A Report from the European Union that Nails E-Health.

Sweden has recently taken the rotating Presidency of the EU.

As part of its preparation it had Gartner develop an in-depth analysis of the successes and potential of e-Health across the member countries. The report reviews the experience of six countries including the UK, France, Holland and so on.

The report is cited here:

eHealth for a Healthier Europe!

S2009.011

Publication date: 01 July 2009

Type: Reports

Source: Ministry of Health and Social Affairs

Download

• eHealth for a Healthier Europe!S2009.011 (pdf 1.3 MB)

The full page is here:

http://www.sweden.gov.se/sb/d/12090/a/129815

This is a just superb piece of work and needs to be read by all interested in the area.

A must not miss document that makes it clear just how visionless and ignorant the present e-Health powers (NEHTA, DoHA and Ms Roxon and her office) are!

You would think somewhere among this collection of people might have had the wit to have commissioned work of this quality to clarify what is needed.

Read and weep at the quality of the leadership we presently have.

David.

This May Be a Much Better Way to Do Shared Electronic Health Records.

The following caught my eye a few days ago. It really looks very useful indeed.

EMIS unveils EMIS Web

25 Jun 2009

Leading GP IT system supplier EMIS has unveiled its next generation IT system EMIS Web, ahead of an official launch in the autumn.

The system, which has been in development for five years, is scheduled to receive NHS Connecting for Health accreditation in November and the company hopes it will become widely used by 2010. A roll-out date will be offered to all practices within two years.

EMIS claims the system will set a new standard for the NHS by enabling clinicians outside general practice to access a patient’s GP medical record, view other patient information that will be recorded on the system, and to add to that data.

Patient data will be accessible from non-EMIS systems using an interoperability portal called the Medical Interoperability Gateway (MIG).

GP system suppliers INPS and iSoft and out-of-hours provider Adastra are also to use the MIG to share data.

Yesterday, EMIS said it was also holding talking with other healthcare IT suppliers including Ascribe, Oasis and IMS Maxims. Local service providers Cerner and CSC have declined to take part, saying it is outside their contractual commitments under the National Programme for IT in the NHS.

Sean Riddell, managing director of EMIS, told EHI Primary Care that EMIS Web would hold the GP patient record together with what would, in effect, be a series of other separate records such as a podiatry record, a record of information supplied by patients, a diabetes record and a district nursing record.

GPs will be able to see the information on the other records, with patient consent, but will only incorporate the data they want into their own record.

Riddell added: “The main differentiation between EMIS Web and other systems is our concept of one patient and a series of virtual records.”

Data is shared and viewed with explicit patient consent and according to local data sharing agreements.

Outside of general practice, the system is already being used by the NHS as part of the pilot-phase of EMIS Web.

Lots more here:

http://www.ehiprimarycare.com/news/4967/emis_unveils_emis_web

Here are some of the details from the web-site:

EMIS Web - the future of integrated care

EMIS’s new primary care system, EMIS Web, uses the latest technology to drive GP computing to the next level.

The system will deliver two key benefits to general practices: access to shared patient records between GPs and community or secondary care, and advanced functionality for everyone in the practice.

Building on the success of existing LV and PCS systems, EMIS Web offers general practices all the very best of EMIS’s development expertise in 20 years of being the market leading clinical system supplier in the UK.

And the best part is that users of EMIS LV and PCS don’t have to wait to start benefiting from the new technology: EMIS Web will be rolled out a module at a time, so that they have the latest technology as soon as we have finished developing and testing it. New modules will seamlessly ‘plug in’ to existing LV and PCS systems, to create LV Web and PCS Web.

A shared record for GPs

GPs will be able to access their patient data as normal, either hosted centrally in a secure Enterprise environment or on servers at the practice. If the latter option is chosen then the practice’s data will be replicated in EMIS Web, using EMIS’s data streaming process. Community healthcare professionals will also submit patient data to the central EMIS Web database, enabling GPs to access data recorded about their patients by other healthcare professionals.

EMIS Web will be a fully interoperable system meeting the requirements of Connecting for Health (CfH), and as such will exchange data securely with the Spine. This will facilitate, in the first instance, CfH projects such as EPS2 and CRS.

A shared record for other healthcare professionals

Clinicians providing care outside of the general practice setting, such as specialist clinics or community care, will have access to a summary of the patient’s GP medical record so that they have an accurate and up to date picture of each patient’s health. They will record notes that can be accessed by the patient’s GP.

Advanced EMIS Web functionality will be available for these users too, with user interfaces tailored specifically for each role, including relevant templates and Read/ SNOMED codes.

This is enabled by interoperability – systems exchanging data securely, in context and in real time. This puts vital patient data at the fingertips of those who need it most, when they need it most.

The system will also exchange data securely with third party healthcare software, to add to the patient’s record vital patient data from organisations that use other systems, such as Adastra out of hours systems and INPS clinical software.

Interoperability

To provide EMIS users with additional IT functionality, EMIS systems interoperate with a wide range of third party primary care IT suppliers, to offer products and services such as integrated ECG readings, automated arrivals software and document management. EMIS Web interoperability will also facilitate patient services such as EMIS Access online appointment booking and patient access to medical records. To complete the interoperability picture, EMIS Web will exchange data with secondary care IT providers, such as Anglia ICE online test requesting.

More on the site:

http://www.emis-online.com/primary-care-systems/emis-web/

It seems to me EMIS have a practical and sensible architecture that can really make GP and Specialist practices hum while at the same time enabling access to relevant information by those who need it with the agreement of the patient and clinicians.

I think it is important that GP system providers in Australia and NEHTA take a close look at this and see of this might just be an architecture that is suitable for Australia.

David.

The Commonwealth Department of Health Consults on Identifiers - In Our Dreams!

A day or so ago we had the announcement of a consultation process around the NEHTA developed Individual and Provider Identifiers:

The basic information can be found here:

http://aushealthit.blogspot.com/2009/07/having-worked-on-it-for-years-doha-now.html

The direct link is here:

http://www.health.gov.au/internet/main/publishing.nsf/Content/pacd-ehealth-consultation

Government releases UHI consultation paper

I have now had a chance to browse the paper which can be downloaded from the above link.

Of course the document is not a consultation on the UHI. In fact the title of the document makes it clear just what it is:

Healthcare identifiers and privacy: Discussion paper on proposals for legislative support.

Translation. We know we need to get some legislation together to get started – we are not very organised in terms of aligning the jurisdictions - so we will need to just rush forward and hope for the best.

The rather messy situation is well discussed here:

National health data problems

Karen Dearne | July 14, 2009

THE nation's health ministers cannot agree on a uniform privacy framework for patient identifiers and are preparing to launch a Medicare number-based system with just a few tweaks to laws that forbid the use of Medicare data for such purposes.

As part of the $98 million Unique Healthcare Identifier program, Medicare is building a system that assigns an individual patient number to each Medicare number. Doctors and other medical providers will then be able to use the number on the Medicare card to access a person's records wherever they are held.

With the identifier service due to be ready by mid-next year, the Australian Health Ministers' Advisory Council says it cannot wait for public discussion of proposed reforms of health information privacy laws slated by the Rudd government in its response to the Australian Law Commission's comprehensive review.

Instead, the health ministers want to extend existing state and federal laws to include the new healthcare identifiers -- despite acknowledging current arrangements are "a patchwork of inconsistent and overlapping requirements" that cause confusion and increase compliance costs.

The new system is intended to ensure correct identification of patients and their health data, and will underpin more secure information sharing between medical providers.

More here:

http://www.australianit.news.com.au/story/0,24897,25777369-5013040,00.html

You can read a great deal about the NEHTA eID here:

http://www.nehta.gov.au/connecting-australia/e-health-id

The brief summary is as follows (from the site):

“The first requirement of any e-health system is the ability to uniquely identify and authenticate everyone involved in a single healthcare transaction. This includes the person receiving healthcare, the person administering healthcare, the place where healthcare is given and all people accessing health information systems.

The e-health ID Services will uniquely identify all parties involved in a healthcare transaction ensuring there is no misunderstandings about who health information belongs to. e-health ID Services enable healthcare providers to be assured that the information they need relates to the right person, has gone to the right place and was received by the right person.

Once the health information is exchanged it is also important to ensure only those authorised have access to it. Therefore Australia’s e-health system will be underpinned by a simple yet secure authorisation service for healthcare providers and healthcare administrators, using the best technology available.”

It is worth noting that most of the documents there are over 18 months old and, as an example the Concept of Operations (for the UHI) has all sorts of ‘to be determined statements’ running all through it.

As far as I can tell there are no technical specifications as to how the service will work – and the draft privacy framework is over 2 years old. Endless quantities of business requirements however!

The problem with all this is as follows. This is meant to be a public consultation on key privacy approaches and then legislation for the national e-Health identifier system and all that is offered as context couple of motherhood pages on what a good thing identifiers are and how we really need one for health.

Now all that may be true but I think before I signed up to approve what the quite draconian approach of using information on 20 million people to create a new identity database, using information which they gave for another purpose (getting Medicare payments) I would like to know a little more!

I would like to know answers to questions like:

What approaches are used in the rest of the world to address identification in e-Health and is what is being planned global best practice – and what is the evidence for that?

What did the various Privacy Impact Statements that NEHTA has developed say and why have they not been made available for public scrutiny?

What does the business case for this whole exercise say in terms of cost (short and long term) and benefits of this system (short and long term)? How is this system to be paid for when the establishment grants have expired.

Given the issues identified here with a similar system in the UK what steps have been taken to understand if there are implications for Australia?

GP raises concern about PDS security

14 Jul 2009

Renewed concerns have been raised about the security of the Personal Demographics Service after a GP was able to access details of colleagues and staff without being detected.

Dr Paul Golik, a GP in Stoke-on-Trent, Staffordshire, and secretary of North Staffordshire Local Medical Committee, told the GP magazine Pulse that he had accessed his own details and, with permission, those of several other people without the unauthorised accesses being reported.

Dr Golik told Pulse that he was “appalled” that such information was available to everyone with a smartcard. More than 600,000 smartcards have so far been issued, according to NHS Connecting for Health.

Dr Golik added: “It’s basically open – we might as well put our names and addresses on Google. If I know what your name is and roughly how old you are, within about ten seconds I can find your exact date of birth, your full name, your address, potentially your telephone number and your NHS Number.”

More gruesome details here:

http://www.ehiprimarycare.com/news/5024/gp_raises_concern_about_pds_security

As I read it any authorised provider in Australia could do the same thing – all 600,000 of them! If you reckon there won’t be one or two corrupt apples in that many providers whatever you are smoking sure is not legal!

The bottom line is that what DoHA should have done was not produce an isolated partial consultation document with a short deadline, but a complete up-to-date package that addresses all the issues raised above, puts the issues in context and then allows a reasonable time for careful review. There is no great rush and the public should be consulted on the whole package –not just one bit.

This is a Clayton’s consultation of ever there was one!

David.

The Real Reason We HAVE to do E-Health.

The following article puts the case for e-Health in the US as clearly and simply as I have seen it done.

Wednesday, July 08, 2009

Where's the HIT in HCR (Health Care Reform)?

by Bruce Merlin Fried, Esq.

Let's give credit where credit is due. From where I sit, Congress took a big step toward a digital health care system by including the HITECH provisions in the American Recovery and Reinvestment Act of 2009.

Approximately $30 billion in new federal spending was authorized for various health IT activities, the bulk of which goes toward economic incentives for physicians and hospitals to be "meaningful users" of certified electronic health records. Monies were also allocated for extension services, state initiatives, loans and grants. All good.

But I should have known. It was predictable. Certainly there is no reason to be surprised. Having included HITECH and its authorized funding in ARRA, it appears Congress thought its health IT work was done. Were it only that easy.

If we are to have real health care reform, a greater health IT effort is required than what was accomplished in ARRA.

Let's take a brief digression. It is essential, in my mind, that everyone working in health IT -- from the code writers to the technology geeks to the folks in the C suite -- understand that health care reform is the business justification for building a digitized health system. What is driving policymakers to reform the health system is not an altruistic sense of moral obligation.

Sure, there is certainly some of that. But the real driver is the fear that results from a clear-eyed assessment that our current health system is unsustainable. Absent substantial reform, the way we have organized and financed health care will collapse the system (and I don't just mean the health care system, I mean THE system, the economic system of the country).

More here (with links):

http://www.ihealthbeat.org/Perspectives/2009/Wheres-the-HIT-in-HCR-Health-Care-Reform.aspx

As far as the US is concerned Bruce is utterly spot on and everyone from the President down knows it.

How close are we to the same problem – healthcare becoming un-affordable and unsustainable – here in Australia?.

The following comes from Australia’s Health 2008.

This full report is found here:

http://www.aihw.gov.au/publications/index.cfm/title/10585

Health expenditure

• Australia spent 1 in every 11 dollars on health in 2005–06, equalling $86.9 billion, 9.0% of gross domestic product (GDP).

• As a share of its GDP, Australia spent more in 2005 than the United Kingdom (8.3%), a similar amount to Italy (8.9%) and much less than the United States (15.3%).

• Health spending per person was 45% more in 2005–06 than a decade before, even after adjusting for inflation.

• For Indigenous Australians in 2004–05, health spending per person was 17% higher than for other Australians.

• The spending on medications increased by 1.6% between 2004–05 and 2005–06—much less than the average increase of 8.6% per year in the decade before.

Point 3 is the really scary one!

We are a ‘boiling frog’ believing we can keep adjusting inflation adjusted personal spend up by 45% per decade because we are a rich country and so on! Health Spending essentially means out of pocket expenses. How long before the amount is bigger than the aged pension?

Here is the awful number:

“Over the decade, estimated real growth in health expenditure (that is, after removing the effects of inflation) averaged 5.1% per year (Table 8.2). Real growth in expenditure is measured using ‘constant prices’ (see Box 8.2).” (Health Expenditure is the total cost of Health Services etc)

Simple maths tells us that on this path, if sustained, we will double health expenditure about every 14 years. That means it will be about 18% of GDP by 2019 (from 2005-6) and 27-30% or so by 2035.

The 2019 figure would pretty much finish us and the 2035 figure would bankrupt the county –easy as that!

Worse still the clinical workforce are about to hang up their collective shingles and head for the exits.

Even the NHHRC sees a real issue:

“These projections indicate that, over the next 25 years, health and aged care spending will

increase to $246 billion – about one-quarter of a trillion dollars. By 2032–33, health and aged

care services will consume 12.4 per cent of gross domestic product.” (Note to only get here must assume a lot of economic growth which is not as sure as it used to be!)

Page 302 of Interim Report.

Then they say:

“If we continue with business as usual, the fastest growing areas of spending will be for acute

services, such as hospitals and aged care (see Figure 13.2). Changing how much, and where,

we spend will require greater investment in prevention and primary care, coupled with a real

commitment to keeping people healthy.”

The estimates come from here:

http://www.aihw.gov.au/publications/hwe/pahced03-33/pahced03-33-sum.html

Woo hoo. We need way more than that! How can they be so utterly stupid? We need a total health system transformation which drives efficiency, quality, safety etc up with every other trick we can think of to not top 12-15% of GDP by 2030.

See here for the Productivity Commission Estimates of the base state:

http://www.pc.gov.au/__data/assets/pdf_file/0004/13666/technicalpaper04.pdf

Guess what with medical inflation just 1% above GDP growth we get to 17% of GDP by 2030 and 20% by 2045 or so (quite unaffordable of course). Like climate change you can dispute the details of the figures but to pretend there is not an ‘oncoming train’ would be just silly (the precautionary principle applies for sure!)

The bottom line is that tinkering around the edges is not going to work! If we want to be able to afford the clinical care we actually need we must change to have less waste, less re-work, more efficiency, higher quality and so on. Health IT can help a great deal along with programs to increase evidence based practice and research that ensures we only do those things for patients that have a real chance of helping. What these things are and how to apply the information that is already available could also do with more effort – along with the preventive approaches so long promoted.

We are all going to regret it if we do not begin a transformation to an evidence based, e-Health enabled Health System sooner rather than later.

David.

Seems They Are All Lining Up to Be Enthusiastic!

E-Health Record To Help Ensure Better Treatment - 13 July 2009

A National e-health record promises to ensure patients have access to more expedient and better informed medical treatment, Medicines Australia chief executive Ian Chalmers said today.

Welcoming today’s decision by the Australian Health Ministers’ Conference to move towards establishing a secure national e-health system, Mr Chalmers said patients and healthcare professionals would be the big winners.

“If healthcare professionals understand what treatments a patient has received and what medications have been previously prescribed and dispensed, they will be much better placed to determine quickly the most appropriate treatment option.

“This initiative goes to the core of Quality Use of Medicines.

“An e-health record will help ensure doctors and other health professionals prescribe the right medicine to the right patient at the right time and at the right dose.

“This is a significant step in ensuring medicines are used correctly and avoiding adverse outcomes through the misuse of prescription medicines.”

Mr Chalmers said a national e-health record would also provide an important opportunity to deliver an advantage to Australia’s extensive clinical trial capability.

“There is an opportunity to capture greater value from an e-health record system by ensuring the system also provides remote access to the medical records of trial participants in Australia who have consented to such use of their details.

“Remote access to trial data would remove geographical barriers to participation in clinical trials.

“This would shorten the time taken to complete clinical trials in Australia and would therefore improve Australia’s attractiveness as a destination for global investment in clinical research.

“Medicines Australia has long argued for a national e-health system. I congratulate the Australian Health Ministers’ Conference for taking forward this initiative.

“It is important that all stakeholders have the opportunity to consider this proposal carefully. I look forward to engaging with the Health Ministers during the consultation period.”

ENDS

CONTACT: Jamie Nicholson

Medicines Australia, Media Communications Manager

The release is found here

http://www.medicinesaustralia.com.au/pages/view_news.asp?id=141

I wonder why this insight has suddenly come after so long! Could it be a bit of empire building from an organisation with a lamentable record in building and deploying software for clinicians?

David.

Note: In this comment I confused Medicare Australia and Medicines Australia - so the comment is partly incorrect. See comments. D.

Full Text of the AHMC Release is Now Available.

Media Releases and Communiqués

First step taken towards national e-health system

In an out-of-session communiqué, the Australian Health Ministers’ Conference has announced that the first step has been taken towards a national e-health system. National consultations are set to begin on the legislative framework to underpin the governance, privacy and agreed uses for national healthcare identifier numbers essential to a secure national e-health system.

PDF printable version of First step taken towards national e-health system (PDF 17 KB)

13 July 2009

National consultations are set to begin on the legislative framework to underpin the governance, privacy and agreed uses for national healthcare identifier numbers essential to a secure national e-health system.

Healthcare Identifiers are unique numbers that will be given to all healthcare providers, healthcare centres and healthcare consumers. These unique numbers will provide a new level of confidence when communicating patient information between the myriad of private and government healthcare providers and systems.

To date there has been no single method of accurately and reliably identifying the patient receiving healthcare, the healthcare providers or the organisations managing care.

Mismatching of patients with their records and medical results is a documented problem for the health system. There is a clear link between avoidable patient deaths and poor medical records management.

All Australian residents will be allocated an Individual Healthcare Identifier (IHI) to support better communication between healthcare providers involved in patient treatment – but no patient will be forced to use it to access any health service.

The IHI service will be managed initially by Medicare Australia – a trusted and secure provider of dedicated health related services. This will be separate to its funding and claims functions. The IHI will not replace a patient’s Medicare number, which is used for claiming government healthcare benefits.

The IHI service will hold only enough information to clearly identify the person. No clinical information or medical records will be stored in the IHI service and an IHI will not need to be declared for an individual to receive healthcare.

The Australian Health Ministers’ Conference asked for consultations to be held so that a broad range of perspectives can contribute to making the legislation robust and effective – balancing the privacy of personal information with the healthcare benefits that can be gained through better sharing of health information.

Consultations with key industry stakeholders will be held during July and a discussion paper detailing the legislative framework will be available online from 13 July to allow broad community input.

The consultations on the drafting of legislation build on earlier consultations with key stakeholders about the recommendations in the Australian Law Reform Commission’s report on its review of Australian privacy laws, including health privacy protections.

The Australian Health Ministers’ Conference believes strong privacy protection for patient health information is fundamental to delivering high quality individual and public health outcomes.

The discussion paper can be accessed online at www.health.gov.au/eHealth/consultation from 13 July.

The release is found here:

Enjoy – comments are welcome! I would note I had believed we took the first steps in 1999 with the Health On-Line reports that led to HealthConnect – but it seems I have simply developed a state of severe confusion or historical amnesia. (We won’t even mention the June 1993 Health Communication Network Business Plan – will we? - Everyone who was involved in that is probably dead by now )

David.

Having Worked on it For Years – DoHA Now Wants to Consult on e-Health Identifiers!

The following arrived on the NEHTA RSS today.

From:

NEHTA RSS

Link:

http://www.health.gov.au/internet/main/publishing.nsf/Content/pacd-ehealth-consultation

Government releases UHI consultation paper

Important facts to note:

------

Submissions will not be made publicly available but will be shared with relevant government agencies to inform jurisdictional consideration of national privacy arrangements. Please note that submissions or comments will generally be subject to freedom of information provisions.

The closing date for comments and submissions is 5pm (Australian Eastern Standard Time), 14 August 2009.

-----

Don't you love these people! As always, terrified someone might have an opinion they are not comfortable with. Have they actually heard of democracy?

I wonder after the development of all the Privacy Impact Assessments (PIAs) over the last few years – and a failure to publish them – why they are not released to encourage and facilitate informed discussion? Your guess is as good as mine!

Could it be, to release them, might just alert people to things they may have missed?

Can you really believe COAG authorised this work in 2006 and we are hoping it might start in 2010. Speedy Gonzales this collection of bureaucrats are not! (why do comparisons with an inability to organise a few drinks in a brewery leap to mind?)- see intro on web link!

Of course, whatever they propose still have to get through the Senate. That might mean a start date in 2020!

David.

The NHHRC Final Report will be Released Soon. What Must it Say About E-Health?

The Final Report of the National Health and Hospitals Reform Commission is due out in the next couple of weeks.

As soon as I spot it I will provide a link. I assume it will be found from this front page:

http://www.nhhrc.org.au/

For the e-Health component of that reports to be seen as being in anyway useful and positive I believe it will need to make the following points.

First that leadership and governance of the e-Health space are crucial for success. The report should recommend how a satisfactory level of leadership, governance and accountability is to be achieved for the needed investment. Within the governance framework there has to be total clarity as to what the ongoing role of NEHTA should be and how the critical things it either does not or cannot do can be delivered. Clearly I believe just ‘business as usual’ or handing it all over to NEHTA and hoping they will ‘fix it’ is utterly flawed and idiotic. Also flowing from the need for governance and leadership is a deep requirement to ensure e-Health governance is clear that implementation of systems must be conducted in ways that understand, and are sensitive to, the culture of the health sector. Lastly in this area is a crucial need to learn from experience overseas to get the balance of local versus national implementation approaches correct.

Second it should be quite clear that as the health system is about patient care and patient safety that the emphasis on technology deployment should be in those areas where those outcomes can be improved.

Third it should recognise that in the times of Web 2.0 and individual interest by patients in their health records that Personal Health Records will have an important supplementary role to the provider health records.

Fourth it should recognise that Health IT provides the capability to provide far more efficient and connected care for patients and that any re-engineering of the health system should fully and properly take advantage of these capabilities. Just automating a broken or inefficient manual system is just not good enough.

Fifth the report needs to reflect a version of this basic truth:

“Every industry except healthcare has figured out how to become more efficient by replacing administrative work with information technology, he said. Nurses spend a third of their time documenting – a procedure Cutler said often involves printing digitized information and re-entering it into another IT system.”

See here:

http://www.healthcareitnews.com/news/saving-healthcare-industry-emrs-are-beginning-not-end

In a nutshell – Information Technology can do a lot for efficiency and effectiveness in things like administration, human resource management, supply chain management and billing – as well as clinical safety, performance and so on. – Both need to be properly addressed

Sixth there needs to be a clear realisation that without a significant investment in Health IT any hope for long term sustainability of the health system, especially in the era of the ageing population, is out the window.

Seventh there has to be an overall plan and vision for how e-Health and the other proposed reforms are going to interact. Neither can be planned, or successfully realised, in isolation. This needs to be recognised clearly and each needs to move forward assisted by the other.

Eight it needs to be clearly articulated that we need a nationally funded system for the provision of both consumer and professional health information to optimise both patient understanding an clinical care.

Ninth there needs to be a recognition that we have an e-health skills and capability deficit and that this needs to be formally addressed.

Last the report has to either strongly recommend implementation of the Deloittes developed National E-Health Strategy or offer an obviously more cogent and appropriate plan.

These ten points I rank pretty much equally. They all have to be in place.

When we see the report I will provide my view of the quality of the report and the e-Health outlook based on what is provided by the NHHRC and the Ministerial Response to the NHHRC report.

I am hoping I will be a happy camper - but somehow I doubt it.

David.