Draft Submission to the BCG NEHTA Review from Dr David G More.

Note: This is a draft – any comments from readers will be considered and may be included in final submission to the BCG – Due on 27 July, 2007

Executive Summary

E-Health in Australia is rapidly becoming a national disgrace and the opportunity cost of not addressing it in terms of both money and lives is rising relentlessly.

The following offers an expert, independent view of NEHTA’s performance to date and recommends two key steps to remedy the currently disastrous situation.

These are:

Urgently the governance of NEHTA needs to change. The Board needs to have 2-3 representative E-Health Experts (from ACHI, MSIA, Industry etc ) and one or two independent experts added with the Jurisdictional representation dropped to 3-4 members. The Board also needs a highly qualified technical and a highly qualified clinical advisory committee with real influence and teeth. Note: The Australian Health Information Council (AHIC) – which should also have broad stakeholder input - is the right entity to ensure NEHTA stays focussed on delivery in the context of an AHIC managed strategy which I recommend below.

Longer term – six months – A consultative, inclusive, national E-Health Strategy, Business Case and Implementation Plan must be developed. This will then need to be reviewed and properly resourced and funded – managing the state / Commonwealth divides etc. NEHTA should then be managed by the governance approach recommended in that strategy and take its priorities from there as well.

Once this is done some hope and certainty may return to the E-Health Domain in Australia.

(I look forward to discussing the contents of this submission with BCG. I can be contacted via my blog by e-mail)

Background of Preparer of Submission.

David MORE MBBS(Hons) BSc(Hons) PhD FANZCA FJFICM AFACHSE FACHI

Much deleted as irrelevant for blog post!

For the last 15 months Dr More has been writing a blog on e-Health in Australia. The blog describes itself in the following terms:

“This blog provides a commentary on the progress (or not) of e-health in Australia from the perspective of some-one who has worked in the field for over 20 years and has become a bit jaded with the lack of apparent progress in a very important field.”

The blog now has over 4700 page views a month and is widely read and discussed by many participants in the e-health arena.

Strategic Analysis of Australian e-Health

E-Health is an overarching term to describe the deployment of ICT to support the operations of and to improve the outcomes (clinical, operational, financial and administrative) of the health system.

Experience from all over the world has shown that the implementation of e-health solutions in the health sector is a major challenge. Writing in the British Medical Journal a couple of weeks ago (BMJ Volume 334(7608), 30 June 2007, p 1373) Joan S Ash got it as close to right as I have ever read when she wrote”

“Why is implementation of health information technology such a universally difficult process? It is because we are transforming health care through information technology rather than simply automating old processes. Workflow and work life must change, which means people must adapt. Such change is deeply disruptive. The related personal and organisational challenges are enormous, yet efforts to manage change receive inadequate attention and funding.”

It is my view that NEHTA, an organisation that has virtually no practicing clinicians working with it and manifests virtually no insight into the way the health system really works, has totally overlooked this reality and has so ensured it is essentially irrelevant to the Australian Health System at large.

NEHTA’s problems have been also made much more dramatic and intractable by the following:

1. NEHTA’s lack of any real customers. The private sector simply ignores NEHTA and the public sector merely pays lip service to NEHTA’s recommendations. They have to get on with business while NEHTA plans to offer some “building blocks” some time in 2009.

NEHTA seems to have an almost ‘Field of Dreams” approach to what it is planning and developing in terms of identity management and terminology. They assume if it is built, they will come. I really wonder how true that actually is?

2. The fact of the Australian Health Information Council (AHIC) vacating the field between 2005 and early 2007 – removing the last vestige of any peak Strategic Planning entity which could guide the technically orientated NEHTA in sensible directions and provide some real-time feedback as to the relevance and applicability of what NEHTA was doing.

There is considerable confusion about the division of responsibility between NEHTA, AHIC, Standards Australia and the e-health component of the Department of Health and Ageing.

3. The lack of clarity about just what NEHTA is a Pty Ltd Company which seems at once to be both a Standards Developer and a Standards Taker, as well as having no real governmental authority.

4. NEHTA was meant to be a core enabler of E-Health progress but its approach has resulted in the deferral in all sorts of potentially useful initiatives while its staff try to understand the complex tiger they now have by the tail.

5. The recognition among a range of stakeholders that progress in E-Health is important and has not gone anywhere near as well as might have been hoped. See my open letter to Minister Abbott:

http://aushealthit.blogspot.com/2007/03/open-letter-to-minister-tony-abbott.html

And the Departmental Response:

http://aushealthit.blogspot.com/2007/06/minister-abbot-responds-to-open-letter.html

6. The blunt, and occasionally almost over the top, media management tactics NEHTA is known to employ and of which I have first- hand knowledge.

7. NEHTA’s failure to appreciate just how sensitive citizens are to retaining control of their private health information. They have not addressed this issue adequately in my expert view.

I have recently (May 2007) summarised my views of NEHTA’s current performance.

See http://aushealthit.blogspot.com/2007/05/nehta-how-far-has-it-come.html

The relevant part of that post is the following:

I think the answer to the question of what NEHTA has achieved is that "It is too early to tell yet” as the probably apocryphal story suggests was said by the great Chinese revolutionary Chou En-lai when asked for his for his evaluation of the French Revolution.

This said there are two things that can also be said. First , what NEHTA is attempting is no doubt a major complex challenge and second that so far, from the point of view of an external observer, they seem to be going about their brief very incompetently. From where I sit the risk of overall failure looks worryingly high.

What have they and are they doing wrong?

The key things I see as mistakes are:

1. The failure to develop an operational Strategic Plan, Business Case and Implementation Plan to facilitated the delivery of the outcomes sought by Health Ministers in August 2004 when NEHTA was authorized (Based on the Boston Consulting Group work of the same year).

2. The decision to corporatize the NEHTA entity which has removed NEHTA from effective public scrutiny and review and has disengaged the body from many of its public sector clients.

3. The ongoing lack of quality in many of the NEHTA documentary deliverables. Other than the document relating to the adoption of HL7 there have – in the last year – been a series of either useless or incomplete or excessively impractical documents produced with have added minimum value to the Australian E-Health domain. ( A secondary problem is the ‘ex cathedra’ approach to document release).

4. The continuing lack of transparency regarding NEHTA internal decision making with commercial-in-confidence and secrecy being made an art form quite unnecessarily. Given the public policy and standards role NEHTA is meant to play there should be totally open policy development processes and all strategic advice received by NEHTA should be made public for comment and feedback. Equally the NEHTA Board should publish relevant and adequately detailed minutes of the policy aspects of their meetings.

5. The failure to seek proper engagement with the Medical Software Industry.

6. The failure to ensure the boundaries between the roles of DoHA, the Australian Health Information Council, the States and Standards Australia’s IT-14 Committee were well defined and able to be understood so roles and responsibilities were clear.

7. The tokenistic way much of the stakeholder consultation has been undertaken and the almost Joh like “don’t you worry about that” style of management. The privacy consultations undertaken so far are examples of listening at its worst.

8. The obvious “tail wagging the dog” mode of operation seen in the way the NEHTA Executive and the NEHTA Board interact. Given the public sector backgrounds of the Board members if they actually understood what was at stake and enough of what was happening internally within NEHTA to manage it actively I am sure it would be a different, more open, more consultative and much more useful organisation.

9. The failure of the NEHTA Board and Management to recognise there are urgent issues which need to be addressed at both State and Commonwealth levels. The time frames NEHTA is working to are excessively relaxed – especially given the level of resourcing and staff available.

10. The sectional focus – on Public State Hospital Issues and Commonwealth Issues with minimal focus on either the private hospital or private practitioner needs. The lack of a holistic Health System Wide vision and approach is a key failing.

11. The delays that are now becoming obvious in a range of the work program components. The worst apparent examples are in the Benefits Realization , Shared EHR and Medicine Terminology areas.

To date the only successes I can see are the acquisition of the national license for SNOMED CT and the decision to adopt HL7 as a messaging and possibly EHR content Standard. Not much really for the $20+ million NEHTA has cost to date – excluding the money being spent on the UHI projects. Progress on the needed extensions to SNOMED CT before it is useful has been slow and seemingly badly managed if the delays in delivery are anything to go by.

The bottom line is that what NEHTA is trying to do is very badly needed, but the way they are going about it is deeply flawed in my view and the direction needs serious modification.

I have also expressed what I believe are significant process issues with the present review. These may be reviewed at the following URL:

http://aushealthit.blogspot.com/2007/06/nehta-review-i-sure-hope-it-helps.html

With that broad overview of my concerns I offer the following specific comments in response to the specific questions asked by the review –while suggesting the scope of the review – which does not appear to address the entire national E-Health Strategy, and NEHTA’s role in it, is just too narrow to have a satisfactory outcome.

Responses to Specific Questions (See Appendices)

Section 1.0

1a. – NEHTA actually commenced operation in November 2004 and so has been in operation over 2.5 years. In answer to “Has NEHTA achieved what was intended for it?”
No – see details in the section above.

1b. “Was NEHTA tasked with the right objectives in the first instance”

No – The absence of an overarching national E-Health Strategy has meant there has been incoherent and unfocussed activity and not much in the way of real outcomes.

NEHTA should have been something like the delivery arm of an E-Health Strategic Implementation Office.

1c. See above

1d. NEHTA has slowed down progress and alienated many of the volunteers who used to undertake standards work. The quality of the work they have done has been excellent but must now be seen as being under threat due to withdrawal of corporate support and other gradual reduction in resources.

1e. See recommendation below

1f. The recent meetings involving the MSIA and others make it clear the engagement model is deeply unsatisfactory. The only ones who are happy are those who are being awarded lucrative contracts by NEHTA as best I can tell.

1g. Significant good outcomes in E-Health will not be achieved with the current investment levels. The investment is not coherent, planned and rational at present. A symptom of the lack of an agreed overarching national E-Health Strategy, Business Case and Implementation Plan.

Section 2.0

I do not believe any of these questions can be addressed in the absence of national E-Health Strategy, Business Case and Implementation Plan. To fiddle around with NEHTA without being clear where all the other actors fit is folly in my view.

Concluding Remarks and The Suggested Way Forward

In my view NEHTA has been a dismal failure which has been characterised the worst possible outcomes for all the key stakeholders.

As I argue elsewhere in my blog there is opportunity to make a real difference in health service delivery without waiting for NEHTA’s long term R&D program to deliver –if it ever does.

See http://aushealthit.blogspot.com/2006/03/australian-e-health-strategy-why-what.html

Urgently the governance of NEHTA needs to change. The Board needs to have 2-3 representative E-Health Experts (from ACHI, MSIA, Industry etc ) and one or two independent experts added with the Jurisdictional representation dropped to 3-4 members. The Board also needs a highly qualified technical and a highly qualified clinical advisory committee with real influence and teeth. Note: The Australian Health Information Council (AHIC) – which should also have broad stakeholder input - is the right entity to ensure NEHTA stays focussed on delivery in the context of an AHIC managed strategy which I recommend below.

Longer term – six months – A consultative, inclusive, national E-Health Strategy, Business Case and Implementation Plan must be developed. This will then need to be reviewed and properly resourced and funded – managing the state / Commonwealth divides etc. . NEHTA should then be managed by the governance approach recommended in that strategy and take its priorities from there as well.

Once this is done some hope and certainty may return to the E-Health Domain in Australia.

Appendices

Appendix 1 - Call for Submissions

The Boston Consulting Group (BCG) has been selected to undertake an independent review of NEHTA, and assess any future role that it should play. As part of the review, BCG would like to receive submissions on:

1. NEHTA’s effectiveness in meeting its objectives during the two years since its inception, including:

a. The consistency of NEHTA’s current role and function with its objectives as laid out in the NEHTA constitution[1] – “Has NEHTA achieved what was intended for it?”

b. The appropriateness of NEHTA’s objectives, given the needs of eHealth development in Australia - “Was NEHTA tasked with the right objectives in the first instance”

c. NEHTA’s goals, strategies and work plan, including any gaps or overlaps with the work of other bodies

d. Progress achieved in deliverables and outcomes, especially with regard to the development of standards and the establishment of core information infrastructure for eHealth.

e. NEHTA’s structure and governance arrangements

6. The consultation and communication process NEHTA has undertaken, including:

§ The engagement process that has been conducted

§ The completeness and quality of the content that has been communicated

§ The outcomes that have been achieved as a result of consultation

7. The funding for, and value for money achieved by NEHTA, including:

§ The balance of resources committed to different activities and objectives

§ The level and mix of sources of funding

2. Possible roles for NEHTA or a similar entity in the context of future eHealth reforms, including:

1. Roles and responsibilities for existing players and/or potential new players, including NEHTA, in eHealth reform going forward

2. Priority next steps in delivering eHealth objectives

3. Vehicles and sources for funding the next steps
   
   
4. Potential governance models
   
   
5. Ongoing operation and maintenance of standards and infrastructure established by NEHTA

Submissions should be received by the 27^th July 2007 by:

Email: addressed to nehta_review@bcg.com

Fax: Addressed to NEHTA Review Team – Fax No 02-9323-5666

Mail: Addressed to: NEHTA Review Team

BCG

Level 28, Chifley Tower

Chifley Square

Sydney, NSW

2000

In addition to collating written submissions, BCG will be scheduling interviews with a number of stakeholders to gather supplementary data.

Appendix 2.

Article 3 of NEHTA Constitution

Objects :

The objects of the Company are all or any of the following:

To provide the critical standards and provide and manage the development of infrastructure, software and systems required to support connectivity and interoperability of electronic health information systems across Australia;

To research, develop and implement national health information projects including (but not limited to):

3.1.1 clinical data standards and terminologies including the development of standards, and common terminologies for health information for clinical service delivery, planning, policy-making and research purposes and communication between health systems in Australia;

3.1.2 patient, provider and product/service standards and directories/indexes that contain information necessary to uniquely identify patients, providers, products and services and other relevant information across the whole of the health sector in Australia;

3.1.3 identification standards to define the data structure and specification for the capture and storage of information required or the identification of patient, provider and product/services in Australia;

3.1.4 a product services directory which contains information for identification of products and services;

3.1.5 consent models governing collection and handling of electronic health information;

3.1.6 EHR standards;

3.1.7 technical integration standards to define the structure and rules by which information is exchanged between systems and users;

3.1.8 supply chain efficiencies, including exploring options such as common forms of procurement, standard contracts and common purchasing processes;

3.1.9 user authentication and access control to ensure compliance with privacy laws and the consent models which have been developed;

3.1.10 EHR secure messaging and information transfer, including identifying and managing the development of a national security model for messaging and information transfer between health care providers' systems;

3.1.11 a knowledge centre, providing knowledge-sharing and expert advice to the public and private sectors on business case development and implementation requirements for health information systems so as to meet national standards and architectures; and

3.1.12 to encourage health information industry reform and to facilitate opportunities in driving technological reform in health information technology, so enabling consistent interoperability and implementation of national health information technology priorities.

Any additional object which 100% of Members determine should be included in this Constitution at a General Meeting.

---

[1] A copy of article 3 of the NEHTA constitution is attached for reference

The UK NHS Health IT Community - An Invaluable Site for Health IT.

Last week , when I received my regular bulletin from the United Kingdom’s NHS Health Informatics Community I realised I had not pointed this site out to those who browse here.

The site can be found at:

http://www.informatics.nhs.uk/

With free registration there is access to a range of invaluable and worthwhile resources.

An example of the sort of useful content that is available is the following.

Management Briefing on the impact of Clinical Physician order entry systems on improving patient safety

In this paper Dr Bates discusses health information technology has many benefits for both organisation and patients. Achieving success for any application implementation depends on a variety of issues and Dr Bates explores some of the problems some groups in America have had in the past. He reviews the failures and successes of the computerised physician order entry (CPOE) system and explores the similarities between what is beginning slowly implemented in America compared to what currently happening in the NHS. The paper closely follows on from the Masterclass Dr Bates gave in May and includes links to other Health Informatics papers.

This is the next in the series of Faculty management briefings, and was overseen with the help of the Faculty of Health Informatics Board. The aim of these briefings is to provide the reader with the essential knowledge of a subject which is important in the world of today’s busy NHS professional.

Our library of topics is getting bigger and covers a wide spectrum which will be relevant to all leaders within the NHS. Previous briefing topics cover such areas as:

UK cross-border transfer of electronic patient information

Knowledge Management

Telehealth and Telecare in England

Leadership within Health Informatics

Any feedback on this or any other management briefing is welcome, along with any suggestions you may have for a future briefing. Keep a lookout for forthcoming briefings on Patient Records and Patient Involvement by Dr Amir Hannan and The EHR the possible dream by Professor Denis Protti. If you wish to contribute to our library of briefings please contact ian.mcgovern@nhs.net

Attachments: (No. of attachments - 1)

65 Kb ETD Management Briefing No 5 - Patient Safety V 1 - (04-Jul-07)

It is really worth registering and having a good look around. While obviously there is a strong UK bias there is plenty for all! Registration also allows you to establish topic based e-mail alerts matched to the areas of your interest.

Enjoy!

David.

Amazing News Announcement from NEHTA

Allowing that the date was meant to be 5 July 2007 (Not June – at least that is when it arrived by my RSS Feed) this is just amazing!

Release Begins.

National recruitment drive kicks off in July

5 June, 2007. NEHTA stages a national recruitment drive as the NEHTA work program gains momentum.

A national recruitment drive is underway as NEHTA’s 2007/08 NEHTA work program gains momentum. The recruitment drive will target high calibre people interested in working in a challenging and rewarding environment and contributing to health reform in Australia. Positions across a number of projects will be available – in particular we will be targeting Business Analysts, Technical Analysts, Project Managers, Solutions Architects, Developers, Relationship / Account Managers, Technical Writers, Policy Officers, plus a variety of Clinical Terminology and Clinical Information roles ideal for clinical or healthcare professionals.

NEHTA, CEO, Dr Ian Reinecke maintains rapid growth has necessitated an aggressive push to add to the highly qualified and experienced people already on staff. ”Many of our key people have Masters and PhD qualifications in various disciplines including information technology and others are specialists from the health and medical research sectors,” he said.

Since NEHTA’s inception, the growth in staff numbers has been rapid and recruitment activity has been constant. However, as the work program has evolved, and as many projects head towards implementation, the need to anticipate unprecedented staffing requirements has increased. “Our ability to recruit and retain the best available talent is pivotal to the delivery of our project commitments,” Dr Reinecke said. “We are confident that we will be able to attract the people we need to get the job done.”

Position details will be posted on the Employment page of the NEHTA website progressively in July and August or enquiries can be sent to careers@nehta.gov.au.

End Release.

Just three comments:

1. Many of these jobs were being advertised on the 21 May, 2007 and are still being advertised 08 July, 2007 (e.g. Integration Manager, Policy Adviser and Pharmacists to undertake Medicines Terminology work). Seems either the pay, conditions, locations or future prospects with NEHTA must be lacking.

Hence the “National Recruitment Drive”!

2. I would have thought that, if the Boston Consulting Group Review did not have a pre-determined outcome that we have yet to be told, recruitment should be rather more conditional than it seems – if large payouts are to be avoided. Do the NEHTA recruiters know something we don’t? It is, of course, possible all these jobs are funded from the COAG money of 2-3 years ago and it just needs to be spent (? wasted if major change is suggested).

3. All the people NEHTA is seeking are likely to be smart enough to be aware of the NEHTA Standard Operating Procedures and Practice ( enforced secrecy, lack of consultation with stakeholders - especially clinical ones, abolition of consultative committees etc) and probably also already have reasonable jobs. They will ask themselves – why move? Without major internal change it is virtually certain many of these jobs will not be filled and the already over extended time-lines will blow out even further.

Wait for announcements of delays and budget blow outs. I suspect they are around the corner.

David.

Useful and Interesting Health IT Links from the Last Week – 08/07/2007

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

These include first:

http://www.ihealthbeat.org/articles/2007/7/3/PHR-Project-Moves-Forward-With-UserCentric-Health-IT-Applications.aspx?a=1

PHR Project Moves Forward With User-Centric Health IT Applications

by Colleen Egan, iHealthBeat Editor

The race is on to unite technology with personal health maintenance. Last July, nine teams were chosen from more than 165 team applicants to develop personal health record tools to help people manage individual medical issues, and now, researchers are going to try to get approval from their toughest critics: consumers.

Robert Wood Johnson Foundation's PHR initiative program -- called Project HealthDesign -- has two phases. In the first, six-month phase, the teams created "user-centered personal health applications that address specific health challenges faced by individuals and families," according to the project's Web site. Teams are now in the second, 12-month prototype phase, in which the designs are tested in certain populations. The projects target a variety of groups, from sedentary adults to teenagers learning to take an active role in their health to children with chronic illnesses.

The program's goal "was not to be constrained by the world as it is but rather to think about the world as it could be," Mark Frisse, director of the Vanderbilt University project, said.

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

This is fascinating as it describes the wide range of specialised areas that the PHR might address and how such focussed systems might make a difference in the care of individual patients. Useful links are included in the article.

Second we have:

http://www.healthcareitnews.com/story.cms?id=7389

Government launches healthcare IT standards compliance web site

Healthcare IT News

By Diana Manos, Senior Editor 07/02/07

WASHINGTON – The federal government announced last Friday the launch of a new web site to help vendors test their products for compliance with standards needed for participation in the National Health Information Network (NHIN).

The web site, developed in partnership by the Certification Commission for Healthcare Information Technology (CCHIT), Healthcare Information Technology Standards Panel (HITSP), the National Institute of Standards and Technology, and the Office of the National Coordinator for Health Information Technology “provides HIT implementers with access to the tools and resources needed to support and test their implementation of standards-based health systems,” said a HITSP email to its members and stakeholders.

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

This is a really important move to bring together in a “one stop shop” all the information, resources and tools needed to make sure the best interoperability possible as the National Health Information Network is developed. This is the next step beyond just developing a standards catalogue.

The new HITSP web site can be found at http://xreg2.nist.gov/hit-testing/

A visit to this site is recommended for all involved in this area to consider the usefulness of this approach and how it may be replicated in Australia.

Third we have:

http://www.ehiprimarycare.com/news/item.cfm?ID=2827

BMA votes for non co-operation on central records

29 Jun 2007

Doctors have voted for a public inquiry into NHS Connecting for Health (CfH) and have called on the BMA to advise doctors not to co-operate with the centralised storage of medical records.

The National Programme for IT was the subject of strong criticism at the association’s annual representative meeting (ARM) this week where doctors claimed the NHS IT project was doomed to failure unless a grip was taken on the project and that patient information held on the NHS Care Records Service (NCRS) was not secure and confidential.

Dr Charlie Daniels, a GP in Torquay and chairman of Devon Local Medical Committee (LMC), told colleagues that patients and doctors would be the biggest losers if there was no public inquiry to into NPfIT.

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

Here is an invaluable lesson on what happens if you don’t take the clinicians along with you. I hope NEHTA, the Boston Consulting Group NEHTA Review and AHIC take careful note and move to ensure the same does sort of thing is not replicated here – assuming anything significant actually get started.

For those who have on-line access to the British Medical Journal – the following is also more than mandatory reading and very concisely put touching on the same general topic area.

BMJ Volume 334(7608), 30 June 2007, p 1373

How to avoid an e-headache

[VIEWS & REVIEWS: PERSONAL VIEW]

Ash, Joan S associate professor

Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health and Science University, Portland, Oregon, USA, ash@ohsu.edu

The scope and boldness of the National Health Service’s Connecting for Health initiative are unprecedented. While nations worldwide have set health information technology as a high priority to combat medical errors and increase efficiency, England has outlined the most courageous goal of this kind, aiming towards a national electronic health record service. Implementing systems nationwide, or even regionally, is extremely difficult, yet England is making admirable progress and essential iterative adjustments. Ongoing evaluation efforts, such as those described in Hendy and colleagues’ study in this week’s BMJ, are necessary to guide such adjustments. Temporary setbacks are inevitable and we must learn from them.

Why is implementation of health information technology such a universally difficult process? It is because we are transforming health care through information technology rather than simply automating old processes. Workflow and work life must change, which means people must adapt. Such change is deeply disruptive. The related personal and organisational challenges are enormous, yet efforts to manage change receive inadequate attention and funding.

How can we succeed in such implementations of information technology? Firstly, we must define success explicitly and understand that our goal is long term, and that we will inevitably stumble along the way. Many, perhaps most, successful implementations of clinical systems have been preceded by suboptimal ones, yet these are too often concealed. We must begin to share these experiences openly and cherish these opportunities to learn how to improve implementation efforts. Boldness breeds occasional blunders, which can teach us much about what is required for eventual success.

….. (continued at the BMJ Site)

Fourth we have:

http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20070705/FREE/70705004/1029/FREE

HIPAA, privacy discussions divide AHIC testimony

By: Joseph Conn / HITS staff writer

Story posted: July 5, 2007 - 12:22 pm EDT

Whether the federal privacy rule under the Health Insurance Portability and Accountability Act of 1996 is adequate to the task of protecting privacy of patients in the new environment of electronic health-information exchange is a matter of divided opinion, according to oral and written testimony before an HHS work group last month.

The answer was "no" for privacy advocates and an information technology vendor who testified, and "yes" for representatives of an existing healthcare data exchange and a coalition whose members include providers, pharmaceutical manufacturers and distributors. The June 22 meeting of the American Health Information Community's work group on confidentiality, privacy and security lasted most of the day.

Much of the testimony centered on responses to a "working hypothesis" put up for public comment by the work group in May and its underlying assumption, that the HIPAA privacy rule—particularly its current scope—is inadequate to today's health IT needs.

As it stands, the privacy rule HHS first produced in 2000, and amended profoundly in 2002, does not give patients control of the use and transmission of their sensitive healthcare information, and the privacy restrictions that do apply only pertain to three classes of "covered entities" specified under HIPAA: payers, providers and claims clearinghouses. Those two privacy rule limitations were the focus of much of the discussion in the testimony.

One element of the work group's hypothesis is that there should be one or more "enforceable mechanisms" to ensure that privacy and security requirements are met. Under the exiting rule, enforcement is delegated to HHS' Office for Civil Rights. The office had received more than 27,000 complaints of possible HIPAA privacy rule violations through April. In three years of privacy oversight, the civil rights office has not issued a single fine against a HIPAA violator. HIPAA provides no individual cause of legal action against privacy violators.

Another working hypothesis posits that all organizations that handle protected health information "should be required to meet privacy and security criteria at least equivalent to any relevant HIPAA requirements" and that the rules apply to them directly, not through "business associate" agreements with covered organizations, as is the case today.

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

While this debate is happening in the US context there are parallels here in Australia where few citizens know just what happens to all the data collected by Medicare Australia and the private Health Funds for good or less publicly acceptable reasons. The move to have Health Funds rebate an increasing range of services separate from Government may indeed bring un-anticipated challenges in the future.

Lastly we have:

http://www.bizjournals.com/eastbay/stories/2007/07/02/daily46.html

Kaiser Permanente records 2.7 million patient e-mail messages, 8 million visits to online features

East Bay Business Times - 2:57 PM PDT Friday, July 6, 2007

by Chris Rauber

Kaiser Permanente released results late Thursday of what it called "the largest study to date" on how e-mail changes the way patients access medical care, showing that millions of Kaiser members are using e-mail and other online features to replace office visits and phone calls.

The Oakland-based health care giant said more than 1.4 million enrollees have signed up to use the KP HealthConnect online service, generating more than 2.7 million e-mail messages since September 2005. And 1.9 million of those messages -- or 70 percent -- were generated by Kaiser enrollees in high-tech-happy Northern California, said Holly Potter, an Oakland-based Kaiser spokeswoman for the HealthConnect program.

"We are also seeing steady increases in the number of members registered and using these features each month," Potter told the San Francisco Business Times. "In the month of May alone (the latest month for which numbers are available) 191,661 messages were sent by members in Northern California."

The HealthConnect service is available in seven of eight Kaiser regions nationwide, said Potter, and will roll out to 150,000 Kaiser enrollees in Ohio in October. Overall, Kaiser has 8.7 million enrollees in nine states and the District of Columbia; three-quarters of them reside in California.

Potter said the relatively low usage rate of e-mail so far -- about two messages per registered online user -- is actually good news, because "one of physicians' fears is that they'll be overwhelmed" by patients' e-mail.

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

This is fascinating to see the level of adoption by the Kaiser Permanente patients of the on-line services. This really is a HealthConnect!

Finally a must not miss report found by Dean Sittig of the Health Informatics Review.

The Value of Information Technology-Enabled Diabetes Management

Free report from the CITL: Their analysis demonstrates that all forms of ITDM improve processes of care, prevent development of diabetic complications, and generate cost-of-care savings. Technologies used by providers seem to be the most effective in improving the lives of patients with diabetes, and diabetes registries appear to be the most effective of all. Based upon the current evidence, our analysis indicates that patient-centered technologies offer the least potential for benefit. We believe that an integrated provider-patient platform, which adds patient-centered technologies to a registry and reminder system, would add benefits beyond a registry alone.

The report can be downloaded from the following URL:

http://www.citl.org/_pdf/The_Value_of_IT_Enabled_Diabetes_Management.pdf

Indeed I must say the present issue of the Health Informatics Review (for July 1, 2007) has an excellent range of topical material.

Go to the following URL and enjoy!

http://www.informatics-review.com

All in all quite a truly fascinating week!

More next week.

David.

HealthConnect Waste of Money Alert!

A day or so the following advertisement was brought to my attention.

HealthConnect Project Manager

Added: 27/06/2007

Fixed Term Full Time at Bendigo Hospital

Are you an experienced project manager interested in progressing the implementation of electronic health records in the Bendigo Loddon region? This position provides a fantastic opportunity to apply your skill in project management to progress the Victorian electronic health agenda.

The initial HealthConnect solution in Bendigo will result in a secure means of communication between health professionals involved in client care through the provision of access to a client’s summary health record. It will support the processes involved in complex integrated and coordinated care delivery while protecting the sensitivity of health care information.

The successful candidate will be responsible for the implementation of the Shared Electronic Health Record solution across Bendigo Health and its Consortium agencies.

Applicants should ideally have a tertiary qualification in a Health, Business or Information Technology discipline. Demonstrated skills and experience in project management are required for this position. Excellent communication skills and an ability to work with clinical staff and IT staff alike is essential. On line applications only

Title: HealthConnect Project Manager

Salary: To be negotiated

Hours: Full-time or as negotiated (Bendigo Health applicants may be considered for secondment)

Status: Fixed term until July 2008

Police check: Will be required from external applicants at time of commencement

Salary Packaging & Salary sacrificing: Available

Selection Criteria

• Experience in setting up and managing large projects in a complex environment, ideally in a healthcare or hospital/community health setting.
• Experience in liaising and communicating with key project stakeholders, with effective outcomes.
• Experience in establishing or working with project Steering Committees and other high level committees.
• Proven ability to communicate, both verbally and in writing, in a clear, concise and logical and effective manner.
• Proven ability to set realistic deadlines and motivate and manage staff to ensure these deadlines are met.
• Possessing complex analytical, conceptual and planning skills.
• Knowledge of project management techniques, tools and methods.
• Knowledge of information systems and processes and their role in a modern health organisation.
• Knowledge of current technologies and processes and their role in promoting re-use of business processes, particularly in healthcare.
• Experience in information system analysis, design or consolidation.

I the found there was another job being advertised for this project manager's boss!

http://mycareer.com.au/consumer/find/job/view.aspx?jobid=5198053&s_cid=589375

Executive Director - Information Services, Bendigo Health

• New key leadership role
• Tree change opportunity
• Attractive remuneration package

Bendigo Health is one of the state’s major healthcare providers with a 672 bed multidisciplinary service and around 3000 staff. This newly created position reports to the Chief Executive and will participate as an important member of the Executive Team.

The key purpose of this role is to:

• Direct, coordinate and deliver systems support to Bendigo Health operations

• Lead the ongoing maintenance and development of the Group’s

• Communications and Information Technology (CIT) services

• Take a leadership role within the Loddon Mallee Regional Alliance in the development of an integrated regional “health of health information” resource.

Primarily the successful applicant will be responsible for planning and managing the provision of information and information systems to support effective and efficient health care delivery and meet the strategic business objectives of Bendigo Health. In addition, planning and implementation of the CIT improvements that will support the delivery and ongoing development of integrated health services throughout Bendigo Health in line with the key outcomes of the Strategic Plan.

The successful applicant will be tertiary qualified (in CIT preferably with postgraduate studies) and be a credible, results oriented, effective and efficient IT professional. Sound problem solving skills with a systemic perspective together with the ability to manage for growth and understand the bigger picture are essential. Further information on the role requirements are contained in the Position Brief including the Key Selection Criteria (KSC).

The state of play in Health Information in this region – which covers about ¼ of Victoria occupying the north west section of the state is described in the 2005 / 6 Annual Report. To quote:

“Health Information Services

The vast amount of patient activity at Bendigo Health means a great deal of record-keeping and that is the role of Health Information Services. As an illustration of the increased activity, the number of records through the Homer tracking system has grown in the past five years from 176,264 in 2000/01 to 294,440 in 2005/06 – an increase of 60 per cent.

The average size of a patient record has increased by almost 87 per cent in the past 10 years, and 154 per cent in the past 20 years.

Patient records:

This year Health Information Services started using the acute patient record for all hospice and rehabilitation inpatient episodes – resulting in improved communication between campuses and continuity of patient care.

Despite increased patient numbers, Health Information Services has consistently completed timely coding of records for all inpatient episodes across Bendigo Health. Staff have also begun the benchmarking of key service activities against external organisations – both major metropolitan and rural.

Electronic discharge summary:

Staff have begun trialling an electronic discharge summary, developed in house by information technology staff based in the Surgical Unit. Next year it will be introduced across all units of the acute campus. The electronic discharge summary is updated at discharge and forwarded on to a patient’s general practitioner. It also allows for direct links to diagnostic results.

Next year Health Information Services will be investigating and implementing electronic reporting of pathology and radiology reports. This will reduce the volume of documentation stored in patient records and provide an audit trail of the viewing of all results.

Advanced coding:

The Health Information Manager has completed the HIMAA Advanced Coding course. These advanced skills will contribute to the promotion of accurate coding of inpatient episodes, achieving maximum WIES potential for Bendigo Health. (WIES is a funding formula for the acute campus).

In renal dialysis, auto coding has been introduced and it has reduced the time taken to code these episodes per month from around four days to 15 minutes. Introducing bar-coding of the patient identification number on patient records has meant improved accuracy in tracking patient records within Health Information Services and has streamlined identification of patients for the Pharmacy Service.”

Further on we learn about the technology directions of the Region.

Information and Communication Technology:

A small team of computer experts and communication technicians keeps the huge amount of electronic information accessible to clinical, support and administration staff.

Virtual Private Network:

Achievements this year include implementing a Virtual Private Network (VPN) for data communications. This is improving security and reliability of the data network to Bendigo Health’s remote offices. There are some 18 office locations now serviced. This was previously provided by the use of VPNs over the internet, but this meant that data traffic was competing with other internet users’ data traffic which can inhibit performance. In conjunction with our Internet Service Provider Bendigo Community Telco, we have created a corporate Virtual Private Network which means that no data traffic travels over the internet, and all traffic comes back to a central point, where it is monitored.

Data Network Security:

Following a review of the way clients access email and applications, and their ability to access their data from remote locations, a security hardware solution was purchased. This has enabled all email to be encrypted between Bendigo Health’s data network and all remote users, wherever they are on the internet.

Secure email to GPs:

We have set up the Collaborative Health Unified Message System – a secure email system which
delivers pathology results over the internet to GPs. Once the results are authorised, they are encrypted and delivered so GPs can view them and allocate them to their correct clients in an electronic medical directory. Results were previously downloaded and a paper record was also delivered. Now there is no need for paper records to be sent. The Collaborative Health Unified Message System has been a joint project between the Pathology and Information and Communication Technology departments of Bendigo Health, the Bendigo Division of GPs, and our pathology application provider, Kestral.

New website:

In conjunction with the Public Relations unit, Information and Communication Technology staff have organised the smooth transition to our new website (still located at www.bendigohealth.org.au ). The website information has been updated and presented in a more user-friendly fashion. We encourage feedback from the public, patients, clients, supporters and job seekers; to assist, there is a form available on the website.

Systems integration:

The setting up of an interface between our Patient Management system and our Pharmacy system has further reduced duplication of information and data transcription errors.

Installing the Birthing Outcomes System in our Maternity Services has meant replacing a paper records system with a fully electronic patient record.

Bendigo Health has been selected as one of two health consortia to develop and implement a Shared Electronic Health Record as part of Victoria’s role in the National e- Health Agenda -HealthConnect. This will be an exciting time.

We have also participated in the tender, selection and contract negotiation of a state-wide PictureArchiving Communication System (also known as digital medical imaging) and there will be more on this next year.

This system will eliminate 90 per cent of “film” (x-ray) printing and save around $200,000 per year, with all images available digitally on computer when and where they are needed.

Unique patient record and electronic discharge summary

The Systems Integration team has worked on both these projects.

Bendigo Health had two patient management systems in place - for acute and sub-acute patients so if a patient moved between the two they had two different identifying, (UR) numbers. The development of a single patient medical record is saving time and improving patient flow across the continuum of care. It also is allowing for the development of other improvements such as electronic discharge summaries for acute, sub-acute and psychiatric areas.

The electronic discharge summary is explained in more detail on Page 39.”

What all this describes is a health care service organisation that has quite obsolete patient administration systems that has had a few technical people trying to provide a few additional small systems where they can. This is not a technically advanced base on which new and improved systems should sensibly be developed.

While not wishing to be a kill-joy this is obviously a budgetary clean out project to spread some budgetary largesse into the region from the long since dead HealthConnect.

How can one develop an electronic health record sharing project in the absence of a clinical system (which Homer is certainly not) to create the information that is to be usefully shared? Unless I totally miss the mark the region does not have the source systems to feed any form of useful Shared EHR that could provide worthwhile care co-ordination – and certainly not in the next 12 months.

After the number of years spent trying to develop a useable and viable HealthConnect what are the chances anything new, useful or innovative will come from a project conducted in this infrastructure poor area. Very low indeed I would suggest.

One would hope that if someone of the competence of the person sought in this advertisement was to be found they would be much better tasked with replacing the obsolete 20 year old Homer PAS system and devoting whatever spare time they had to implementing results reporting – rather than undertaking yet another demonstrate nothing, doomed to fail, ill-conceived record sharing project that can’t be NEHTA compliant as NEHTA has yet to get its act properly together on the Shared EHR front and define how the SEHR should be done and deployed.

I wonder what other money wasting projects the last dying gasps of HealthConnect will choose to pour out taxpayer provided funds out on.

David.

Note: I regret the long quotes from the 2005/6 Annual Report – but this was by far the best way to get a feel of the IT maturity of the region. This is not a place to innovate within at this point in time – it is a place that needs basic clinical and administration systems got in place and settled in first. That is where the money should be going.

D.

The Mess that Seems to be State Health IT.

This week the Australian Financial Review (AFR) published what amounted to a review of where the Australian States are with their Health IT funding and implementation.

The article was entitled Focus on healthier data links and was written by Renai LeMay.

I would provide the relevant URL, but the current AFR web site is so utterly useless that is simply not possible. For those who subscribe to the paper the article appeared on July 3, 2007 on page 35.

The article opened by setting the scene by pointing out that:

"State health departments are poised to splurge more than $1 billion on new technology over the next few years as they ramp up plans to replace and link core patient and clinical information systems.”

From the article we learn that, most recently, in Western Australia there has been a request for funding from Treasury to replace its state-wide clinical information systems. Interestingly was are also told that the money will come from the $335 million over 10 years allocated by former premier Geoff Gallop in 2004. Clearly the sense of urgency is missing over there in the West. More information on WA is available at http://aushealthit.blogspot.com/2007/06/mess-in-west.html.

Next we learn, that Tasmania's Department of Health and Human Services is planning to issue a tender for new patient and pharmacy administration systems in the 2007 financial year. We can only hope they do better this time than the last time when they went out and bought a large scanning system calling it a patient record system.

We are also told that Qld Health is another leading the spending charge, with the state budget in early June allocating $150.3 million towards Queensland Health's information and communications technology function. It will be a new CIO spending that money as the incumbent has just resigned, no doubt somewhat tired after all that has gone on in Qld Health in the last 2-3 years. (law suits, implementation cancellations etc)

South Australia also gets a mention for is huge 10 year plan. Details can be found at http://aushealthit.blogspot.com/2007/06/useful-and-interesting-health-it-links_17.html

The article the goes on to point out that:

“NSW and Victoria appear to be slightly ahead of the other states when it comes to improvements in core health systems - at least in terms of the amount of money being spent.

NSW Health has already budgeted about $300 million towards the area until 2009, including a $40 million contract for an electronic medical records system awarded to United States-based supplier Cerner in November 2006.

In Victoria, the state's Department of Human Services is implementing HealthSMART, a $323 million technology replacement program slated to run from 2003 through to 2009.” Again I have provided additional detail which can be found at http://aushealthit.blogspot.com/2007/06/is-healthsmart-as-smart-as-it-claims.html

Sensibly the article points out that all these funds (at a bit over $1.0 billion) over between five and ten years hardly amounts to a ‘hill of beans” when compared with the annual public hospital expenditure.

The most recent Australian Institute of Health and Welfare report provides the following figures.

“Recurrent expenditure on public acute and public psychiatric hospitals was $23,991 million in 2005–06, 5.6% greater than expenditure in 2004–05 after adjusting for inflation. Salary payments accounted for 62.1% of total recurrent expenditure in 2005–06, and Medical and surgical supplies accounted for 9% of total recurrent expenditure. The average cost per separation was $3,698 excluding depreciation and $3,839 including depreciation.”

Kindly the journalist (Renai LeMay) had told me of the broad thrust of his planned article and asked for any comments I might have. These were trimmed in the sub-editing process so I provide the original version below:

My comments on all this would be along the lines of:

1. Some states are planning to make considerable investments while some have already made some major investments.

2. Unfortunately it seems that there is not enough learning and sharing of experiences between the States as we keep seeing centralised, one-size fits all approaches being adopted - when experience shows there have been many difficulties, delays and clinical annoyance and alienation when this is what is done.

3. There does appear to be a lack or procurement and project management expertise in many of the projects conducted so far and the States planning to update need to make sure they get high quality staff and advice to have the investments deliver benefits.

4. It would be useful to make sure an appropriate overarching health strategy linked to the health needs of the State is in place as well as well considered implementation plans to deliver the acquired systems on time and budget - with proper risk management in place both financially and contractually. Management of the strategic instability of State Government directions due to the political cycle is also a major risk to all these investments.

All in all this really is a depressing picture with a lack of urgency, implementation delays, procurement problems and so on leading one to wonder what needs to be done to get this right.

I suspect rather more local autonomy and control, within somewhat less constrained product and implementation frameworks, might be a good place to start.

David.

The Human Services Access Card – What are its Chances?

Just as the Canberra politicians were about to depart for the “long winter parliamentary break” the Minister responsible quietly tabled an exposure draft of the proposed legislation for public consultation until August 21, 2007

The bill is entitled the “Human Services (Enhanced Service Delivery) Bill 2007 No. , 2007 (Human Services) A Bill for an Act to enhance the provision of Commonwealth benefits, and for related purposes” The full text of the bill, some explanatory notes and some fact sheets.

All this can be found and downloaded from www.accesscard.gov.au.

For those so inclined comments can be made by email to: accesscard.bill@humanservices.gov.au.

What I wanted to briefly consider is what this new bill means for the future of the overall project. My overall take is that while some of the rough edges have been knocked off the total package the risk of the Access Card becoming a de-facto national ID card has not been reduced to an acceptable level.

The reason I say this is principally that the Government is still insisting that a human readable number and photograph will be on the front of the card.

On this topic the relevant fact sheet states:

“One of the biggest weaknesses of existing Commonwealth issued benefit cards is their vulnerability to fraud because of their lack of security features. The inclusion of a photograph, card number and signature on the surface of the access card are integral to the ability of the access card system to effectively reduce fraud, protect individual identity, and streamline access to government services.

THE PHOTOGRAPH

The photograph of the card holder taken during the registration process will be stored on the Register, in the card’s chip and will be displayed on the surface of the card.

Only the Office of Access Card and participating agencies will have the software capable of reading the photograph from the chip of the card. This restricted access means that in addition to the legislative provisions and encryption technology protecting the electronic version of the photograph, there will be a further layer of physical security to safeguard the photograph.

A photograph will be displayed on the face of the card to:

• reduce fraud and leakage against taxpayer funded benefits;
• significantly enhance the identity security elements of the card by protecting the card holder’s identity and reducing opportunities for identity fraud and theft;
• increase customer convenience by allowing people to simply and swiftly prove who they are when accessing Commonwealth benefit ts and services both through Government agencies and also through general practitioners and pharmacies;
• improve access to Australian Government relief in emergency and disaster situations by ensuring that there is no interruption to service delivery during periods where terminals are out of service or unavailable;
• secure access to services in a mobile environment such as in rural or remote areas where services may be delivered by a visiting health professional; and
• permit access card holders to use their access cards for such other lawful purposes as they choose.

International accounting firm KPMG has stated that the presence of a photograph on the surface of the card is critical to achieving savings from fraud concession and leakage amounting to some $3 billion over ten years.

This reflects international experience in countries such as France and Germany who, having issued health smartcards without a photograph on the surface of the card, found the card ineffective in combating fraudulent activity. Both countries have now moved to issue cards with photographs.

The five most recent investigations by the Identity Crime Taskforce involving the seizure of fake ID manufacturing equipment have all included templates for making Medicare cards along with thousands of blank plastic cards capable of being converted into Medicare or credit cards.

The absence of a photo on the surface of the card makes it more susceptible to fraudulent reproduction and could result, as occurs today, in a single card being used by multiple offenders to access services and benefits to which they are not entitled.

The Australian Federal Police Identity Crime Task Force’s operational experience has shown that fake Medicare cards feature prominently in 70 per cent of the more serious and organised identity crime investigations.

The use of facial biometric technology will also ensure that only one card is issued per person by identifying duplicate and fraudulent applications. (See fact sheet on Biometrics.)

CARD NUMBER

The access card number assigned to an individual during the registration process will be stored on the Register, in the card’s chip and will be displayed on the surface of the card.

The Agencies within the Department of Human Services, including Centrelink and Medicare, are estimated to deal with over 51 million telephone contacts, 281,000 email contacts and 74 million secured customer transactions each year. The majority of these transactions currently involve the customer quoting a number that is printed on the surface of their existing Medicare, Centrelink or Veterans’ cards.

Maintaining a number on the surface of the access card will mean that these services can continue to be delivered in a streamlined and convenient way. In absence of a number on the surface of the card, individuals would be required to remember their access card number which could be comprised by as many as 12 digits and will change each time a card is reissued.

Without the number on the face of the card, a customer would need to continue to identify themselves by another means, most likely by providing additional personal information which may be intrusive to their privacy.

SIGNATURE

The signature of an individual captured during the registration process will be stored on the Register and will be displayed on the surface of the card. Including the signature on the Register supports customer authentication for claiming benefits when the customer is not physically present when claiming a benefit, for example when a cardholder submits a claim for reimbursement of medical expenses to Medicare.

The signature on the surface of the card provides and additional layer of physical security for the cardholder be enabling a visual comparison of the signature to be conducted at the point of service if necessary.”

Frankly I see this as a lot of ingenuous nonsense. All that has to be done is that the smart card is issued with simply a number on it – and nothing else visible. Then all those who are meant to verify the card have readers which when a card is put in – will display the name, picture and signature for verification.

Indeed it is clear from another fact sheet the readers planned by the government will display the photograph – so just exactly why is it needed on the card as well?

The card cannot then be used by anyone who does not know the associated name and other details either in person or over the phone. By making the personal information strongly encrypted and only readable by a Government reader you create a genuine access key – and not a card that can also be used “for such other lawful purposes as they choose” – i.e. as an identity card. (Function creep if ever I saw it from the Government’s mouth!)

Frankly until the Access Card becomes just that – a access key that is not usable for other purposes I do not believe the Australian public will wear it.

Moreover the Government is being less than honest when it says there will not be a “mega-database”. The central register will contain – another fact sheet states – the following:

“The Register will contain only information that is needed for the card holder to access health benefits, veterans’ and social services. This includes, but is not limited to:

• name, sex, date of birth and address;
• photo and signature;
• registration status, access card number and expiry date;
• concession status and veterans’ information if applicable;
• contact information such as residential address, postal address if applicable, phone and/or e-mail address; and
• whether or not the card holder is a customer with any of the participating agencies.

Individual customer records will continue to be held separately by Centrelink, Medicare, the Department of Veterans’ Affairs and other participating agencies.

Only those people with a legitimate operational purpose will be given approval for access to the Register in line with the confidentiality provisions in the legislation. Access to the information contained in the Register will also be governed by the Information Privacy Principles of the Privacy Act 1988.”

That sounds like a pretty large database to me containing contact information which many different types of miscreants (from violent abusers to debt collectors) would love to be able to access. We know from other incidents such a huge data-base acts as a honey pot for such people and at least some officers will be happy to receive payment for disclosing such information.

All in all, until the Access Card becomes just that, I will continue to see it as a bad idea and continue to hope the legislation just doesn’t quite make it.

David.