National E-Health Strategy – Some Useful Resources.

Since it seems we are to have an E-Health Strategy developed for Australia (again) it seems to me it would be worthwhile to put together a few thoughts and to point to a few places that might be worth visiting.

As regular readers will know I have been on about this topic for a while. Looking back it seems I first raised the issue almost 2 years ago. See:

http://aushealthit.blogspot.com/2006/03/what-is-australias-national-e-health.html

This was followed up a little later by some thoughts that still seem pretty relevant.

Sunday, March 26, 2006

An Australian e-Health Strategy – Why, What and What Could It Achieve?

It seems your humble commentator has been ruffling the feathers of the great and powerful in the e-Health domain. I say this not because anything negative has happened but rather that some of my suggestions appear to be causing at least a minor response. It could be, however, that I am just an optimist and the improved information flows and so on were going to happen anyway. No matter, it is all to the good. Well done NEHTA.

The central issue in e-health as I see it is that Australia has not developed, articulated, discussed and agreed a National e-Health Strategy, which brings together all the work being undertaken around the country, assembles it into some sort of coherent whole and provides forward direction and leadership for all involved. In response to the apparent movement from NEHTA I want here to expand my arguments and suggest just what the National Strategy I am proposing may look like.

Before doing that I must answer the “why do we need one?” question. This is easy. Without a plan in virtually every walk of life there is a tendency to see a lack of progress, waste of resources and repeated false starts. The reason this sounds familiar is that this accurately describes the National progress in the e-Health domain. As a colleague so delightfully puts it – all we have seen is largely ‘Brownian Motion’ with no solid progress in any direction. In large projects, such as National e-Health, even with a plan progress can be difficult and slow, but without one failure is inevitable. The second reason we need a plan in my view is that we humans work best and contribute most if the goals and objectives are clear – hence the need not only for a plan, but for it to be publicly articulated and communicated.

On the basis that we need the plan, what should it contain and what factors and constraints should it consider.

Before anything is done the first step is to ensure it makes sense to proceed with planning. This is done by developing a generalised Business Case for National e-Health implementation. If overseas experience is any guide this will confirm the need for action and a plan.

What is involved in doing a plan? The first thing the National Strategy needs is a current view of just what is going on everywhere, and what is working well and needs to be preserved and encouraged. Next, once we have worked out where we are we need to work out where we need to be. This will involve a lot of consultation with all interested stakeholders to develop a vision of future Health Service delivery and then ensure we can put in place the technology to make it work. Fortunately there has been a lot of work done on the desired future state of the Health System and this can be utilised to guide the planning of the supporting technology initiatives.

Out of the requirements and consultative process there should emerge a number of options reflecting the use of different technical approaches, different priorities, different levels of preparedness to invest and so on. These will ideally be worked up into three or four roadmaps and then a second consultative process with stakeholders and the public will choose the most appropriate. This roadmap will then be worked up, in detail, and all the implications for consumers, professionals and others, risks, costs and so on thought through.

At this point there will exist both a clear reason for action and agreement at a high level as to what direction should be taken.

What might an overall strategy look like. The objectives and mission are easy. What we want from technology is better co-ordination of care (only answer questions once, don’t fall between the system’s cracks etc), greater safety with relevant knowledge provided to carers at the point of care, greater efficiency of service delivery at all levels and ideally our own little personal health record that has all our health information securely stored so that when needed it can be made available to those who need it – our doctor, nurse or who ever.

What technologies and systems do we need? Essentially there are five.

First all our hospitals need clinically rich and administratively effective internal systems that enhance patient safety and operational efficiency. These you can buy off the shelf from a range of Australian and overseas vendors – (IBA, Cerner, etc). These need to be advanced systems that provide excellent care documentation and physician order entry with advanced decision support.

Second our GPs and Specialists need similarly effective systems which manage all aspects of our care electronically and can receive and transmit information (referrals, prescriptions, test requests etc) securely and safely. These can be obtained reasonably cheaply but ideal ones are still a little way off.

Thirdly we need service providers (Specialists, Laboratories, Radiological Practices, Pharmacists etc) to provide their product (i.e. reports etc) electronically. Systems to do all of this are available off the shelf.

Fourthly we need in place a secure set of message standards to allow the information to flow where it needs to go safely and privately. These exist in simple form and are improving quite quickly.

Lastly we need some Standards to ensure all information that flows can be properly and reliably linked to the individual it relates to and contains information in a form that can be properly actioned by the receiving system. These largely exist today.

With some will, and a rational funding plan that pays those who create the information that is of benefit to those who get to use it, implementation need take no longer than three to four years. The Implementation Plan will need to adopt a simple, walk before you run, bottom up style but is eminently doable for reasonable cost given the potential benefits.

There will be some issues with integration with previous initiatives but there is nothing that is not doable in all this, other than the need to have a plan and the will and resources to execute it.

What could this achieve? The answer has not yet been fully worked out but if the experience overseas is any guide savings of 5-10% of the health budget and a considerable reduction in clinical errors of all sorts is well within our grasp. We should stop talking about it and get on with it!

(Please note - for the expert readers - this commentary is very high level and lacks detail - but I am convinced it is basically sound - comments welcome!)

David.

Also here a little later

Sunday, June 11, 2006

An Australian e-Health Strategy - The Outline

As the sole reader (nod to Crikey.com) of this blog is aware I have been saying for a while now that Australia is being badly short changed by the lack of a coherent national e-health strategy and implementation plan to frame and put in context both NEHTA and the various State and Commonwealth initiatives.

While developing relatively more comprehensive documentation for publication initially in a different forum, it has occurred to me that what I feel is required can be very simply summarised. In summary what is needed is a two prong approach :

1. The NEHTA work plan to be supported and advanced and where possible and useful increased investment made. In saying this I am recognising that NEHTA will not deliver much of practical use until 2008/9 by its own estimation and that NEHTA will need to operate for a good deal longer (in perpetuity actually) and that reaching its apparent goals may take a good deal longer than a “transition” timeframe.

2. There should be a separate national initiative to get in place nationwide proven health information systems that are known, already to be both practical and to make a real difference to the quality and safety of health care delivery.

I see there are five areas such an initiative should cover.

a. General Practice and relevant office based Specialists should be encouraged and provided with incentives to obtain and use advanced ambulatory EHR systems with sophisticated Clinical Decision Support.

b. Secure Clinical Messaging should be established between Laboratories, Radiology Practices, Hospitals and GPs with documents to be exchanged to include discharge summaries, specialist letters and pathology and radiology reports (and maybe images)

c. Public and Private Hospitals should all implement appropriate clinical and patient management systems including Clinical Physician Order Entry, Nursing Documentation and Medication Management using “closed loop” drug administration control.

d. Health Insurers and Medicare should offer their clients Personal Electronic Health Records where individual can record important health information for use, by those they authorise, in their care.

e. There should be a concerted push by the Commonwealth to establish appropriate disease pattern incidence and monitoring systems for monitoring epidemic disease outbreaks and bioterrorism.

All this is totally feasible today using commercially available and in some cases ‘open source’ software. The only block to major progress in the short term and a better long term future is a strategic vision and the appropriate funds. The paralytic inactivity of the Commonwealth in not setting such an proven and doable agenda is a public scandal I believe.

This is all so obvious I am alarmed someone did not think of it ages ago!

David.

Other resources which also need careful review are:

1. The Health Informatics Society of Australia E-Health Strategy Survey.

This can be found by following this URL.

http://aushealthit.blogspot.com/2007/11/hisa-develops-plan-for-australian-e.html

This is a unique and valuable contribution to current thinking on the topic in Australia.

2. The BCG Review of NEHTA and the NEHTA response are useful for a report as to where things were as of October 2007 at the top level.

See here:

http://www.nehta.gov.au/index.php?option=com_docman&task=doc_details&gid=421&Itemid=139&catid=-1

and here:

http://www.nehta.gov.au/index.php?option=com_docman&task=doc_details&gid=423&Itemid=139&catid=-1

3. Dr Andrew McIntyre of Medical-Objects has produced a useful blog exposing his views on the topic as an important developer in the e-Health space.

See the following URL.

http://blog.medical-objects.com.au/?p=34

Additionally a search of my blog finds pointers to all sorts of plans being undertaken in other countries.

Examples include:

Scotland

http://aushealthit.blogspot.com/2007/12/scotland-updates-its-e-health-strategy.html

and

http://www.ehealth.scot.nhs.uk/

The USA

http://aushealthit.blogspot.com/2007/12/usa-plans-to-refine-its-national-e.html

and

http://www.dhhs.gov/healthit/

and

http://www.whitehouse.gov/news/releases/2004/04/20040427-4.html

The United Kingdom

http://aushealthit.blogspot.com/2007/10/shared-electronic-health-records-coming.html

Ireland

http://www.ehealtheurope.net/news/2935/ireland_to_invest_euros_500m_in_e-health

Europe

http://www.ehealth-era.org/publications/publications.htm

A Summary of a huge Europe wide E-Health Strategy research project

Switzerland

http://www.ehealtheurope.net/news/swiss_agree_compromise_e-health_strategy

Sweden

http://www.regeringen.se/sb/d/2950/nocache/true/a/65070/dictionary/true;jsessionid=anNzjDPaXjke

Canada

http://www.hc-sc.gc.ca/hcs-sss/pubs/ehealth-esante/index_e.html

and

http://www.infoway-inforoute.ca/en/home/home.aspx

Northern Ireland

http://www.ehiprimarycare.com/News/1103/northern_ireland_announces_new_health_it_strategy

New Zealand

http://hcro.enigma.co.nz/website/index.cfm?fuseaction=articledisplay&FeatureID=020306

This lot should get the consultants off to a running start. They will need it given the short time they have! There are a lot of lessons to be learnt from each of these countries that may indeed help.

It is of note that the amount of expert commentary on the ‘wrong headedness” of the current tender is building – this really is a serious opportunity wasted.

David.

Useful and Interesting Health IT Links from the Last Week – 17/02/2008

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

These include first:

Howard's access card dumped

February 14, 2008 02:00am

Article from the Daily Telegraph

MORE than $1 billion that would have been spent on introducing a controversial access card for Australians will now be returned to federal coffers, Human Services Minister Joe Ludwig said.

Labor will scrap the Howard government's plan for an access card, which triggered privacy concerns and was compared to identity cards.

It was intended to replace the Medicare card and up to 16 other benefit cards, streamlining access to a range of health and welfare services.

Senator Ludwig said the card would have cost more than expected, without saving as much as it was supposed to. He said the money would be better spent on other policies.

"I'll return almost $1.2billion to the budget for taxpayers," Senator Ludwig said.

Continue reading here:

http://www.news.com.au/story/0,23599,23211302-421,00.html

This finally put the Access Card to be as the money has now been diverted to other tasks – or maybe just held in the surplus as part of the Government’s attempt to settle inflation down.

In some ways the cancellation of this project is sad in some ways, in the sense that with a proper privacy sensitive design and a better designed change management approach the card could have been a useful piece of infrastructure to make life easier for many while reducing fraud. A reasonable idea very poorly executed by the Howard Government.

I fear NEHTA will be equally insensitive about privacy concerns with the Individual Health Identifier and that may indeed lead to its eventual failure – time will tell.

Further information on the topic is here

Access card funds go to health, schools

February 13, 2008 - 5:02PM

More than $1 billion that would have been spent on introducing a controversial access card for Australians will now be returned to federal coffers, Human Services Minister Joe Ludwig says.

Senator Ludwig says the money will boost savings and help fund the government's promises in education and health.

Labor will scrap the Howard government's plan for an access card, which had triggered privacy concerns and was compared to a national identity card.

Continue reading here:

http://news.theage.com.au/access-card-funds-go-to-health-schools/20080213-1s11.html

Second we have:

Commissioner signals new powers as part of privacy reforms

Mandatory reporting for business to get go ahead this year

Darren Pauli 13/02/2008 12:54:45

Amendments to the Privacy Act to be introduced this year include a range of sweeping new powers allowing the Privacy Commissioner to enforce the mandatory reporting of new data breaches.

Under the new laws, Australian businesses will be forced to publicly detail data breaches. The Australian Law Reform Commission (ALRC) has submitted recommendations to reform the Privacy Act in an 800 page discussion paper with 301 proposals.

The reforms will likely give the Privacy Commissioner new powers to amend legislation to facilitate emerging technologies including biometrics, data warehousing of customer information and high profile breaches of sensitive data.

Speaking at the SecurityPoint 2008 conference in Sydney today, Andrew Hayne deputy, acting director for the Office of the Privacy Commissioner, said the new Privacy Act will require public notification of breaches that expose sensitive customer information.

"There will be a requirement for notification of significant breaches in order to make organizations take adequate safeguards [to protect data]," Hayne said.

"The requirement should not be an unreasonable burden on business and it should not result in alarmous [sic] notification.

"Notification should only be needed in cases where breaches could cause serious harm [to customers] such as financial damages or risk of discrimination or embarrassment."

Hayne said defining 'serious harm' is the "$64,000 question".

Continue reading here:

http://www.computerworld.com.au/index.php?id=141805453&eid=-255

This seems to me to be an important reform. It seems to me that any organisation – big or small – that lets identified sensitive personal information out of its doors should automatically inform the affected individuals know the leak has occurred and what information has been exposed. This should not be in anyway optional and any impacts the follow should be fully and properly addressed and if necessary compensated.

Third we have:

CIOs: Errors Prevention a Priority

February 8, 2008

Investing in information technologies designed to help reduce medication errors is a top priority, panelists in a CIO roundtable conference call said on February 8.

The CIO Roundtable was sponsored by Picis, a Wakefield, Mass.-based software company, as a prelude to the Healthcare Information and Management Systems Society Annual Conference, to be held February 24-28 in Orlando.

“We need to spend on the right technology to reduce medical errors, especially medication reconciliation and administration systems,” said Richard McKnight, CIO of the nine-hospital Novant Health delivery system in Winston-Salem, N.C.

Joseph Sullivan, CIO at six-hospital Saint Barnabas Health Care System in Toms River, N.J., offered a similar assessment: “We’re looking for systems that reduce errors, including medication administration, medication reconciliation, pharmacy systems and clinical systems.”

Sharp HealthCare, a seven-hospital system based in San Diego, is testing a new medication reconciliation system, said William Spooner, CIO. The organization wants to devise ways to gather data from its core clinical information systems to conduct retrospective reviews of how errors could have been prevented, he added. “We’re also looking at new applications to track infection events.”

Continue reading here:

http://www.healthdatamanagement.com/news/CIOs25686-1.html

It is good to see that at least Health CIOs in the US know a major issue for Health IT is to reduce the level of errors throughout the health sector.

Fourthly we have:

Some breast cancer Web sites inaccurate, study finds

Mon Feb 11, 2008 7:59am EST

WASHINGTON (Reuters) - Five percent of breast cancer Web sites have mistakes, with those involving alternative or complementary medicine the most likely to be misleading, U.S. researchers reported on Monday.

But breast cancer information available on the Internet is more accurate than others carrying health information, the team at the University of Texas M.D. Anderson Cancer Center in the University of Texas School of Health Information Sciences at Houston found.

"Our current recommendation to patients is to be skeptical, make sure what patients read is applicable to their specific medical well-being and not to take action without consulting a clinician," said Dr. Funda Meric-Bernstam, who led the study.

Writing in the journal Cancer, Meric-Bernstam and colleagues said they could not find an easy way to flag the inaccurate sites.

"Most consumers find online information by using general-purpose search engines rather than medical sites or portals, and most do not go beyond the first page of search results," her team wrote in the journal Cancer.

"Therefore, we used five popular search engines -- Google, Yahoo Directory, Alta-Vista, Overture, and AllTheWeb -- to identify Web pages that consumers are likely to encounter."

They examined 343 Web pages and found one in 20 had inaccuracies. They found 41 inaccurate statements on 18 of the Web sites, or 5.2 percent of sites.

Those displaying complementary and alternative medicine were 15 times more likely to contain false or misleading health information, they reported.

Continue reading here:

http://www.reuters.com/article/healthNews/idUSN1055853120080211?feedType=nl&feedName=ushealth1100

It seems to me that what this survey indicates is that it is difficult for the typical consumer to assess the quality of clinical information web sites.

My recommendation for consumers it to only rely on sites offered my major governments and sites that are under the control of reputable organisations – e.g. the Mayo Clinic, The Cancer Council etc.

Another useful approach is discussed here:

Finding reliable health information online

13 Feb 2008

Lots of health care information is available on the internet, but it can be hard to know what is current and medically correct. Recent surveys have shown that up to 59% of Europeans use the internet as a resource for health and wellness-related information.

Knowing which sites and what information to trust can be a minefield, but one Swiss-based website, the Health on the Net Foundation, has been offering a dedicated website, which aims to protect citizens from false or misleading health and ethical information for 12 years now.

The Health On the Net Foundation (HON) is a non-profit, non-governmental organisation, accredited to the Economic and Social Council of the United Nations, set up by participants of the Use of the Internet and World-Wide Web for Telematics in Healthcare conference in 1995. Its aim was to create a centralised, legitimate way for people to find accurate health information.

Continue reading here:

http://www.ehealtheurope.net/comment_and_analysis/296/finding_reliable_health_information_online

Link

HON Foundation

Fifth we have:

Alliance to offer common HIE, RHIO definitions

By John Moore

project sponsored by the Office of the National Coordinator for Health Information Technology to clarify the definition of health information exchange and other common health IT terms will produce a draft of its conclusions next week.

The Chicago-based National Alliance for Health Information Technology manages the effort as a subcontractor to BearingPoint. The project’s Network Work Group focuses on the terms HIE and regional health information organization (RHIO).

Jane Horowitz, vice president and chief marketing officer for the Alliance, said the project’s literature search uncovered 20 unique definitions for HIE and 18 for RHIO. The Alliance now aims to cultivate consensus definitions with the goal of eliminating a barrier to HIT adoption.

Horowitz said a number of HIT terms have overlapping meanings, are used inconsistently or have different meanings in different settings. She said the project seeks practical definitions for the legislative environment and contractual arrangements where parties need a clear understanding of terms.

Other uses for the basic definitions include establishing a dialogue between technology vendors and customers and explaining HIT terms for the general public, the alliance said. “Because there’s so much confusion over these words, it is obviously one of the barriers to adoption,” Horowitz said.

Continue reading here:

http://www.govhealthit.com/online/news/350186-1.html

This is a recurrent problem – defining just what means what – and it is good someone is having a consultative attempt at getting some sense into all this.

Lastly we have:

Microsoft Announces the Amalga Family of Health Enterprise Systems

The new lineup of health information solutions spanning clinical, operational and financial functions will be showcased for the first time at HIMSS 2008.

REDMOND, Wash. — Feb. 13, 2008 — Microsoft Corp. today announced the Microsoft Amalga Family of Health Enterprise Systems. The Amalga product lineup is a portfolio of enterprise-class health information system solutions spanning clinical, operational and financial functions. The Amalga family of products will be demonstrated publicly for the first time at the health IT industry’s largest conference, Healthcare Information and Management Systems Society (HIMSS) 2008, Feb. 24–28 in Orlando, Fla.

“One of the healthcare enterprise’s biggest issues is that providers and executives can’t access patient information when, where and how they need it,” said Steve Shihadeh, general manager for Microsoft’s Health Solutions Group. “Microsoft’s Amalga products offer proven solutions that bring together information from across the healthcare enterprise into one, easily accessible view. In fact, the name ‘Amalga’ is based on the Latin word ‘amalgama,’ meaning to bring together different elements.”

The Amalga family of products includes the following:

• Microsoft Amalga. The new version of the product formerly known as Azyxxi, Amalga is part of a new software category called Unified Intelligence Systems that allows hospital enterprises to unlock the power of all their data sitting in isolated clinical, financial and administrative systems. Without replacing current systems, it offers an innovative way to capture, consolidate, store, access and quickly present data in meaningful ways for use by clinicians and executives of leading-edge institutions. Amalga is designed for hospitals and health systems that have invested in a diverse set of IT solutions.

• Microsoft Amalga Hospital Information System (HIS). The new version of the product previously named Hospital 2000, Amalga HIS is a state-of-the-art, fully integrated hospital information system designed for developing and emerging markets. Amalga HIS is built around an electronic medical record (EMR) with complete patient and bed management, laboratory, pharmacy, radiology information system and picture archiving and communication system (RIS/PACS), pathology, financial accounting, materials management, and human resource systems.

• Microsoft Amalga RIS/PACS. The new version of the product formerly known as GCS Amalga is now available as a stand-alone system as well as an integrated component of Amalga HIS. The integrated architecture means that a radiologist can use a single application to manipulate and study images and access the patient medical record. The workstation interface is optimized for radiologist workflow, including support for predefined templates, an intuitive report editor and voice recognition capabilities.

Amalga, the unified intelligence system, is now live at MedStar Health, a community-based network of eight hospitals and other healthcare services in the Baltimore-Washington, D.C., area. As part of the early adopter program, the beta of the new version is in the hands of New York-Presbyterian Hospital, Johns Hopkins Health System, Novant Health, H. Lee Moffitt Cancer Center & Research Institute, St. Joseph Health System and the Wisconsin Health Information Exchange.

“We are excited that we are a part of this early adopter program,” said Ed Martinez, chief information officer at H. Lee Moffitt Cancer Center & Research Institute. “Amalga is the backbone of our Total Cancer Care initiative. It provides instant access to the information, and allows researchers to make and prove their hypotheses within minutes instead of months.”

“We are upgrading to the latest version of Amalga HIS,” said Curt Schroeder, group CEO of Bumrungrad International Hospital. “This application has been a key part of our success, and we look forward to the new features, such as a medication management system designed to assure five ‘rights’ crucial for patient safety: the right patient, the right medication, the right dosage, the right route and the right time.”

Amalga, the unified intelligence system, is being targeted for release to manufacturing in the first half of calendar year 2008. An early-adopter customer program is being established for the released versions of Amalga HIS and Amalga RIS/PACS, which are focused on healthcare providers in countries outside the United States.

Interested organizations should contact amalga@microsoft.com. More information on the Amalga family is available at http://www.microsoft.com/amalga.

Founded in 1975, Microsoft (Nasdaq “MSFT”) is the worldwide leader in software, services and solutions that help people and businesses realize their full potential.

URL for Press Release here:

http://www.microsoft.com/presspass/press/2008/feb08/02-13AmalgaPR.mspx

Continue reading here:

Just a head ups that the behemoth is moving. Makes interesting reading when combined with the MS HealthVault project

More next week.

David.

Useful Reaction to E-Health Tender in the Financial Review.

Just a brief heads up that the Financial Review has published two articles on the National E-Health Strategy Tender.

They can be found at:

http://www.misaustralia.com/viewer.aspx?EDP://20080215000020304888&magsection=news-headlines-home&portal=_misnews&title=Too+much+haste+not+good+for+e-health

and

http://www.misaustralia.com/viewer.aspx?EDP://20080214000020301439&magsection=news-headlines-list&portal=_misnews&title=Move+for+better+electronic+health

Your humble blogger is mentioned along with some other e-Health contributors.

The summary is that the need to do the strategy is agreed but that there are some major issues with the approach proposed and the timeframes.

I hope some common sense will prevail. As a colleague often says in the Health Sector “there is no time to do things properly, but always time to do the same thing again”

It would also be very interesting to see the Australian Health Information Council (AHIC) report e-Health Future Directions which is a driver for initiating the tender but has not been made public. Why on earth would that be?

Finally – just why isn’t the Commonwealth Department running this tender and why is the Victorian Preference Policy in place on a national tender?

David.

Comparative Hospital System Performance Web Sites – A Good Thing?

In the last few years there has been a push to let consumers know a great deal more about Hospital and health system performance. This interesting article appeared a few days ago.

Value of Health Care Cost, Quality Web Sites Might Be Overestimated

by Kate Ackerman, iHealthBeat Associate Editor

Three-fourths of health care opinion leaders responding to a November 2007 Commonwealth Fund/Modern Healthcare survey said that increased quality and price transparency is important or very important to improving the U.S. health care system.

In the last couple years, several states, payers and other health care organizations have responded to this demand for transparency by developing online health care cost and quality Web sites. The thinking is that by providing consumers with information to make informed health care decisions and by injecting competition into the health care market, costs will decrease and quality will increase.

However, consumers so far have been slow to use the information, and physicians often don't know how or if they should act on the data. Touting the sites as a mechanism to transform the health care system might be overestimating their value, some health experts say.

Continue reading this excellent article here:

http://www.ihealthbeat.org/articles/2008/2/8/Value-of-Health-Care-Cost-Quality-Web-Sites-Might-Be-Overestimated.aspx?a=1

Further web information can be found at the links below:

• Center for Studying Health System Change
• Colmers, "Public Reporting And Transparency," Commonwealth Fund, 1/07
• Commonwealth Fund/Modern Healthcare Opinion Leaders Survey

The issue has also been explored recently (as previously mentioned on the blog) in the following article:

http://www.annals.org/cgi/content/abstract/148/2/111

Systematic Review: The Evidence That Publishing Patient Care Performance Data Improves Quality of Care

Constance H. Fung, MD, MSHS; Yee-Wei Lim, MD, PhD; Soeren Mattke, MD, DSc; Cheryl Damberg, PhD; and Paul G. Shekelle, MD, PhD

15 January 2008 | Volume 148 Issue 2 | Pages 111-123

Background: Previous reviews have shown inconsistent effects of publicly reported performance data on quality of care, but many new studies have become available in the 7 years since the last systematic review.

Purpose: To synthesize the evidence for using publicly reported performance data to improve quality.

Data Sources: Web of Science, MEDLINE, EconLit, and Wilson Business Periodicals (1999–2006) and independent review of articles (1986–1999) identified in a previous systematic review. Only sources published in English were included.

Study Selection: Peer-reviewed articles assessing the effects of public release of performance data on selection of providers, quality improvement activity, clinical outcomes (effectiveness, patient safety, and patient-centeredness), and unintended consequences.

Data Extraction: Data on study participants, reporting system or level, study design, selection of providers, quality improvement activity, outcomes, and unintended consequences were extracted.

Data Synthesis: Forty-five articles published since 1986 (27 of which were published since 1999) evaluated the impact of public reporting on quality. Many focus on a select few reporting systems. Synthesis of data from 8 health plan–level studies suggests modest association between public reporting and plan selection. Synthesis of 11 studies, all hospital-level, suggests stimulation of quality improvement activity. Review of 9 hospital-level and 7 individual provider–level studies shows inconsistent association between public reporting and selection of hospitals and individual providers. Synthesis of 11 studies, primarily hospital-level, indicates inconsistent association between public reporting and improved effectiveness. Evidence on the impact of public reporting on patient safety and patient-centeredness is scant.

Limitations: Heterogeneity made comparisons across studies challenging. Only peer-reviewed, English-language articles were included.

Conclusion: Evidence is scant, particularly about individual providers and practices. Rigorous evaluation of many major public reporting systems is lacking. Evidence suggests that publicly releasing performance data stimulates quality improvement activity at the hospital level. The effect of public reporting on effectiveness, safety, and patient-centeredness remains uncertain.

These two articles explore the issue of just how useful complex information is to consumers. It seems to me that while lacking transparency is always a bad thing it is vital that the information that is released is both easily understandable and comparable so the consumer has something reliable to base decision making on.

As noted in a previous blog there are well thought out comparable clinical outcome performance indicators available and it is these that should be used – with appropriate explanations – to inform the public on hospital performance.

It is interesting to note that the major effect that has been detected following data release is an increase in internal quality improvement activity. If this activity is well directed this over time is surely a good thing indeed and makes such transparency a reasonable goal –with the caveat that the indicators being worked on a relevant and accurately reflect desired clinical and patient outcomes.

It seems to me this is still a work in progress.

David.

A National E-Health Strategy for Australia is Coming! Can it Succeed?

Well, blow me down! I have just had one of my core suggestions taken up! We are to have a National E-Health Strategy developed!

The important parts of the tender are as follows: (Sorry for the formatting - useful comments are at the end.)

Part A. Information for Tenderer

Purpose of this Document

This document is a Tender Brief and has been prepared to provide information to assist prospective Tenderers in the preparation and submission of proposals for the development of a national e-health strategy.

Project Overview

On behalf of the National e-health Information Principal Committee (NEHIPC) the Department of Human Services is seeking suitably qualified and experienced parties to develop a national e-health strategy that:

· Provides a vision for and desired outcomes of national action in e-health over the next 5-10 years

· Identifies priorities and next steps for development and implementation of a national e-health system

· Provides advice on the governance arrangements needed to oversight and manage national e-health projects and infrastructure

Key dates for this proposal are indicated below. These dates are advised as a guide to projected timelines, only. The Department of Human Services will attempt to maintain this schedule, but reserves the right to vary key dates where necessary:

Tenders advertised	13 February 2008
Closing date for submission of Tenders	7 March 2008
Shortlisting completed by	11 March 2008
Interviews conducted by	14 March 2008
All tenderer A Tenderers advised of Tender outcome by	28 March 2008
Service/project commencement by	28 March 2008
Service/project completion	28 July 2008

Project Objective

The objective of this project is to develop a national e-health strategy through the identification of a national vision and goals for e-health. The strategy recognises existing and projected national and international efforts in e-health while also considering future developments in health service delivery. The strategy provides a practical roadmap for further national e-health development and implementation in this country, and allows prioritisation of existing and future investment in national e-health infrastructure and activities.

The strategy should:

Specify a vision for e-health in a national context to include discussion of:

· Models for health service delivery

· Enablers for improved efficiency and quality

· Consider population and demographic changes

· Workforce and skills

· Service delivery sustainability

· Physical transportation

· Emerging risks and influences

· Plan for change

· Identify drivers and influences of change

· International influences – vendors, products and standards

· National and jurisdictional legislation

· Identify key priorities, goals and practical strategies and initiatives to support the national e-health vision

· Identify options for next steps in national collaboration in e-health over the next 5 - 10 years, which leverages existing national and international investment and experience. This must include:

· A review of the scope, funding and timetabling of existing and future significant national and state government e-health projects and initiatives. This would be based on an audit commissioned by NEHTA within the last 2 years and direct consultations with jurisdictions regarding any more recent developments;

· Advice on priority areas for progressing national collaboration in e-health (in accord with health system reform priorities including desired outcomes and models of care) and the benefits to be derived from proposed initiatives;

· Analysis of international experience that may guide prioritisation and practical implementation of e-health initiatives in Australia;

· Advice on a practical pathway for optimal pursuit of national e-health priorities, including timelines and parties responsible for each milestone. Gaps in current effort, incentives to promote uptake and opportunities to harness learnings from existing programs and projects must be identified. The pathway should identify necessary action and responsible parties to deliver sharing and utilising health information electronically, including incentives for uptake and any possible sanctions.

· Provide options for strengthened e-health governance. This must include:

· An analysis of existing national governance arrangements for both e-health and information management under the Australian Health Ministers’ Advisory Council (AHMAC);

· Options for strengthened AHMAC governance arrangements in line with national e-health directions, including how any new arrangements align with other organisations and committees progressing the national e-health agenda;

Identification of governance structures needed to oversight and manage national e-health priorities, including e-health infrastructure and programs. In considering these structures reference will need to be made to the regulatory arrangements necessary for the effective and efficient operation of the future national e-health environment.

Scope

“E-health” is defined by the World Health Organisation (WHO) as ‘the combined use of electronic communication and information technology in the health sector.’ It refers to the health care components delivered, enabled or supported through the use of information and communications technology. Examples include clinical communication systems such as online referrals and e-prescribing, and electronic health records. E-health is identified as a key enabler of models of care delivery, patient centred care, supported self-care, remote access and monitoring, and health system sustainability.

The strategy should recognise existing national and jurisdictional efforts and investments in e-health by Australian, State and Territory health departments, the National E-Health Transition Authority (NEHTA), the Australian Health Information Council (AHIC) and the National E-Health and Information Principal Committee (NEHIPC).

The strategy should focus on those aspects of e-health which are both necessary and sufficient to establish robust and effective national approaches to the creation, communication, storage, use and analysis of information.

The national e-health strategy should be inclusive of both public and private health sectors, to guide the next phase of national e-health collaboration.

The strategy will articulate priorities for e-health that are measurable and grounded in local and international evidence.

The strategy will need to take account of the current and emerging issues in health service delivery facing government (Commonwealth, States and Territories), health care providers and consumers, in identifying priorities and governance arrangements.

The e-health strategy will address the dimensions of information, information management (for primary clinical purposes and secondary reporting, evaluation and research), information technology, communications technology, medical technology and all associated enabling infrastructure (such as policy and legislative frameworks). It must assess and leverage work completed to date or currently underway.

Period of Service

The period of service is to commence on 28 March 2008 and the contract period will be for 3 months, ceasing on 28 July 2008.

Extension of Contract

Subject to satisfactory performance and agreement of the successful Tenderer, the Department of Human Services reserves the right to extend the contract period to a total period of 6 months.

Background

Department of Human Services

The Department of Human Services, Victoria, on behalf of the Australian Federal, State and Territory Health Departments and the NEHIPC, is seeking suitably qualified and experienced parties to develop a national e-health strategy.

The Department of Human Services is responsible for a wide range of services to diverse client groups across Victoria. The principal function of the Department of Human Services is to ensure the delivery of a range of health, housing and community services.

The Department of Human Services’ Mission Statement is:

To enhance and protect the health and well being of all Victorians, emphasising vulnerable groups and those most in need.

Policy Context

In 1993 the Australian Government and the States and Territories, recognizing the importance of a strategic national approach to the development of health information management and information communications technology, signed the first National Health Information Agreement (NHIA). The NHIA between the Australian Government, the State and Territory health authorities, the Australian Bureau of Statistics and the Australian Institute of Health and Welfare provides the foundation for the development, collection and exchange of uniform health data and information and tools to support analysis, research and comparison at all levels of the health system.

National governance arrangements were established under the NHIA to oversee developments in statistical standards and other national information projects. Under the first NHIA uniform national data standards were developed and the National Health Data Dictionary, which contains metadata standards for a range of health services, was established.

In 1995 the National Health Information Development Plan was released, promoting the development of high priority health information and equitable cost effective service arrangements. In 1998, the National Health Information Management Advisory Council (NHIMAC) was established to advise Health Ministers on options to promote a national uniform approach to more effective information management in the health sector. In 1999 NHIMAC released Health Online: A Health Information Action Plan for Australia. Under Health Online national action plans were developed focusing on health information standards, telehealth, supply chain reform in hospitals and electronic decision support.

Australian Health Ministers established the National Electronic Health Records Taskforce in November 1999 to evaluate the potential of electronic health records for the Australian health care system. Based on the Taskforce recommendations, Ministers agreed in July 2000 to jointly fund a two year project to assess the value and feasibility of HealthConnect. The purpose of HealthConnect is to facilitate the adoption of common standards by all e-health systems so that vital health information can be securely exchanged between healthcare providers. HealthConnect trials have been operating in the Northern Territory and Tasmania since 2002. Trials commenced in North Queensland in 2003 and in New South Wales and Brisbane in 2005.

Health information management and technology governance arrangements evolved over this period with the establishment in 2003 of the Australian Health Information Council (AHIC) and the National Health Information Group (NHIG). AHIC and NHIG were established to provide leadership on information management and technology, and to coordinate advice to Health Ministers. The key role of AHIC is to provide independent advice to Health Ministers, via the Australian Health Ministers’ Advisory Council (AHMAC), on long term directions and strategic reform issues. NHIG was established to provide advice to AHMAC on planning and management requirements, and to manage and allocate resources to health information projects and working groups.

During 2005 and 2006, AHMAC reviewed its subcommittee and working group structures. As a result of the review, NHIG became the AHMAC Principal Committee on National Health Information Management (NHIMPC). In December 2007, AHMAC CEOS considered advice commissioned from KPMG regarding the scope and governance arrangements for strategic development of health information management in Australia. In January 2008, AHMAC agreed that the NHIMPC be reconstituted to take on a broader responsibility in relation to e-health alongside its existing focus on information management. Reflecting this broader focus the Principal Committee has been renamed the National E-Health and Information Principal Committee (NEHIPC), with the new structure and membership yet to be finalised.

Provisional meeting dates for AHMAC in 2008 are as follows:

· 6 March (Hobart)

· 5 June (Melbourne)

· 9 October (Adelaide)

Provisional meeting dates for the NEHIPC in 2008 are as follows:

· 16 April (Melbourne)

· 19 July (teleconference)

· 17 September (Melbourne)

· 26 November (Melbourne)

NEHIPC is chaired by Ms Fran Thorn, Secretary of the Department of Human Services in Victoria. The NEHIPC currently comprises a representative from each Australian jurisdiction (as its core membership) and a representative from the Australian Health Information Council, the Australian Institute of Health and Welfare, the Australian Bureau of Statistics, the National Health and Medical Research Council, Medicare Australia, the Australian Commission on Safety and Quality in Health Care, the Department of Veteran’s Affairs and the New Zealand Ministry of Health.

A number of standing committees and set for purpose working groups provide specialist advice to NEHIPC, and the Chairs of these committees/groups also attend NEHIPC meetings as observers. These currently include the:

· Statistical Information Management Committee (SIMC);

· Health Data Standards Committee (HDSC);

· National Health Performance Committee (NHPC);

· Population Health Information Development Group (PHIDG); and

· National Advisory Group on Aboriginal and Torres Strait Islander Health Information and Data (NAGATSIHID).

In 2005, Australian Health Ministers noted the need for further cooperation on significant national e-health projects including clinical data standards and terminologies, consent models, secure messaging, user authentication, supply chain and electronic health records standards. This was endorsed by the Council of Australian Governments in June 2005. The National E-Health Transition Authority Ltd (NEHTA) was established in July 2005 to support the adoption of e-health in the Australian health sector.

On 10 February 2006 Council of Australian Governments (COAG) agreed that:

From February 2006, governments will accelerate work on a national electronic health records system to improve safety for patients and increase efficiency for health care providers by developing the capacity for health providers, with their patient’s consent, to communicate safely and securely with each other electronically about patients and their health. This requires:

· Developing, implementing and operating systems for an individual health identifier, a healthcare provider identifier and agreed clinical terminologies; and

· Promoting compliance with nationally-agreed standards in future government procurement related to electronic health systems and in areas of healthcare receiving government funding.

(Better Health for all Australians, COAG Communiqué, February 2006)

Funding was assigned to NEHTA to progress three significant infrastructure projects in the development of e-health, namely to establish the Individual Healthcare Identifier (IHI), the Healthcare Provider Identifier (HPI) and to establish a national clinical terminology. These three initiatives form the building blocks towards a national approach to a Shared Electronic Health Records system. COAG further agreed that Australian Health Ministers would report back to COAG no later than 2008 on progress and next steps towards a national e-health records system and appropriate cost sharing arrangements.

In December 2007, both the Australian Health Information Council (AHIC) in its report e-Health Future Directions and the Boston Consulting Group in its review of NEHTA, recommend the development of a national e-health strategy. It is also one of the key tasks listed in the revised terms of reference for NEHIPC endorsed by AHMAC in January 2008.

And also this part is important.

Key project deliverables are:

· A draft and final strategy fulfilling the requirements articulated in 3. and 4. To include:

Ø A discussion and key recommendations concerning the National eHealth Strategy, the Implementation Plan and the recommendations on governance of the implementation plan

Ø A vision, implementation and sustainability plan for e-health in Australia and its role in the planning, delivery and management of healthcare in this country.

o A recommended “future state” of e-health in the context of its proposed role in the planning, delivery and management of healthcare across Australia

o A definition and assessment of the current status of e-health capability, nationally both public and private, as well as at a jurisdictional level, with an assessment of the current level of contribution e-health is making to healthcare delivery and management and the investment in place to support this.

o Concept architectures and designs including information to support decisions taken in developing these. This must clarify which major components should be managed centrally (national), which could be either central or distributed (jurisdictional) and what should be geographically/regionally based.

o Identification of the major initiatives that would need to be undertaken to develop an e-health capability that optimally supports the Australian healthcare system and how each initiative will impact health outcomes and healthcare delivery capabilities. Initiatives need to be clearly defined and include high level detail of how impacted business processes would work. Each initiative needs to be scoped with a high level project definition that identifies outcomes, resource requirements, timelines, costs, benefits, dependencies, risks and issues. Costs must be fully inclusive of establishment as well as implementation costs.

o Definition of all enabling work that will be required to support the implementation plan. This will include areas such as standards, legislative and policy frameworks. Identify any changes or development that will need to be undertaken to support the implementation, whether these are already underway (by whom) or who should be addressing them (e.g. information privacy, consent models, additional standards).

o Prioritisation of initiatives to align with current national and jurisdictional health priorities as well as a process to recognise those that will emerge from the National Health and Hospital Reform Commission (NHHRC).

o A high level implementation plan, including assumptions and dependencies, with associated investment, costs and benefits plans. The plan should include strategies and incentives to maximise the take up of new capabilities.

o An assessment of capability in Australia to deliver against the proposed implementation plan. This must, particularly, consider issues of workforce capability (e.g. ICT, health informatics, healthcare) and market capability in this country. Identify strategies to manage these issues and ensure that the Australian workforce develops appropriately.

o An assessment of supply and demand factors in the private sector market for e-health products and services with a particular focus on vendors’ willingness and ability to develop and market products, issues driving private sector health care providers’ to acquire and use those products, and recommended approaches to address any shortcomings identified.

o Proposed governance structures to support and oversee the strategy and the implementation of the plan, including roles and responsibilities

o Description of all enabling work that will be required to support the implementation plan. This will include areas such as standards, legislative and policy frameworks.

o Clear statement of all assumptions that underpin the recommendations and estimated costs.

Ø A high level communication plan regarding the national e-health strategy itself, to inform key stakeholders of the planned future direction.

Ø Presentations and support to briefings related to the e-health strategy as follows:

o Presentations of the final strategy to key stakeholder forums (5 expected including but not limited to the CIO sub-committee of the NEHIPC, NEHIPC and AHMAC); and

o Support to the NEHIPC for related e-health strategy briefings on the final deliverables

o Regular meetings with the project steering committee established to oversee the project. This committee will comprise senior representatives from the Australian Federal, State and Territory health departments.

o Consultations with experts and stakeholders in Australia, as agreed with the e-health strategy steering committee.

==== End of Tender Quotes. (The full tender is available at http://www.tenders.vic.gov.au/domino/web_notes/etenders/etdrpublishing.nsf?Open)

First – let me say it is great to see such an initiative being undertaken. However this is really not a request for the plan that is required I believe. Why?

Firstly, three, or even six months, is not anywhere near enough time to address the complexities that Australian e-Health will face in the next 5-10 years.

Second the idea of using a Current State of e-Health Assessment developed by NEHTA a year or so ago is hardly an ideal information base from which to conceive the future.

Third the documentation seems to ignore the vital fact that the major stakeholder in all this is the Australian population who have a right to more efficient, safe and evidence based care. It is they who need to be convinced investment in e-Health will benefit them. Right now the consumer has no idea why they need EHRs or e-Health.

Fourth the brief is not focussed on a clinical outcomes perspective. By that I mean that the vision should be framed in terms of how the health status of the nation can be enhanced through the use of e-health – not some vision of a technological ‘future state’.

Fifth the strategy documentation does not appear to include development of a specific implementation justification business case to demonstrate the value of implementation of the proposed strategy. A persuasive national business case is the only way the required funding will be made available.

Sixth the overall process and deliverables being requested has a distinct 1980’s Information Systems Planning feel, rather than the dynamic, persuasive and compelling strategy that is needed to energise the health sector to move forward.

Seventh, without clear Health Sector wide analysis of where benefit can be gathered proper prioritisation is difficult if not impossible.

Eighth, all the background information simply tries to deny and sweep under the carpet the mess we have seen over the last decade with shifting priorities, staff turnover, inadequate evaluation of trials and so on. This is not the way to start. An honest look back is vital, before trying to move forward.

Ninth, by doing a short form plan, which is wanted by Government to meet the Health Care Agreement agenda, we don’t get the plan we need. The smart thing would be to use this as a starting point for detailed planning focussed on real outcomes after that issue is sorted.

All in all, unless we can move this retro approach to E-Health Strategy to one more consistent with 2008 and beyond we run the risk of yet another failed planning effort – which would be a huge pity.

David.