the URL above for full article)

The lessons provided in this long article are well worth considering carefully.

Lastly we have:

http://www.smartcardalliance.org/articles/2007/07/11/gemalto-to-deliver-35-million-e-health-cards-for-german-citizens

Gemalto to Deliver 35 Million e-Health Cards for German Citizens

Latest generation of patient cards will be produced in Gemalto’s site in Filderstadt near Stuttgart.

Amsterdam, the Netherlands, July 11, 2007–Gemalto (Euronext NL0000400653 GTO), the world leader in digital security, today announces it has been awarded the tender held by insurance organization AOK (Allgemeine Ortskrankenkasse) to supply and personalize e-health-cards for their insured in Germany. The contract win comes after Gemalto took part in Germany’s first healthcare pilot program based on highly secure microprocessor cards.

Gemalto’s new advanced digital healthcare solution will avoid duplicate examinations and therefore lessen unnecessary use of healthcare services. In addition, the new health card will be able to carry electronic prescriptions, which will reduce significantly paperwork. Finally, by allowing data update once the card is in the field, the new system enables insurance funds to potentially adjust their cost of ownership.

Gemalto’s latest-generation card will also act as an active security device to perform strong authentication of the patient therefore contributing to reducing fraud costs and increasing privacy. It will enable secure access to an electronic medical file that will include emergency data such as blood group, allergies alerts and ongoing treatments records. Authorized healthcare professionals can read personal information only if the patient consents by entering the card’s Personal Identification Number.

“Gemalto has been a long term partner to health insurance companies since the first generation of health cards back in the mid 90s’. We are proud and honored by the decision of AOK to get us to contribute massively to this program by providing German citizens with enhanced security and privacy management devices.” commented Jacques Seneca, Executive Vice President, Security Business Unit at Gemalto. “The quality of our product developed in our Munich R&D center, the capabilities and flexibility of our production and personalization site in Filderstadt near Stuttgart, as well as our high level of commitment to this project have provided us with a strong competitive advantage when it comes to meeting the stringent requirements of rapid large-scale deployments such as this.”

This new reference strengthens Gemalto’s positioning in the healthcare sector, following previous achievements in Algeria, Belgium, China, Finland, France, Mexico, Puerto Rico, UK, USA and Slovenia.

Note to editors

The health program the German government is launching involves 80 million patients, 350,000 doctors and dentists, 2,000 hospitals and 22,000 pharmacies.

The German health service is highly decentralized, with some 250 different insurance companies, each having their own infrastructure and supply process. The health insurance plans are either state-regulated or private. Around 90 percent of the population is covered by the state health insurance and the rest opt for private medical insurance. State health insurance beneficiaries do not have to pay for the visit to their doctor, nor for their medication (apart from a small fixed fee).

With the current system, insurance funds need to issue their customers with a new card whenever their administrative data change, whereas the microprocessor card-based system allows updating the information once the card is in the field, thus reducing operational costs. The electronic health card will carry the prescription and should make about 700 million handwritten prescriptions per year redundant.

…..( see the URL above for full article)

This provides an interesting insight into a very large “Access Card” like project which seems to be off and rolling in a much better way than the current initiative on this side of the world. Note the EHR and prescription functionality that is planned.

All in all some great reading to start the week!

More next week.

David.

David Agrees with Dr Ian Reinecke – Readers Faint over their Weeties!

A day or so ago the following article appeared:

“Health resists IT, sticks to the script

John Breusch

The Australian Financial Review | 18 Jul 2007 | News

This country's health sector is looking like the last bastion of the old-fashioned paper trail, writes John Breusch.”

In the article the views of a number of commentators are reported. Sadly the reporting really does not live up to the expectations AFR readers have for insight into what they are being told. The general flow of the article is fine.

First it points out that there are simple health transactions that have yet to be computerised and notes that in virtually every other aspect of the ordinary citizen’s life has been impacted, usually quite positively by the deployment of Information Technology and the Internet.

The article then goes on to say:

“Everyone can see the extraordinary benefits that connectivity could deliver. After all, health care isall about knowledge: patients, doctors, nurses, hospitals and researchers all sharing information about what's wrong, how things are tracking and what needs to be done."

It is just after here that the wheels start to come off.

It is claimed that, on the basis of a” recent study by Michael Georgeff, director of e-health at the Monash Institute of Health Services Research, estimates that, in the field of chronic disease management alone, better information sharing could deliver benefits worth some $4 billion a year.”

This is a big call and it is hard to imagine a credible case for that scale of benefit can be put in a 19 page document (which is all it is)!

Further on in the article it is also claimed that a structured approach to reaching these benefits is not required. All that is needed is to connect everyone and that "The key message: don't spend time getting agreement on the data, don't spend time ensuring all the systems conform - get connected,"

I have to say that when Dr Reinecke says that we need rather ‘cooler heads’ to assess all this then I am 100% with him. He makes the point, correctly that the internet has been around for a good while and working e-health has not suddenly emerged out of nothing.

I am afraid Professor Georgeff – the director of the one man e-health unit of the Monash Institute of Health Services Research - simply does not appreciate the complexity of dealing with, communicating and safely processing health information.

I have a feeling that now Dr Reinecke has been at NEHTA for over two and a half years he, and his team, are starting to come to grips with just how hard and complex all this actually is.

E-Health in Australia does not need silly proselytising of unsupportable views about the self organising nature of E-Health – rather it needs clear pragmatic strategic planning and implementation.

Where I part ways with Dr Reinecke is his apparent belief you can develop a business case for the introduction of an (National Shared) EHR, which is apparently scheduled to go to the Council of Australian Governments (COAG) meeting next year (2008) without a clear definition of what the systems you are proposing are and what their capabilities need to be both centrally and our peripherally in the health system.

To date NEHTA’s studious avoidance of in depth engagement with the GP and Specialist Community leads me to think the capabilities and functionality required for these people has slipped well and truly under the radar. I hope I am proved wrong and that what is finally produced in the way of a business case is both complete, compelling, implementable and affordable. We will see in due course how on track their thinking is when the now rather delayed NEHTA Benefits Study is finally released in more detail than a few PowerPoint slides.

It also would have been good had the AFR done some more in-depth research to better understand the issues before going to print.

David.

Previous Boston Consulting Group Report on Australian E-Health (2004)

For those that would like to review the earlier BCG E-Health Report – which does not seem to be readily available on the web the following links should be helpful.

Main Report

Appendices

Have an enjoyable read to see how much has not really changed!

David.

Publish Your Submissions to the BCG NEHTA Review

As all those reading here are very likely to know, submissions to the Boston Consulting Group’s (BCG) review of NEHTA closes on the 27^th July 2007.

Given the usual approach that has been adopted by NEHTA in terms of confidentiality and secrecy I thought I should offer to publish, on the blog, any submission individuals or organisations feel they would like to have made public – to ensure more transparency of the review process.

If you are an organisation I am happy to provide a link to your submission if that suits better.

I plan to submit, and publish, my final submission early next week.

Please send me what you want to say and you can be sure many of your colleagues will see your – unedited – comments.

David.

NEHTA has the Allocation of Its Resources and Efforts Wrong!

I was reflecting on a rather interesting series of messages in the GPCG_TALK e-mail list on the transfer of medical records between practices which were using different software – and it occurred to me that the importance of this topic was significantly underestimated in more than the obvious way. My concern centres around the lack of focus and standards setting for GP and Specialist Ambulatory Care / Office systems. Why the concern? The answer is that it is these systems which will have the biggest impact and benefit for our health system.

While we have yet to see the actual report NEHTA claims that the benefits from adoption of more E-Health can be found in the following areas (From May 2007 presentation):

Major sources of benefits

1. Benefits from appropriate use resulting in service substitution

2. Better clinical decision support in:

- Prescribed medications

- Referrals

- Clinical ordering (pathology & imaging)

3. Electronic consultation substitution

4.Reduced rate of population chronic disease progression

5. Reduced hospital costs

6. More efficient community pharmacy processes

7. Improved medication adherence

By the estimates contained in the same presentation it looks to be that between 60 and 65% of the benefits are to flow from improved clinical decision support.

It is also clear from the NEHTA benefits study (of which we have only yet seen a few slides) that there is, on their part, an assumption of major planned change in the connectivity of practices and in the expectations for consistency and safety in clinical practice. This can only happen if the systems on the edge of the health system (i.e. used by GPs and specialists) are much more capable than is the case at present.

The Australian Medical Workforce – when last counted in 2004 (Published in 2006 by the AIHW) was made up of the following active clinicians:

Primary care practitioners - 22,011 (40.8%)

Hospital non-specialists - 6,202 (11.5%)

Specialists - 19,043 (35.3%)

Specialists-in-training - 6,710 (12.4%)

The targets for decision support are the 40% who are GPs and probably roughly 2/3 of the specialists who are in other the fully procedural practice and are in what I would term are in office based practice (In the US called ambulatory practice). This amounts to well over 60% of practitioners.

The other obvious target is community pharmacists to provide a back-up review of the drug related aspects of clinical activity.

So just what a NEHTA’s plans to upgrade and improve the computer support of those who can make a major difference – rather than those who are hospital based and are a much smaller part of the problem?

With its penchant for telling everyone else how to standardise, communicate, process health information and data –and now knowing where the ”paydirt“ lies – what about a major switch of focus to improve GP and Pharmacy Computing?

A very good place to start may be to work with DoHA to identify how best to support GP / Specialist / Pharmacy computing and start working on standards for decision support, usability etc for ambulatory practice. A mandatory standard to ensure all practice systems are able to import and export clinical data in a usable form could be a very useful additional work item. It could be enforced easily through payment / non-payment of Practice Incentive Payments based on compliance with the portable record capability standard.

Additionally, if the work on identifiers and SNOMED CT is going to have any useful impact in the foreseeable future it needs to be linked with a decision support and discrete data messaging upgrade for all the 40,000 or so front-line clinicians.

Why is this major and obvious focus not on the agenda at all? We don’t need a Shared EHR any time soon, we need individual practitioners with effective systems first!

I certainly plan to make this point as clearly as I can to the Boston Consulting Group Review of NEHTA.

David.

The NEHTA Deliverable Silliness Continues.

All of a sudden the NEHTA RSS feed lit up on Friday to let us all know we have some more NEHTA documents to consider.

What was on offer really left me somewhat amazed.

First NEHTA seems to have concluded that Australian Health Software developers need a hand to get their heads around how to code web services based applications. To assist they have thoughtfully provided code on how to implement Web services that conforms with their guidelines using a series of toolkits based on Microsoft and Java technology.

Having however undertaken the task they then cover themselves with the odd disclaimer.

First they say:

“This document is provided for educational purposes only. The method it describes is only one approach; there might be other, equally valid approaches."

Then they point out:

“The code samples in this document are designed for simplicity and ease of understanding, rather than robustness and reuse. They are not written for use in a production system."

A few things strike me about all this.

1. If NEHTA was serious about helping why did they not provide a downloadable working instance of each of these approaches with the source in machine readable form – for testing, review and discussion. Having no reference implementation and being given the code in .pdf form is hardly a real help.

2. On the second page we have the following:

Copyright © 2007, NEHTA.

This document contains information which is protected by copyright. All Rights Reserved. No part of this work may be reproduced or used in any form or by any means—graphic, electronic, or mechanical, including photocopying, recording, taping, or information storage and retrieval systems—without the permission of NEHTA. All copies of this document must include the copyright and other information contained on this page.

So, it seems use of the code is not actually encouraged. Clearly the code should have been released with an appropriate open-source license attached so the clinical community could use, evolve and feed-back suggestions etc.

3. Just what is actually going on with NEHTA feeling the need to provide programming examples? I leave it to others to suggest what is happening here but can’t help wondering if there is not something like a “search for relevance” aspect to all this. I can really think or a whole lot of different ways for NEHTA to be helpful than this.

4. While I have nothing against MS or Sun I wonder why other Web-Services Toolkits are not apparently being encouraged – particularly open-source ones such as the Open Health Framework from the Eclipse Foundation.

Second we have another Clinical Data Specification Document. This one covers the data specification for Diagnostic Imaging and runs to some 228 pages.

The document is entitled Diagnostic Imaging Data Specifications Version 1.0 – July 2007.

What is interesting is that the commencement of the development of this document actually preceded NEHTA’s establishment – having begun in 2004 (i.e. it is a part of the HealthConnect Clinical Information Project which seems to have just continued on regardless). What is it we have been waiting for for about the last three years.

I quote:

“The Diagnostic Imaging (DI) data group specification forms part of a suite of data specifications that NEHTA is developing for the Australian Health Informatics Community. The suite comprises specifications for a range of health topics (represented as “data groups”), which are generally agreed to be of high priority to standardise in order to achieve the benefits brought about by semantic interoperability in the Australian health care setting.”

It is also important to recognise what this document is not: I quote again:

“While this specification defines the data groups and data elements required to support diagnostic imaging requests and reporting, it is important to note that this specification does not cover the following:

• Implementation guide describing how the data groups are intended to be implemented in electronic applications/systems such as Clinical Information/ Electronic Health care Record Systems (CIS/EHRS), Radiology Information Systems (RIS) or Picture Archive and Communication System (PACS).

• Terminologies for diagnostic imaging procedures and reporting, their development and binding to the diagnostic imaging data elements.

• Structured document specifications for diagnostic imaging requests and reporting

• Electronic interchange format specifications for diagnostic imaging requests and

reports.

These specifications may become targets of future NEHTA work programs. The timelines for the further development of diagnostic imaging specifications and relevant extensions to SNOMED CT will be guided by the priorities identified by the NEHTA Board, and the international priorities of the International Health Terminology Standards Development Organization.”

What this is saying is, as I read it, is the following. We started on this project in another era, there is still a lot more work to do, the terminologies required for this to be useful are not developed (and won’t be for a while if ever) but we thought it would be good idea to release it. Oh, and also there is no commitment on NEHTA’s part to do any more on this – i.e. it is probably an orphan and you should use at your own risk (if you choose to ignore it is Copyright © 2007, NEHTA.)

This is made pretty clear in the following from the associated release note:

“Ongoing Development

Because the development of a terminology and data specifications is an iterative process, these specifications will evolve to accommodate changes in healthcare practices and feedback from users that share Diagnostic Imaging information between systems.

The timing of the further development of diagnostic imaging specifications and extensions to SNOMED CT will be guided by the priorities identified by NEHTA’s benefits realisation study and health departments, as well as the directions taken by the International Health Terminology Standards Development Organization.

NEHTA’s current terminology priority is the development of appropriate quality assurance processes, including the use of metrics and automated tools to build, manage and audit data. Such tools will support collaborative terminology development.”

Who in their right mind would take any notice of this specification with that level of commitment from NEHTA. No one with half a brain I would suggest. This is just another piece of useless orphan and probably terminal shelfware!

Third we have a range of documents covering web-services based e-procurement. Now I am not an expert in this area but I was fascinated by the scope of what was made available:

“Of the set of document types identified in the Australian Standard for Health Supply Chain Messaging [HSCM2004], the following subset has been identified as important to the jurisdictions: Purchase Order, Purchase Order Response, Purchase Order Change, Despatch Advice and Invoice.”

What seems to be missing is – to quote again:

“All catalogue, order fulfilment logistics and payment related parts of these processes have been deemed out of scope for the first version of the NEHTA e-procurement architecture.”

So while suppliers are being asked to provide data for the National Product Catalogue (NPC), it is not to be used by the jurisdictions for now and delivery tracking and payment will remain manual as well – so we (the jurisdictions) don’t have to pay our bills too quickly – I assume!

Since I am told many jurisdictions will not be ready to use the NPC until 2009 this may not be a problem, except for the ongoing waste involved in not implementing e-procurement fully.

On behalf of my better half I do have to say, however, I was pleased to note a report she wrote with a good mate years ago, which showed the scale of possible e-procurement savings, was referenced. Pity it has taken seven years for some apparent action.

“[MORE2000] More, E. and McGrath, G.M., Health and Industry. Collaboration: The PeCC Story, Canberra, NOIE, AGP. DOCITA 8/00, May, 2000”

The first time I have managed to drag my wife into the blog !

As a side comment NEHTA also provides Version 1.0 release of the WSDL and XSD files for the E-Procurement Technical Architecture. The Technical Architecture can be downloaded from http://www.nehta.gov.au/.

The disclaimer which comes with it would put a Microsoft or IBM to shame!

“*Disclaimer*

The NEHTA E-Procurement WSDL interfaces and associated XML Schema Files ("the WSDL") are delivered in good faith, free of any charge, and "as is" and without any express or implied warranties. In particular, to the fullest extent permitted by statute and law, NEHTA expressly excludes any express or implied warranties that the WSDL:

* is complete, correct, or error or defect free;

* is of any particular quality or is of merchantable quality;

* is fit or suitable for any particular purpose;

* does not infringe the Intellectual Property Rights of any other person.

Subject to this provision any warranty which would otherwise be implied is hereby excluded. Notwithstanding this limitation where legislation implies any condition or warranty and that legislation avoids or prohibits provisions in a contract excluding or modifying the application of or exercise of or liability under such condition or warranty, the condition or warranty shall be deemed to be included. However, the liability of NEHTA for any breach of such condition or warranty shall be limited to the re-supply of the WSDL.

Without limiting the generality of the above, by using the WSDL, the user is deemed to have agreed with NEHTA:

* that user must assess the suitability of otherwise of the WSDL for the user's purposes; and

* that user assumes all risks and consequences associated with the use of the WSDL or any output or product resulting from the use of the WSDL and, to the fullest extent permitted by statute and law, the user releases NEHTA from any and all responsibility or liability for any risks or consequences of use of the WSDL or any output or product resulting from use of the WSDL and, to the extent not released or not capable of release by user, user indemnifies NEHTA against such risks or consequences.

Copyright © NEHTA 2007

The WSDL contains information which is protected by copyright. All Rights Reserved."

Has anyone else noticed just how obsessive NEHTA is with copyright? I wonder why? An experience DoHA had with the Pharmacy Guild maybe?

David.