Back to the Future for E-Health

Last week CHIK Services conducted their annual Health IT conference (Health-e-Nation 2006). The slides and materials from this very useful gathering are now available on the web.

Of particular interest was one line in the presentation from Dr Ian Reineke (CEO, NEHTA). In this he says that the momentum for e-health is rising and that "The stage is set for Governments to consider a national system of electronic health records".

Reading this I must say I almost choked on my Wheaties. To my certain knowledge the stage for this was set in 1997 with a House of Representatives enquiry followed in 1999 by a large report recommending what eventually became HealthConnect in 2001/2.

Nine years into "consideration of national EHRs" we are now told the stage is set for what must be re-consideration, given the passage of almost a decade!

More than that we have the NEHTA Chairwoman (Ms Patricia Faulkner) tell us that we will all have a Shared EHR at some point in the future but that it will be six-eight years into the future.

What has happened to all the work done thus far and all the money spent. One can only assume very little since we are now to "re-consider".

The truths obvious from all this is are:

1. No national plan for Shared EHRs currently exists.

2. Those considering e-Health and Shared EHRs know they won't be around six to eight years from now to have to account for their level of success in delivery this time when what is happening now is reviewed.

3. Unless there are real funds to support develop the Shared EHR in next months Budget we can be sure "six to eight" years is an optimistic estimate of the likely time frames.

I look forward to being found to be wrong, but I doubt it.

David

RAND Corporation and the Value of Health IT

As a sign of its importance the Annals of Internal Medicine has published, a month in advance of its print date, an important systematic review of the Impact of Health Information Technology on Quality, Efficiency, and Costs of Medical Care. This is a crucial review and establishes that, at least in some circumstances, there are positive impacts on quality, efficiency and costs from the implementation of Health IT.

The evidence for such value in organisations with a high level of IT sophistication was very compelling indeed and given the expertise deployed in undertaking the review can be considered definitive. In the hands of experts Health IT makes a significant positive difference.

The less good news was that, while the value appeared to obviously be available to smaller and less advanced organisations, evidence this was actually the case was lacking.

The authors then go on to, very sensibly in my view, recommend more work to adduce the required evidence and ensure the business case for Health IT deployment is as robust as possible in all sensible settings - especially in the community ambulatory setting.

What this review and the body of evidence it collects shows is that Health IT works. It is now up to those with the relevant responsibilities to learn the lessons available from this work and move forward for the good of all of us.

David

An Important Release of Information from the U.S.

Late last week the Markle Foundation released its so called "Common Framework" for Secure Health Information Sharing. This framework offers Policy approaches to the protection of private health information and Technical approaches the effective and timely sharing of relevant information.

Importantly the "Common Framework" is not a pie in the sky specification but is a demonstrated set of policies and technology which has been shown to work between 3 major sites in Boston, Indiana and California.

The importance of these demonstrations ought not be underestimated - especially as it has been achieved in a standardised conventional way and the two special pieces of software developed to enable the information sharing have been made available in open source form.

With NEHTA saying they have a three year window in which to develop the required standards for Australia it seems clear the work Markle has done needs to be carefully reviewed here. It is interesting that the approach adopted is web services based - as is being recommended by NEHTA for Australia.

It is also important to note this US initiative has avoided any need for a universal patient identifier of the sort now under development - in some form - by NEHTA.

However, it is important to recognise that care is required with the wholesale adoption of Web Services approaches - as is made clear in a recent Computerworld article entitled "Researcher: Web services security risks largely ignored".

Secure and safe sharing of clinical information is a key to safe health services delivery. I hope the work done in the U.S. can help speed up the progress in Australia.

David

They Just Don't Get It - Personal Privacy does Matter

All in all it has been a very bad week for NSW Health IT. Both the major daily papers, The Sydney Morning Herald and The Australian have been running stories pointing out how a number of years of careful policy work related to the privacy of Shared Electronic Health Records has been swept aside - basically to meet a political time line for implementation of a trial EHR system - termed Health-E-Link.

It seems the NSW Minister for Health was persuaded that every one in the target population (citizens over 65 years living in the Hunter Region who visited local outpatient facilities) would love to to have their details available for sharing with any authorised practitioner on a compulsory basis. Later it was decided that once the details were collected the citizen would have 30 days to "opt-out" of record sharing. However the records are not deleted - merely made unavailable.

Even worse the clients of the system have no say in what will be captured - so the only way to avoid having a record established is not to attend the public services in the area.

Not surprisingly, many advocacy groups and other interested parties (dismissed as "privacy zealots" by the Minister, are less than impressed with this outcome, saying to a group we don't mind records but we want a strong say in who accesses these records and under what circumstances. They are also annoyed that the regulations to allow this information capture were slipped through quietly with no public consultation or announcement.

Just the other day a powerful coalition of privacy advocates enumerated what is required in the way of privacy for records to be made available for sharing between health practitioners.

The key points they itemised were put in the following terms:-

"We urge you to build a foundation for medical information technology that is based on the following longstanding ethical and privacy principles and protections:

• Restore the patient's right of consent
• Give patients the right to opt-out of having their records in any national or regional electronic health system
• Give patients the right to segregate their most sensitive medical records
• Require audit trails of all disclosures
• Deny employers access to medical records
• Require that patients be notified of all suspected or actual privacy breaches
• Preserve stronger privacy protections in state laws
• Enact meaningful enforcement and penalties for privacy violators"

All this is utterly reasonable and practical - and is what should be done - to ensure citizens are comfortable with shared records and these recommendation accord closely with what has been developed both in the UK and indeed for the Commonwealth under the HealthConnect banner.

Frankly NSW is a rogue state that will put the cause of health information sharing in Australia back decades unless a major policy about-face occurs. Those responsible for this should recognise they have made a grievous mistake and suspend the trial until proper reasonable controls can be put in place.

David

NEHTA Interoperability Framework - Version 1.0

Yesterday NEHTA released their Version 1.0 Interoperability Framework. At the highest level this document attempts to define how the actors in the Australian e-Health domain are intended to move towards interoperability.

The document is not for the faint-hearted as it is a complex piece of work written in a style that makes no concessions to the technical or health understanding of the audience (which is said to be senior people in the e-health community in Australia essentially).

It seems to me that the value of a document such as this needs to be assessed on the value it provides to its intended audience and the change it will justify and sponsor in e-Health activities in Australia.

I think it would be fair to say the reaction thus far has been along the lines of suggesting the paper is part of an R&D program and that only once more detail and guidance is provided will much value be delivered in the real world. When e-health software developers and vendors are asked "what will you do different tomorrow?" the answer seems to be universally "Nothing".

I have reviewed the document quite carefully and my comments are as follows:

1. This is clearly a "work in progress" and should not be considered in any way final or to be offering firm guidance - consultations on its impact are still to happen with NEHTA's owners.

2. The document as it presently exists does not review available options to many of its recommendations or explain the basis for its selections.

3. The document admits much of its basis is unproven and may not be available for 3-5 years - adoption of the "bleeding edge" approaches is not wise in a sector as conservative as Health I believe. It is possible the keenness for SOA may pass as implementation experience is gained in large complex environments.

4. The proposed standards catalogue does not have scope to hold the full range of available standards that may address a topic and explain the reasons for selection of the preferred ones and at what point such preferences may be reviewed.

5. The theoretical approach adopted and the time frames suggested do not really confront the urgent need for technology to enable Health System Reform as soon as possible.

6. It is, again, not clear, just what is the strategic and requirements context in which this document was developed. There is discussion of development of undefined NEHTA solutions and this must be a cause for concern given the track record of NEHTA like organisations in the software development area.

7. It is by no means clear just what is planned to fall under the influence of this framework - given that at present it is far to vague for any practical implementation.

8. Given legacy systems can last 10+ years in this sector - it is vital to know how these are to be dealt with and have this provided in a route-map provided for all to review and discuss.

9. Yet again archetypes are cited as a good thing - but yet again there is no explanation of how the required information infrastructure is to be developed and managed.

All in all I don't believe this document adds much that is useful to progress in e-Health in Australia. It would have been better to have a much broader consultative process before Version 1.0 was reached so at least some of the issues I and others have raised could have been addressed.

David

Is E-Health Getting Harder?

Today's post has been provoked by my having been sent a report into an e-health conference which was conducted in mid September 2004 in Sydney and which brought together many luminaries in the field. The tone of the meeting was quite optimistic but, while all the important issues were raised (privacy, change management etc), it seemed there was considerable confidence that success was just around the corner - and that by the end of 2005 concrete outcomes would be clearly demonstrable. Further optimism flowed from the fact that NEHTA had recently been established and that this would quickly make an impact in the standards area.

Eighteen months later we seem to have stalled in some important ways.

Firstly the time frame to get basic delivery of the management of the identify of providers and consumers has slipped to the end of 2007 and we have seen that it is now clear development of the required extensions for SNOMED-CT (covering medications, devices and some other areas) is also going to take until 2007.

To date the details of how each of these will be achieved has not been made public so it is hard to know just how high the likelihood of success is.

Internationally it has also become obvious that progress is slower than may have been hoped for. Examples include the delays now being experienced in the well resourced Connecting for Health Initiative in the UK, the slowness with which progress is being made to finalise both HL7 V3.0 and the ISO/CEN EN13606.

It seems intrinsically many major initiatives are more challenging than they initially appear. For this reason the start small and develop at a pace that all can accept is increasingly appearing to be better and better advice.

It is interesting that an article expressing a similar sentiment appeared very recently on the US Modern Medicine website entitled "Dr. McCoy to sickbay: Not 'stat' but with all deliberate speed".

It seems to me we need to select some important do-able goals, get them done, and then take the next step - remembering that in 2006 it is the human and cultural issues that will give the most trouble - not the technical ones.

David

A Government Mouthpiece

On Monday I was "lucky" enough to listen in on the first two hours of the NEHTA 2006 Vendor Forum. On the whole I felt that NEHTA provided little evidence that they had mastered the complexity of Health IT and, sadly as expected by now, they still did not unveil a coherent e-health strategy that could put their initiatives in a comprehensible format.

The whole day was sprinkled through with flavours of Web Services and its bigger brother Service Orientated Architectures (SOA). While the slides were colourful, what was not made clear is that Web Services and SOA are both still very much works in progress and still having much of their implementation complexity worked out. I think it is rather early in the 'hype cycle' to hitch Australia's e-health future to these, as yet, unproven technological approaches. Time will tell, but another false architectural start - like HealthConnect - would be a very bad thing.

The worst aspect of the day was a speech given by a DoHA representative who should have known better given his background. His argument was based on the premise that because it is not possible to work out how to distribute the benefits from Health IT between governments, consumers and providers each should fund their own infrastructure. This is facile in the extreme. It is well known that the majority of benefits flow to the payers (Government in our case) and consumers and that most of the costs are incurred by the providers. If there is not a policy response to this stark fact nothing will happen - as has largely been the case to-date.

The only reason any competent bureaucrat would assert otherwise has to be because they have been told there will be no money and they need to put the best spin possible on a sad situation.

It will be interesting when the NEHTA Benefits Realisation Project identifies the truth. I wonder where DoHA will hide then?

David

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