Healthelink – Trundling Towards Failure?

Its now been about eight months (March, 2006) since the NSW Health Minister announced the commencement of the Healthelink trials in the Hunter and at Westmead so it seems about time to consider what has been reported or leaked out about progress.

The concept of the trial is as follows:

Healthcare providers (hospitals, GPs, diagnostic providers and community services etc) in two specific areas treating two specific categories of patients (the 65 + in the Hunter and the young children in Westmead) have an encounter record created each time they attend a participating facility.

The idea is that over time a longitudinal health record on each individual will be built up.’

On each encounter both demographic and clinical information will be captured.

The encounter from the GP, for example, will capture the following information automatically at the end of a consultation. Quoting directly from an Healthelink information sheet.

“The following fields will be extracted from GP electronic health record systems following completion of each consultation:

a Patient demographic data

• Surname, Given Names
• Date of Birth
• Medicare Number
• Gender/Sex
• Contact details (e.g. address, phone numbers)

b Consultation data

• Provider/clinician – name, role and location
• Diagnosis/reason for visit
• Allergies
• Pathology/radiology test results (when a GP associates a report with a patient record)
• Medications - Prescription Order Information (Script number, GP name and ID), Prescribed Medication (Name, Route and Instructions) and Medication Administration Information

GPs will be encouraged to enter the data into the coded fields (e.g. reason for visit, medications) in their practice clinical systems as only these data will be sent to Healthelink. Free text information entered into the clinical notes for example will not be sent to Healthelink. The coded field only approach means that GPs can be confident that a sensitive free text comment entered into the clinical notes will not be sent to Healthelink and will not be available for other providers or the patient to view.”

With this background a few comments and discoveries made while researching the progress of the project are worth sharing.

First, the exclusion of the text notes and the expectation of using the coded information in the diagnostic fields is quite problematic. Experience from HealthConnect trials in the NT showed coded data was often not provided and this often led to the situation where it was impossible to understand just what a particular encounter was about. Healthelink looks likely to have similar data-quality issues.

Second, a review of the patient searching capabilities provided to users of the system confirm the worst fears of those concerned with privacy protection. A search on a partial name and approximate age (+/- 5 years) generates a weighted (for match) listing which contains a pretty full demographic record with full name, address etc. Just the sort of thing abused wives etc want to keep to themselves! The system should insist on a much higher level of initial knowledge – not that even this would help in the case of an abusive spouse.

Third, the system has no apparent concept of location etc – so if you are on the data-base and have not opted out you are findable. Extension of such a system state wide is clearly very problematic.

The record displayed by the system once the patient is located is also not segmented into more or less confidential information which means the patient has to make a choice to opt totally in or out on the basis of the most sensitive piece of information in the record as far as they are concerned.

All these issues are in addition to the lack of initial consent to having information stored as would be the case had ‘opt in’ been selected. For reasons best known to itself the NSW Department has decided to ignore not only its own earlier reports on the matter but also its own explicit Health Privacy Principle.

“HPP15 Linkage of Health Records

“Personal health information must not be included in a system that links health records in one service with health records in another health service unless the individual it relates to has expressly consented”.

A specific regulatory exemption from HPP15 has been provided for the Healthelink pilot. Whether this exemption should be retained after the end of the pilot will form part of the pilot evaluation.

The regulation provides for the use of an “opt out” consent model. This ensures health consumers will continue to be able to exercise the choice as to whether or not they participate in Healthelink and to exercise this choice at any time.”

I am aware that at least some physicians are by no means convinced this NSW regulation does not violate the Commonwealth Privacy Act.

Leaving the whole privacy issue aside there are a few other points to be made and question to be asked.

1. Just why has all this taken so long?

Taken from the March 2006 Project Outline:

"In March 2000, the NSW Health Council set an objective for the NSW health system to implement the Electronic Health Record (to be known as Healthelink) by 2010. Health Ministers also endorsed the proposal for a National Health Information Network, known as HealthConnect. The NSW Healthelink pilots were endorsed as one of the trials for the National HealthConnect program.

In May 2004 the Health Minister announced that the Care Junction Consortium consisting of LogicaCMG, Orion International and Healthlink had been selected to work with NSW Health to implement NSW electronic health record pilots – expected to commence operation in the first quarter of 2006.”

We now know what was then EHR*NET was the original proposal and the rename came a good deal later. We also must wonder why the whole thing should take six years from concept to pilot. At this pace 2010 does not look all that good for a total state roll out. (Note the 2002 implementation plan of EHR*NET indicated the project would be complete by June 2007 – time to really pick up pace!)

2. In a very recent (25/09/2006) GP information document we find the following:

“How would the Practice apply for the GP Testing Grant?

The Healthelink system is complex and although the components of the system will be thoroughly tested centrally, assistance will be required with testing the system once installed at practices and as used by GPs. Healthelink is therefore requesting that practices offer to assist the testing process and become early adopters.

A grant of $10,000 will be available to these practices subject to signing up to participate, meeting the eligibility criteria and being in a position to install the Healthelink software by 30 November 2006 or a date otherwise agreed with Healthelink. More details are available in the GP Testing Grant Agreement. “

I wonder how the announcement of this largesse was missed by the press and when the decision was made to be so generous!?

It seems to me this is a sign of desperation on the part of the project to have practitioners concerned about liability and indemnity to get moving.

3. It seems to me there will some real issues involved in the scalability of this system in a technical and user sense. Having a search operate across million people data-bases may turn out to be a real challenge.

4. There is also a real issue about just what impact the system as presently conceived will have on practice work flow and what value the practitioner will receive. The lack of proper integration between Healthelink and the practice management system may prove to be very difficult to use in practice - switching between one system and another. To have the system used properly it needs to be quick to access and consistently provide useful and relatively complete information.

5. The project's approach of making records unavailable for 30 days clearly makes very little sense and needs to be reviewed in the context of an overall privacy approach review.

I am afraid this project has all the signs of a project that is on the ropes. I hope not since it has taken so long to get this far. In many ways I am not surprised. As those who have read this blog for a while will know I have always been convinced that the complexities and difficulties associated with shared summary electronic health records have been very underestimated.

Maybe a strategic re-think and revision of the privacy approach can grab victory from the jaws of defeat. I hope so.

David.

The AusHealthIT Manifesto – What is the Blog On About?

Since starting the blog in March I have written getting on for a hundred posts and have seen interest in the blog and comments slowly increase over that time. It has seemed to me that, with the research and thinking that has required, I now need to crystallise what I am trying to say and make sure I am achieving clarity in the objectives I have for all this. In doing this I want that the reader be under no illusion as to my background, perspectives and views.

As to background, its pretty simple. I am (was) a specialist in anaesthesia, intensive care and emergency medicine who has been working one way or another for the last 23 years to improve the use of information technology in the health sector.

As to perspective I am operating from the following assumptions which I am convinced are true.

First, Health IT is a potential major enabler of quality and safety in the delivery of health services, but is not the whole answer to safer, higher quality health service.

Second, the possible added value in increased deployment of advanced Health IT throughout the Health Sector is very large and delay is resulting in a very large opportunity costs in terms of both lives and dollars.

Third, while health service delivery is an information intensive activity which is able to be successfully assisted with Health IT, failure to involve and work with all types of health professionals and other stakeholder in the planning for and implementation of new Health IT is a catastrophic mistake.

Fourth, the deployment and use of Information Technology in the health sector in Australia is presently largely inadequate, underspent and ineffective.

Fifth it is clear that personal identified health information is seen by the public as something they want to have control over and any plans or implementation approaches that do not recognise this fact are for all practical purposes ultimately doomed.

Sixth, and somewhat paradoxically, what is needed is a carefully developed consensus based National E-Health Plan, Business Case and Implementation Plan which is then delivered in local contexts which respond to local needs but which conform to a national overall Framework (this is especially important regarding the selection and implementation of systems).

Seventh, there is pretty common agreement that most Government initiatives at both Federal and State level have not delivered as well as might be hoped. Most would also agree that at present there is little in the way of Federal Government leadership or direction being provided for the E-Health sector.

Eighth, there is a very large skills gap at both user and Health IT levels which needs to be addressed nationally with some urgency.

Ninth the lack of openness and transparency regarding both HealthConnect and other major Health IT project outcomes and failures has limited the learning that has been possible from the mistakes made so far. NEHTA appears to be replicating this mistake at the time of writing (November 2006). It is vital all lessons are learned – especially from the projects that have not worked out as desired

Tenth, it is important to recognise that commercial providers of Health IT have expertise and skills which should be exploited but equally health organisations need to bring comprehensive project management and change management skills as well as business understanding to any Health IT implementation.

Eleventh, in the words of the late Milton Friedman as far as Health IT is concerned there is “no such thing as a free lunch” (i.e. you have to pay for value received).

Twelfth, it is clear, largely because of the way benefits from Health IT are not recouped by the users of the technology, that there be mechanisms to have those return the benefits they receive to those who do the work.

Thirteenth, it seems highly likely that the major payoff from Health IT is to be found only in very advanced systems which improve clinical decision making and minimise errors both of omission and commission.

Last, there are proven and deployable Health IT solutions which can be successfully deployed today with the right project and change management. It is important to get on with it.

My view is that right now there is a lot of unfocussed, uncoordinated activity going on (some good and some bad) and that it is the time to take a step back, work out, at a national level, what is needed and how best to get there. As a nation in 2000/1 we had some good ideas with HealthConnect but we then lost the plot and momentum by early 2005. We can’t afford another wasted four years.

In the blog I hope to alert and warn where I see mistakes being made and lessons we should already have learnt being repeated. Hopefully the assumptions above will point to those things which need to be assured before investments are made.

Overall I am hoping to foster the change from a heard of cats to a sleek shoal of fish all swimming towards real, practical and achievable goals.

David.

Correction to Comments on South Australian Oacis System Security.

It seems I have been misinformed regarding the level of security offered by the Oacis.

John Mleczko, Director Projects Branch ICT Services, Department of Health, South Australia has informed me of true security status today. I quote from his note.

“In response to statements made in your article "Personal Health Information Privacy - The Elephant in the Room" posted 28 Oct 2006 10:04PM CDT you ask for correction in regards to access to the Oacis system implemented in South Australia's major metropolitan public hospitals.

You suggest “a clinical user at one hospital, once logged on, could access any record of essentially any type for any South Australian”. The security model is facility based hence this is incorrect which means a user at a hospital can access the records of their patients at that hospital. You also suggest that access is “non-individualised and non role based”. Access to Oacis has always been individualised and role based.”

He then goes on to explain, in detail, the various steps taken to ensure the logged on users stay within the correct bounds – including warnings, audit trails etc.

This is good news.

In response I have asked the following questions by e-mail.

“Hi John,

Thanks for that...Just so I am clear this means that the access privileges for a medical registrar who is in charge of a hospital over night has his/her privileges changed according to the time of day (own service versus whole hospital) and that the intern in Emergency only sees results undertaken at that hospital - even if there are results at IMVS etc for the same patient done recently?

When I last chatted to people involved (a year or two back I admit) it was suggested to me that once you had medical or other high level access to the database it was essentially "open slather" - or is that only for those providing information into Oacis who clearly would seem to need to be able to access the whole results data base - for historical comparisons if for no other reason.

As you know audit trails and warnings have hardly been 100% effective at the Tax Office and CentreLink

If it has always been true that there were no group log-ons to Oacis I am happy about that!

I will happily place an edit noting your comments once I am clear.

On a related issue, given Oacis is a shared database just what control does the individual patient have about the recording of data on that database and who can see the data. This becomes an obvious issue as soon as any information is made available in a shared way. Does a patient admitted to an Oacis using facility have the choice of what is shared from say previous admissions (e.g. they may want to suppress a pathology report mentioning products of conception etc)?

Cheers

David.”

One of the Oacis brochures from 2004 has an intern saying how useful it is to be able to access information from previous admissions so clarity is important I believe.

I will keep everyone informed as information becomes available.

David.

A Do Nothing E-Health Minister – Incapacity, Inactivity or Just Bad Advice from the Department?

Its getting to the time of the year when the Health bureaucrat starts to think of all things Christmas and congratulate themselves on a year well spent.

How is the report card looking this year I wonder?

In this context I guess it would be about time to remind Minister Abbott of what he said to the Sydney Morning Herald on September 6, 2005 and to use that as a benchmark.

See:

http://www.smh.com.au/news/next/erecords--a-healthy-chart-buster/2005/09/05/1125772438601.html

“Abbott's patience runs out

Federal Health Minister Tony Abbott admits to "a great deal of slippage" with the Federal Government's $128million national electronic medical records program but says he is working to ensure that patients get benefits within 12 months.

"I will do everything I can to meet these deadlines and I will be disappointed if we don't," he says.

His comments come after he told a breakfast briefing at Parliament House that he was "sick of trials and studies and working groups", and wanted to see electronic health records making a difference in patients' lives by the middle of next year.”

What do we see 14 month later?

A Department of Health and Ageing Report Card

Well it has been a year of focused but quite secret activity. The E-health Program from DoHA seems to be divided into five areas:

1. E-Health Business Development.

The emphasis here is on Managed Health Network Grants for development of health networking. They were announced December 2005 and the funds must be spent by June 30, 2007. Sadly no winners have yet been announced so the spend fest is likely to be amazing.

The earlier Eastern Goldfields Regional Reference Site, where amazingly expensive broadband access was provided to practitioners. The viability of the network is now questionable without the government subsidy

2. E-Health communications

This provides access to the HealthConnect Archive which has been pretty stable since February 2006. The June 2006 E-Health Newsletter has been reviewed earlier.

3. E-Health Governance

Progress here has been that the Council of Australian Governments (COAG) has announced 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.”

The strength of this commitment was emphasised by the disappearance of the Australian Health Information Council which is meant to be the peak advisory body to COAG on such matters. Clearly E-Health governance isn’t actually happening as best one can tell.

4. E-Health Major Programs

There are four major programs:

1. Broadband for Health.

Giving practitioners broadband internet access – clearly practitioners can’t find the $40 per month to pay for it them selves (tax deductible business expense of actually less).

2. HealthConnect

Said to be as follows:

“HealthConnect is an overarching national change management strategy to improve safety and quality in healthcare by establishing and maintaining a range of standardised electronic health information products and services for healthcare providers and consumers.”

Not much change seems to be happening federally (I will review the State HealthConnect initiatives in a separate post) and no one knows, or at least I don’t, what the “standardised electronic health information products and services for healthcare providers and consumers” are.

As most know, the E-Health Implementation Branch (previously responsible for all this including HealthConnect) has been wound down, after Dr Brian Richards and then Tam Shepherd left. Now it is being led Lisa McGlynn (who is ex NSW Health – but not an expert e-health or technology I am told).

I am also told all the original staff (with any corporate knowledge of e-health which they may have built up) have moved on, and the incoming staff are all people who have never worked in health and know nothing about e-health or IT. Apparently the States and Territories can’t get any sense out of them at all now. Many commentators have suggested to me they think that this tactic is deliberate to wind down the branch to nothing.

3. HealthInsite.

An excellent idea and well implemented. By far the best initiative of DoHA. Pity they have not had a few more good ideas since this service began in mid 2002.

4. NEHTA.

It is very hard to comment on NEHTA since it is a privatisation of Government accountability to ensure that if it does not work the Minister can't be blamed and that the truth will never be known as Freedom Of Information does not apply.

Sadly NEHTA is not an outsourced e-Health Government strategy - or the Government would have had an outsourcing contract with all the usual performance hurdles and rewards.

The NEHTA Directors must be hoping some concrete results will be delivered soon since the organisation now has over sixty staff and, as yet, it is hard to see that much has been delivered other the FUD (Fear, Uncertainty and Doubt) on the part of all the other actors in the E-Health space.

My view is that unless there are some really useful and practical outcomes within the next six months (i.e. having been in action for just on three years (Authorised by COAG July 2004)serious questions will start being asked. The opportunity cost of all this inactivity is really astronomical in terms of patient suffering and lives lost.

5. E-Health Strategic Policy.

This section comes direct from the DoHA web site

“Information regarding e-Health strategic policy and how it is being implemented is found in this area of the website.

Strategic policy alignment takes a strong focus on the monitoring and analysis of trends and technology, in order to drive the Australian Governments' e-Health agenda. The work involves the provision of advice on Departmental, other government and independent e-Health related activity and the establishment of appropriate regulatory frameworks to enable e-Health nationally. Much of this work is linked with the National E-Health Transition Authority (NEHTA) work program. Further information about NEHTA and the work program can be found at the following site: www.nehta.gov.au

Page last modified: 21 April, 2006”

Sadly there is not a word about policy other than it has been passed to NEHTA, and can be understood as a work-program!

What does this all amount to?

I would contend it amounts to a virtually total abdication of central government involvement in E-Health. We have seen no significant concrete progress and the National E-Health Strategy, Business Case and Implementation Plans remain non-existent and the relevant Federal bureaucracy seems to have essentially imploded.

I hope next November I can write a happier report. I suspect our Health Minister must be very disappointed and frustrated in the progress made in the last twelve months!

David.

The Drug Pricing Scandal and How the Sick are Ripped off in Australia.

First, apologies to the die hard Health IT readers. For once I am going to stray from the chosen Health IT path, due to a deep sense of gob smacked outrage.

In the last week or so we have had the Federal Health Minister – Mr Tony Abbott – claiming he has just done a wonderful job negotiating a great reduction of the cost of generic prescription medicines and how grateful we all should be.

Without putting too fine a point on it that was just total codswallop.

A day or so the Wall Street Journal made available the pricing for Generic Prescription Medicine from Wal-Mart – the US retail chain. I grabbed the seven page price list document to see just what was on offer.

Essentially what is available is one months supply of a very large range of life saving medicines in a wide range of therapeutic classes for $US4.00 – i.e. $A5.30 per month.

Included in the list are Anti-Allergy, Anti-Inflammatory, Anti-Anxiety, Anti- Depressant Anti-Psychotic and so on medicines. Also included are a wide range of antibiotics (including Penicillin, Amoxycillin, Bactrim, Cephalosporins and even Ciprofloxin), 2 statins drugs, some hormones (e.g. Thyroid Replacement Therapy and Prednisone) and even multi-vitamins and Prozac.

The only major class of drug I could not find were the proton pump inhibitors for which the H2 Receptor Antagonists are nearly as good and just as safe. The PPIs will be off patent very soon I am sure (They are in Australia I believe) or it might be they are a bit more costly to manufacture.

The stand out saving for me was that Meloxicam – an anti-inflammatory for osteo-arthritis that I take was available for $5.30 a month rather than the $29.50 I presently pay! Without going into details my monthly $100 prescription costs could be adjusted down to about $20 a month with little or no change in the quality or safety of my treatment.

This really is a huge con with the drug companies and the pharmacists getting rich off the back of those unlucky enough to need prescription medicine. With this fix in a huge number of people are being ripped off and many, I am sure, are missing out on effective medicines that could make a great difference to the quality and quantity of their lives due to costs they may not be able to afford.

Our much vaunted Pharmaceutical Benefits Scheme looks to like a wonderful cosy drug company – pharmacist – government cartel to me. Transparent it certainly is not and how – with these sort of savings possible – one can justify keeping the supermarkets out of the area is beyond belief.

We will now return to our usual program with that off my chest.

David.

Note – Please e-mail me if you want a copy of the list – its only about 50Kbyte so easy to e-mail.

Clinical Software Certification – What’s Practical, Necessary and What Makes Sense?

In the last few months there has been some correspondence in the Medical Journal of Australia and elsewhere on the topic of the safety of clinical software and the possible need for certification of such software.

In this commentary I want to consider this suggestion from a range of perspectives including practicality, barriers to implementation, likely impact on quality of care and so on. I would also like to point out that from my perspective, while I believe it is vital, certification of clinical software is likely to prove clinically challenging, technically complex as well as commercially contentious.

Before going any further it is important to say that I recognise the inherent difficulty and complexity of the topic and need to take a perspective that ignores the system user – recognising the unreality of pretending areas such as user skill, attention, competence and experience are not important in the overall outcome. What I seek to achieve here is to try and identify the different components of an approach that may address the issues around having the practitioner be confident that the system they are using is providing the best possible aid and support for their care delivery.

What attributes are needed for the purchaser and user to be sure this to be so?

I would suggest the following are important.

1. Data Model

The target system needs to have a sufficiently rich data model to support both the usual data capture required in a clinical EHR system as well as the detailed – and hopefully structured information required for automated decision support. This means that at the very least crucial laboratory results (e.g Haemoglobin, Creatinine etc) will be captured in atomic form.

Clearly there is also the need to address coding / terminology in appropriate areas (e.g. diagnoses, medications etc) to ensure useful values are held and are computable to support clinical decision making.

2. Functionality

The functionality of the EHR system that is required for quality care delivery has been the subject of much work over the years and is quite well understood. The requirements contained in the General Practice Computing Report in Australia and the HL7 and CCHIT specifications for the US provide quite reasonable guidance in this area.

Clearly the full scope of these requirements including clinical decision support and clinical pathway management and tracking are required.

3. Knowledge Database(s)

While vital, here we arrive at a major difficulty. This is at least one area where the quality, scope and depth of what is required is likely to prove less than straight-forward to define.

4. Interoperability

As attractive as ‘vendor lock in’ may or may not be to commercial software providers it is anathema to software customers and users. For this reason all information stored in the EHR should be exportable in a standard – and preferably standardised form to any certified competing product.

5. A Commercial Future

With use over time the value of the information held in a clinical system becomes progressively larger. The purchaser / selector of a system, which will be expected to be operational for ten years or longer, needs to be confident of the commercial viability of the software provider in terms of maintenance, updates, recurrent costs and so on.

6. Messaging and Communications Capability

Systems these days do not live in a vacuum and they need to be able to securely transmit and receive both clinical and administrative information in a seamless and standardised fashion.

7. Usability

It is important any systems should be engineered to be both easy to use and also to be designed using the principles applied to aircraft-cockpit design where the important information cannot be overlooked easily or without warning.

It should be noted that while the emphasis in this article has been on ambulatory systems all the forgoing is just as relevant to the hospital and other larger provider sectors.

The next issue is how is assurance obtained that these attributes are indeed present and are of the quality etc required.

Given the current political situation it seems to me that what is required is a CCHIT (Certification Commission for Healthcare Information Technology in the USA) like organisation, funded by, but at arms length from, Government that can work with users and all the other stakeholders to develop the requirements and criteria in each of these areas and then offer incremental and reasonably in-expensive paths to certification.

The CCHIT approach of developing roadmaps of requirements and capabilities to be delivered over a known time-frame I see as remarkably sensible and pragmatic and well worth adoption.

Clearly the Australian CCHIT would need to work collaboratively with both system developers, academia, clinicians and standards bodies to develop and then assess systems against the agreed criteria. This said it would also be important to have very professional leadership of the commission in place to ensure there is no easy route for less than high quality systems to be certified. A half baked process would be far worse than no process at all.

My guess this would be of the order of a five year project to get where we need to be with initial certifications possible in two to three years.

To not go down this path will leave individual purchasers and vendors possibly, indeed almost inevitably, liable for possible errors of omission or commission. The Government must really act to provide appropriate coverage for all those in the E-Health sector.

The other step I believe is required is that there be financial incentives for the clinical users to both install and then use the advanced systems as we know from the study reported yesterday that it is only the actual use of capable quality systems that makes a real quality and safety difference.

The business case for the Commonwealth to do this in the Ambulatory Sector I am sure would be totally compelling!

David.

A Vision of E-Health Nirvana - We Know What is Needed!

It seems that, given my advanced age and galloping decrepitude, that I will not last to ever see the E-Health nirvana. However, today, HIMSS Analytics has published the report that will allow me to slip off to the grave a “very happy Vegemite” knowing, at least, nirvana is possible!

Today, the following appeared in the overnight issue of the Health IT Strategist (HITS) – the Health IT publication from Modern Medicine in the US.

"Greater benefits seen in advanced apps: study

There are few substantial correlations between improved healthcare outcomes and "incomplete" electronic medical-records systems, according to a new white paper from the Healthcare Information and Management Systems Society and its not-for-profit subsidiary HIMSS Analytics, but the more sophisticated the EMR system, the more it improves the quality of care.

"Perhaps it’s appropriate to borrow a line from the addiction-recovery industry," the report stated. "When it comes to the electronic medical record, it appears that half measures avail us nothing."

On the other hand, along with improving quality of care, the white paper stated that advanced applications such as computerized practitioner-order entry and clinical documentation can also increase hospital revenues related to pay-for-performance initiatives.

The findings are based on a study of 107 University HealthSystem Consortium hospitals that looked at how well hospitals did on 63 quality measures developed by the Agency for Healthcare Research and Quality and how advanced the hospitals’ EMR systems were. The study split the EMR systems into eight different stages of implementation, but no hospital in the study had implemented a system in the highest stage, and less than 1% had implantations in the levels five or six. In fact, most hospitals were still in stages zero, one and two.

The report concluded that there was a significant increase in quality scores between the 39 level-three hospitals and the 22 level-four hospitals. A main difference between the two levels is that level-four hospitals have implemented CPOE. According to the report, stage-three hospitals had six slight positive correlations between their EMRs and AHRQ’s quality measures and only one strong positive. Level-four hospitals, however, had nine strong positive correlations and 11 slight positives. The strong correlations included the areas of acute stroke, heart failure in-hospital mortality percentages and gastrointestinal hemorrhage in-hospital mortality percentages.

-- by Andis Robeznieks / HITS staff writer"

The report, which makes very interesting reading, and draws, I must say, quite conservative conclusions, can be found at the following URL.

http://www.himss.org/content/files/UHCresearch.pdf

The core conclusion, re-stated is that to make a real difference with clinical systems what is needed is both Clinical Physician Order Entry and Clinical Decision Support based – not just on simple error checking but on ensuring that evidence based clinical protocols are being adhered to as frequently as possible. Obviously this makes perfect intuitive sense and supports the studies mentioned previously on the blog that show at the real benefits of clinical computerisation are really only to be had when advanced systems are deployed. (See the blog article Saturday, August 26, 2006 Interactive Electronic Decision Support Benefits - Keys to the Literature).

The findings of the report have a number of important implications.

1. There is more to assessing the value of a clinical EMR system than Return on Investment (ROI).

2. We are further assured that the major investments suggested by this blog are, in fact, necessary and that half measures are a waste of time and money. The UK has it right to at least attempt a quantum leap in the level of health system automation – the debate now is only really around are they going about it the right way!

3. The identification of the need for advanced systems to achieve real clinical outcome improvements makes a mockery of the penny pinching approach to Health IT being adopted by the present Australian Government.

4. The transformation task to get Australia from where we are now to where we need to be to really improve health outcomes and patient safety is a really, really big one that is not being helped by the lack of a National E-Health Strategy.

5. It is largely pointless attempting to develop benefits models and benefits realization approaches unless you make clear assumptions about the advanced nature of the systems required and ensure the business case recognises the scale of both the cost and the benefits.

6. It is no longer sensible to not have clear guidelines as to the capabilities and functionality that should be delivered to ambulatory (GP and Specialist) and hospital practice.

NEHTA needs to change focus and really start addressing these implications if it is not to become part of the problem rather than part of the solution.

David.

Identity Management – The References.

It occurs to me, following a couple of e-mails from some of those interested, it might be worth providing a few pointers to where some useful further information can be found for further research and reading.

The topics and URLs are as follows:

1. Australian Office of the Access Card

http://www.accesscard.gov.au/

This is a new site and has the work of Professor Fels and his taskforce as a sub area at the following URL

http://www.accesscard.gov.au/consumer_privacy_task_force.html

The full press release is worth a careful read as is the Government’s response which is also available at the site.

Media Release

Access Card Consumer and Privacy Taskforce Recommends Safeguards

08 November 2006

Safeguards to protect personal privacy and security and to maximise consumer convenience have been recommended by the Access Card Consumer and Privacy Taskforce.

“Comprehensive legislation to define and regulate the role of the card and associated databases is needed. This will build public trust and confidence, and establish safeguards regarding current and any new future government uses of the card”, Professor Allan Fels AO, Chairman of the Taskforce and Dean of the Australia and New Zealand School of Government said.

“The card is a health and social services access card. It should not be allowed to develop into a national identity card by virtue of “function creep”. Legislation should ensure the card is not a national identity card nor an electronic health record nor have any link with tax records nor be required to be carried by individuals.

The legislation should also prohibit anyone requiring individuals to produce the card (except when they are accessing defined Commonwealth benefits and services).

“The legislation needs to define what the card will and won’t be”, Professor Fels said. More details of the recommended legislation are in the report of the Taskforce.

“Function creep” can be minimised by requiring any new future government uses only being permissible by legislation. Function creep can also be reduced by limiting the ultimate capacity of the card.

Australians should own the card. This will give individuals better control and limit the scope for government and others to determine future uses. There should, however, be some limitations on inappropriate usage of the card e.g. tampering with it, or altering prescribed information on the card.

Card holders should not be required to have their legal name on the face of the card if they have a preferred name they commonly use. There are legitimate reasons why consumers would want to have a name displayed on the card which differs from their legal name such as those who use Australianised names, middle names, changes of name in indigenous communities and maiden names. Their legal name, however, would be stored on the chip and on the register.

The Taskforce accepts that there needs to be a photo on the face of the card (as well as in the chip and stored in the secure customer registration system). This will minimise fraud, increase convenience for card users and government agencies and improve its capability for proof of identity (where consumers choose to use it for that purpose).

“Regarding the storage of the photo on a national photographic database, there is merit in considering the storage in the form of a template rather than in the form of real photos. This would reduce possibilities of fraud and misuse”, he said.

“However, this must be weighed up against cardholder and government convenience. If a card is lost, as frequently happens, the cardholder would have to be rephotographed if the photo was not stored in real form”, he said.

“If there is to be a real photographic database, it is critical that there be maximum security precautions. This should be held separately, within the register, from other cardholder data and there should be stringent special controls to prevent unauthorised access and improper usage”, he said.

The Taskforce is sceptical for the need for a digitised signature to appear on the card. The signature seems to be of limited use and it increases the dangers of identity theft and fraud. Again, whatever the outcome, digitised signatures should be subject to rigorous controls to prevent unauthorised access and improper usage.

The Taskforce accepts that there needs to be a number associated with each card, even though this means that each cardholder then has a unique number assigned to them.

“The taskforce considers that the number should not appear on the reverse of the card”, he said. If the card number is not displayed it reduces the risks of the card slowly developing into a “unique personal identifier” number for the Australian population (that is, each Australian eventually has a unique number assigned to them). Also, if the card number is displayed it increases the risk of fraud. This risk outweighs some advantages for government administration and user convenience. In the alternative the government should give consideration to making the inclusion of a unique number on the reverse of the card a matter of genuine choice for the card holder.

When consumers register for their card they will bring documentation to verify their identity. Should copies be taken of these documents and retained on file in accordance with existing practice?

The argument for the copying and retention of proof of identity (POI) documentation relates to measures taken to detect and control fraud.Such records are accessed by relevant Departments where there is some suspicion of illegal behaviour or identity fraud, or in cases where original documents are subsequently lost or destroyed. Such a procedure may, in some instances, also be required under statute.

The Taskforce supports capturing proof of identity documentation for the purposes of establishing identity and verifying their authenticity but has recommended that they should not be scanned, copied or kept on file after they have been verified.

The Taskforce notes statements by the Government that the card is only to be used for access to health and welfare services. The Taskforce notes that the Government is also in the process of considering the adoption of a National Identity Security Strategy which aims to require a very high (“Gold Standard”) proof of identity.

However, the Taskforce does not believe that the ‘Gold Standard’ being considered for a National Identity Security Strategy is necessarily appropriate for use by to facilitate delivery of health and social services benefits. The most disadvantaged and marginalised members of the community who may be unable to provide sufficient documentation to establish their identity should not be unnecessarily burdened by this process.

The Taskforce has recommended an extensive public information campaign explaining the nature of the card.

The Taskforce makes a number of recommendations to the Government for the ongoing design and implementation of elements of the card. Fundamental to further consideration of these elements by Government is the continued process of consultation that needs to occur between the Taskforce, the Government’s Lead Advisor and Chief Technology Architect.

The Taskforce is committed to ensuring that the views of all Australians feed into the design of the access card system.

The Taskforce is currently working on the second discussion paper, which will consider the Registration process and will seek to ensure that there is continued consultation with consumer and interested groups. This paper is expected to be released for discussion in November 2006.

The Consumer and Privacy Taskforce

The Consumer and Privacy Taskforce, was established in May 2006 to report on consumer and privacy issues arising from the Government’s announced plans to introduce a new health and social services access card.

The Taskforce released an initial discussion paper released on 16 June 2006. The Taskforce has met with 120 representative groups and received over 100 written submissions.

The Taskforce’s believes that all decisions about the design of the card should be made in as transparent a fashion as possible and be informed by public consultation.
The Report makes 26 recommendations.

A copy of the report can be found at www.australia.gov.au/accesscard. The report is titled Issues and Recommendations in Relation to Architecture Questions of the Access Card.

The Government response is found here:

http://www.accesscard.gov.au/publications.html

2. Report from the UK House of Commons: Identity Card Technologies: Scientific Advice, Risk and Evidence

This can be found at the following URL.

www.publications.parliament.uk/pa/cm200506/cmselect/cmsctech/1032/1032.pdf

3. A Blog on Identity by Kim Cameron.

Kim Cameron is Architect of Identity and Access in the Connected Systems Division at Microsoft, where he drives evolution of Active Directory, Federation Services, Identity Integration Services, CardSpace and Microsoft’s other Identity Metasystem products.

See http://www.identityblog.com/

Of particular interest are the Laws of Identity found here.

http://www.identityblog.com/?page_id=354

In very brief high level summary these seven laws are.

1. User Control and Consent:
Digital identity systems must only reveal information identifying a user with the user’s consent.

2. Limited Disclosure for Limited Use
The solution which discloses the least identifying information and best limits its use is the most stable, long-term solution.

3. The Law of Fewest Parties
Digital identity systems must limit disclosure of identifying information to parties having a necessary and justifiable place in a given identity relationship.

4. Directed Identity
A universal identity metasystem must support both “omnidirectional” identifiers for use by public entities and “unidirectional” identifiers for private entities, thus facilitating discovery while preventing unnecessary release of correlation handles.

5. Pluralism of Operators and Technologies:
A universal identity metasystem must channel and enable the interworking of multiple identity technologies run by multiple identity providers.

6. Human Integration:
A unifying identity metasystem must define the human user as a component integrated through protected and unambiguous human-machine communications.

7. Consistent Experience Across Contexts:
A unifying identity metasystem must provide a simple consistent experience while enabling separation of contexts through multiple operators and technologies.

4. The Australian Attorney General’s release on Identity Theft of May 2006 which refers to the still unpublished National Identity Security Strategy (NISS).

http://www.ag.gov.au/agd/WWW/ncphome.nsf/Page/Identity_Theft

5. The Information Commissioner’s Office of the UK Government.

Has a broad range of material on privacy, ID fraud, identity cards and surveillance including the very recent and terrifying report revealing there is now one CCTV camera for every 14 UK citizens.

http://www.ico.gov.uk/

6. The Office of the Australian Privacy Commissioner.

This is a vital site which in the last year or two under Karen Curtis is really producing some excellent work in my view

http://www.privacy.gov.au/

7. The Australian Privacy Foundation.

Putting the case that the Access Card is just a stealth ID card. It is unclear at this point of Minister Hockey or Ms Anna Johnston are winning the debate. Probably the peak Australian privacy lobby group.

http://www.privacy.org.au/


8. Roger Clarke’s Dataveillance and Information Privacy Home-Page.

A well thought out set of Australian resources from an academic who has been thinking about this area for many years.

http://www.anu.edu.au/people/Roger.Clarke/DV/

I hope these are useful.

David.