Service Improvements

This tiny corner of Cyberspace has now been operational for going on for three months. In that time we have added about thirty articles commenting on the various issues as they emerge in the e-health space in Australia.

While a .atom feed and I believe and RSS feed are available - I have now managed mastery of enough html to provide e-mail updates as well. You can subscribe on the site and it does its best to make sure your e-mail is secure and that you can opt-out again as required. Feel free to tell friends and enemies that they can now know quickly about the views I am putting.

While I have your attention let me make a few points about the experience of writing the blog. First it has been useful in clarifying my thoughts and positions and has acted an interesting exercise in exploration of a range of issues - prompting extra research etc which is all to the good.

I have to say that there are ominous portents for e-health in Australia brewing. First is the awareness that Medical Observer magazine has taken the e-health section it used to have off its website. Seems no one is interested.

Second we note that HealthConnect has been removed in all its guises from the recently announced Australian Budget.

Thirdly there seems to be a pervasive feeling of despondency regarding what is possible in Australia given the politics and Governments (of all shades) views. I see this most in the nihilism and frustration expressed in private e-mail and in correspondence in the GP_Talk forum, HL7-Info and OpenHealth.

The really annoying thing is that it is now clear Health IT, done right, works! It improves care, saves lives and in the hands of competent organisations saves money!

See below for the best facts currently available.

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Chaudhry B, Wang J, Wu S, et al.

Impact of health information technology on quality of medical care
Annals of Internal Medicine 16 May 2006; Volume 144 Issue 10 (early on-line publication)

http://www.annals.org/cgi/content/full/0000605-200605160-00125v1

Background: Experts consider health information technology key to improving efficiency and quality of health care.

Purpose: To systematically review evidence on the effect of health information technology on quality, efficiency, and costs of health care.

Data Sources: The authors systematically searched the English-language literature indexed in MEDLINE (1995 to January 2004), the Cochrane Central Register of Controlled Trials, the Cochrane Database of Abstracts of Reviews of Effects, and the Periodical Abstracts Database. We also added studies identified by experts up to April 2005.

Study Selection: Descriptive and comparative studies and systematic reviews of health information technology.

Data Extraction: Two reviewers independently extracted information on system capabilities, design, effects on quality, system acquisition, implementation context, and costs.

Data Synthesis: 257 studies met the inclusion criteria. Most studies addressed decision support systems or electronic health records. Approximately 25% of the studies were from 4 academic institutions that implemented internally developed systems; only 9 studies evaluated multifunctional, commercially developed systems. Three major benefits on quality were demonstrated: increased adherence to guideline-based care, enhanced surveillance and monitoring, and decreased medication errors. The primary domain of improvement was preventive health. The major efficiency benefit shown was decreased utilization of care. Data on another efficiency measure, time utilization, were mixed. Empirical cost data were limited.

Limitations: Available quantitative research was limited and was done by a small number of institutions. Systems were heterogeneous and sometimes incompletely described. Available financial and contextual data were limited.

Conclusions: Four benchmark institutions have demonstrated the efficacy of health information technologies in improving quality and efficiency. Whether and how other institutions can achieve similar benefits, and at what costs, are unclear.
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Just what has to be done to get NEHTA to develop and articulate a comprehensive e-health plan and to persuade Government to adopt it, is feeling as though it is beyond your simple scribe.

I will, however, press on!

David.

Unscripted Errors – What a Beat-Up!

Over the last few years the Australian Newspaper has developed a reputation for quality reporting in the e-Health space, led largely by Karen Dearne and James Riley (who has been doing good work on the “Access Card” front). It is therefore quite disappointing to note the article, entitled Unscripted Errors, which appeared today providing such alarmist and ill-structured comments from a different Australian journalist.

In essence the article argues that electronic prescribing by GPs, in the absence of them using the software as it was designed and the software lacking the key features (electronic decision support) that make it safe will not help reduce prescribing errors. To suggest this is stating the ‘bleeding obvious’ is a monumental understatement – and indeed is confirmed by the hospital study cited in the article.

It is little more than common sense to say that safety requires all parts of a system to work properly. (Thus having perfectly sound wings on an aeroplane does not help avoid a crash when the engines fail!). It is no news that poor computer systems in the hands of the untrained or careless may do more harm than good. It is also true to say that the current generation of Australian GP prescribing systems, used carefully and intelligently by clinicians trained in their use, are very safe and can make a real difference

In the case of prescribing the ideal system to do the job will have the following attributes:

1. It will be part of a comprehensive Electronic Patient Record which captures relevant information (ideally in properly coded form) regarding the patients illnesses, allergies and other medications (including non-prescribed ones).

2. It will have access to a rich electronic decision support framework which provides guidance as to prescribing based on age, height, weight, disease, other medications and allergies at the least.

3. All the alerts and recommendations made by the system will be evidence based and properly researched.

4. The decision support will interact with the clinician at the point of decision making to ensure all relevant information is considered.

5. The system will be easy to use and have its data bases of knowledge regularly updated and refined.

However even all this is not enough, only when the clinician is both properly trained and prepared both t0 enter all relevant information and respond intelligently to the decision support warnings and alerts will the substantial beneficial reduction in errors and patient harm be achieved.

It is what is needed, rather than what can go wrong in the hands of clinicians given poor software with out proper training, that should have been the emphasis of the article. As it stands the article did nothing but alarm, rather than fostering an effort at improvement which is genuinely needed.

The evidence that such systems work is now overwhelming if they are properly implemented.

Getting this sort of software onto clinician’s desks is yet another area where national leadership could save both money and lives. We should be working to have proper systems, properly implemented, put in the hands of our clinicians, not worrying ourselves into paralysed inactivity because a few might misuse older ones.

David.

HealthConnect Renamed - What To Unclear

In an article in the Australian Financial Review Ben Woodhead writes (subscription required) today:

“The Department of Health and Ageing has stripped references to its $128million HealthConnect project from 2007 budget statements amid speculation over the fate of the controversial national electronic health record program.

The move is likely to increase fears the government will abandon HealthConnect and shift responsibility for the development of a national electronic health record (EHR) framework to the National E-Health Transition Authority .

But it has not completely disconnected itself from the development of a national EHR, and the department has signalled it will work this year on initiatives that will eventually support a nationwide electronic patient record.”

He also notes that in the forward estimates for the next few years there are a total of $70.2 Million for COAG Health Services - Establishing the Foundations for a National Electronic Health Records System as it is described in the budget papers.

Importantly what must be noted here is that these funds – announced a couple of months ago are for “Foundations” not for the National EHR System itself. The foundations are for patient identity, provider identity and SNOMED CT implementation over the next few years.

What does this mean the Government’s strategy for EHRs for consumers is? The simple answer is “who knows?”. While NEHTA is obviously working on the nature of the approach that is to be adopted we see some odd and apparently un-coordinated things happening, such as a separate identity system being developed to support the Medicare Smartcard.

It is also worth noting that the Commonwealth Funding for this NEHTA work is very similar to the amount of money that would have been left over from the previously announced HealthConnect funding.

Currently there is a very large strategic hole in Australia’s e-Health vision. One can only hope it is soon clarified.

David.

Smartcard Stupidity

Another day another foul up for e-health (and a lot else) in Australia. Yesterday The Age’s Michelle Grattan reported in the following terms:

“The man overseeing the introduction of the Government's smartcard has resigned, citing concerns about its implementation, including privacy.

James Kelaher, former head of the smartcard taskforce, yesterday warned that privacy and the confidence of those with a stake in the card - including the public, doctors, pharmacies, states and federal departments - were likely to be compromised by Human Services Minister Joe Hockey's proposed arrangements.”

It seems the fuss is about two issues. Firstly whether there should be a separate agency constituted to establish and operate the Smartcard infrastructure and secondly whether there should be an expert and accountable board to oversee the total project and to ensure that all the necessary community expectations for security, privacy and integrity are met.

On the first point any project of the planned scale (involving over $A1.0Billion in expenditure) clearly needs focussed and dedicated management. To do otherwise breaks every rule in the Project Managers 101 textbook of implementation.

On the second it is clear, given the Australia Card debacle, that public confidence and trust is vital. To keep this all secret and in-house guarantees success for those few souls who oppose what is essentially a sensible initiative, if, and only if, implemented in a consultative, responsive and inclusive manner.

Mr Hockey needs to wake up and listen to the experts on this or a lot of money, time and effort will most likely be wasted.

James Kelaher is clearly a very sensible bureaucrat who has strong principles regarding doing things in the national interest and exposing arrant stupidity.

Well done James!

It should be noted that the writer still has major concerns about the robustness of the proposed smartcard as an e-health patient identifier and hopes the need for e-health levels of ID integrity will not be glossed over in the rush to implementation.

David

Health IT and the Australian Budget

Tomorrow is the one financial day for the year in Australia when the Commonwealth announces its budget for the next year.

What chance any joy for the proponents of e-Health in Australia?

I must say I am pessimistic. After what looked very much like a re-branding of old HealthConnect money into new NEHTA funding a few months back – and with precious little (not surprisingly) to show for that investment as yet, I think the Government will think they have done enough for now.

The usual run of leaks, typical of the pre-budget period, do not appear to have an obvious mention – but that is not to say there won’t be any new funds – given that such funding is unlikely to be “leak worthy” I would suggest.

At the risk of seeming to be repetitive, it seems to me that without a compelling business case for e-health investment, as well as some political will just nothing will happen. In this regard we can hope the NEHTA initiative on Benefits Realisation, announced a month or two ago, might just have some impact.

The obvious worry is that NEHTA recommending dramatically increased spending might be seen as having a ‘conflict of interest’ in seeking to feather its own nest. I am firmly of the belief, to be credible, such a business case needs to have been undertaken by expert, independent outsiders and not done in-house where it can so easily be ignored and left un-actioned.

If there was to be funding – where should it go?

I would like to see a real proper e-Health Business case developed along with a real implementation plan - $3-5M for one year and then sell the benefits and plan to the Commonwealth to become much more pro-active. This is vital and overdue by at least half a decade.

I also want a Certification Commission for Health IT type entity to get GP systems up to snuff - and then to get a real Health IT network going in - that can grow organically like is intended in the US. Start small and provable and get some runs on the board. ($10-20M p.a. for 4 years or so). I would also like to, as the CCHIT is doing, see the scope widen to cover Hospital Computing and so on.

Those two specific initiatives and continuation of other NEHTA initiatives might just move us forward a little.

We shall see tomorrow what the budget brings.

David.

Lessons for Australia from the CCHIT

On the first of May the Certification Commission for Healthcare Information Technology released its initial 2006 criteria for certification of Ambulatory Health IT. The scope of the documents is impressive and reflects what could be reasonably desired in an Ambulatory EHR client system for use in the US context.

The documents sensibly cover the required functionality, important interoperation capabilities and necessary information protection and security needs. After review of these documents and the associated evaluation scripts I would be surprised if 90% of the certification requirements do not fully match Australian needs - with the exceptions being in the areas of terminology, coding and billing.

This is an absolutely invaluable starting point from which NEHTA should be developing similar requirements for Australian Certification after consultation with the relevant users and industry stakeholders.

I particularly like the approach of building in a road map for system developers to permit them to evolve their systems over 2-3 years and to be, via this approach, ensuring a very high standard of system will be in the hands of clinicians only a few years from now.

This is all wonderful stuff and I commend it to readers and the Medical Software Industry Association for detailed review. This work can give us a real head start in the development of Australian certification processes and may mean a few years from now GPs will have access to clinical systems which can really make a difference and which they said they needed back as far as 1997.

David

An ID Card in all but Name – For Now!

Individual identity systems are a topic of great interest for this blog. The reason for this is that patient identification is a key requirement for any form of electronic health record and that NEHTA has been working to design a patient identity management system as one of the “building blocks” for e-health.

It now seems that Australia is to have an “access card” that will be needed to be presented when accessing all Commonwealth Government payment services (Medicare, Social Services and so on – in total 17 different services).

Interesting analysis and a range of opinions are available both here and here.

It is fair to say that denial that the proposed card is an ID card is disingenuous in the extreme and is to be condemned as an attempt at concealing the fact that this proposal goes much further that the publicly rejected Australia Card of the 1980’s in terms of potential for abuse and the scope of linkages being planned.

The claim the card is voluntary is equally a nonsense. If you choose to go without healthcare and social security benefits sure you could struggle on without it for a while at considerable expense – but how long will it be before it is needed to use State run services and finally private services. It will surely become all pervasive without firm legislative limitation – which has not been announced as far as I am aware.

The Government needs to come clean and be clear just what is proposed to manage scope creep and ID fraud before any one should support it.

Lastly it will be interesting to see how the proposed smartcard interacts with the proposed NEHTA patient ID proposal. Does this announcement pre-empt, support, interact with or have any other role in the development of the Australian EHR system.

This commentator will wait and wonder!

David.

Shared Electronic Health Records are Not Easy

A day or so an interesting report appeared in the web magazine ehiprimarycare.com revealing that the plans for the Shared Electronic Health Record (SEHR) for the NHS spine had been significantly scaled back. To quote the relevant section:

"Dr Gillian Braunold, one of CfH’s national clinical leads for general practice, said major diagnoses and major procedures will no longer be included in the initial upload to the spine, a change in policy from proposals issued by CfH in the autumn.

She told EHI Primary Care: “We feel it is sensible to limit the initial record to just prescriptions and allergies because we want to make sure each set of records is fully correct. The profession felt strongly that although globally a practice might feel its records were good it was important to look at each set of records before they went up.”

This outcome can only serve to remind us just how difficult it can be to come up with a useful SEHR and to ensure the accuracy and utility of the data held as well as address all the other issues that arise (privacy, security etc).

Australia’s effort in this regard, termed HealthConnect, presently has a rather ambiguous status. While it has not officially been killed off, it now seems highly likely that it will not be built as originally conceived. This conception was of a large centralised repository which held an initial patient record (with standardised content) and then a series of “event summaries” which were created each time an individual had an encounter with the health system. Over time the event summaries were to form a longitudinal health record which lasted the patient’s life.

The key barriers to success of this project would seem to have been:

1. The lack of clarity about just what the information contents of a summary records should be to meet the benefits objectives of the project.

2. The inability to clearly recognise the importance of, and the need to standardise, the client systems which were to be the sources of the information contents for the SEHR.

3. The lack of provider and client identifier approaches as well as the lack of an agreed clinical terminology. (the need for these is now recognised six years on – and they may be available in 2-3 years)

4. The lack of properly conducted, transparent, well funded trails of the various components required to reach the 2001/2 vision.

5. The difficulty in working through the privacy and legal issues, as well as the consent issues, associated with the whole concept.

6. The lack of a properly thought through and compelling business case for the overall project – leading to a lack of budgetary commitment for the whole enterprise.

7. The lack of recognition that the quality and sophistication of the client systems was crucial to the overall justification of the project.

8. An inability on the part of the sponsors of the project to develop political and public support for the implementation of HealthConnect.

It seems clear to me the UK has been sensible in scaling back what they are attempting and to approach the whole endeavour incrementally – hopefully learning as they go on. I am firmly of the belief “big bangs” are not the way to success in Health IT.

David