Quote Of The Year

Timeless Quotes - Sadly The Late Paul Shetler - "Its not Your Health Record it's a Government Record Of Your Health Information"

or

H. L. Mencken - "For every complex problem there is an answer that is clear, simple, and wrong."

Saturday, November 03, 2012

Weekly Overseas Health IT Links - 03rd November, 2012.

Note: Each link is followed by a title and few paragraphs. For the full article click on the link above title of the article. Note also that full access to some links may require site registration or subscription payment.
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Mind Over Machine: Use Your Brain Waves to Control Your Computer

By Stacey Higginbotham on October 23, 2012
When it comes to controlling our computers, the last five years has seen incredible improvements in user interfaces including amazing touchscreens and much more natural vocal recognition. Now a Toronto company wants to take the UI to the next level—by going directly to the brain. You think it, and the Muse headband will make it happen under very limited circumstances.
InteraXon, the maker of the Muse headband, has listed its device on Indiegogo in hopes of raising $150,000 for building a mass-produced headband that translates your mental commands into a computer action. The example it shows on the site is playing a game using an iPad, where the rotation of a wooden block occurs when the user focuses on it. The user tilts the iPad to change the angle of the rotation.
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Health plans embracing ACOs, boosting IT, study shows

By Diana Manos, Senior Editor
Created 10/26/2012
WAYNE, PA – Health plans are heading toward 100 percent participation in accountable care organizations (ACOs), according to a new study, with 78 percent of respondents already part of one, and 22 percent planning to participate in one. This is all leading to a scramble for health IT.
"While health plans have been preparing for a changing marketplace for a few years, the pace and clarity of their plans are ramping, and their technology needs are expanding," said Ellen Donahue-Dalton, executive vice president and chief marketing officer of Medecision, a Wayne, Penn.-based, care management solutions firm.
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Nursing informatics programs gaining ground

By Anthony Brino, Contributing Editor
Created 10/26/2012
Hoping to fill a projected gap of some 50,000 healthcare IT professionals in the next several years, the Office of the National Coordinator’s Health IT Workforce Development Program is funding community college programs that can train IT professionals in healthcare and train healthcare professionals, like nurses, in IT.
The Bureau of Labor Statistics is also projecting a 20 percent increase in demand for registered nurses during the next decade, and amid increased enrollment in nursing schools, nursing informatics is growing as part of the curriculum.
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Weill-Cornell to launch health informatics master's program

Posted: October 25, 2012 - 3:00 pm ET
The Weill Cornell Graduate School of Medical Sciences in New York will launch a program next year for a master of science degree in health informatics.
The graduate school's Center for Healthcare Informatics and Policy, also called CHiP, is accepting applications for the January program, according to a news release. Students can use the degree to pursue careers in health information technology, analytics, management, research and policy.
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Web-based Prostate Cancer Database Portal Launched for Patients

October 25, 2012
The National Proactive Surveillance Network, the Ceders-Sinai Samuel Oschin Comprehensive Cancer Institute, the Prostate Cancer Foundation, and Johns Hopkins are jointly launching what they are calling the world's first online medical database designed to help men track the progression of their prostate cancer while avoiding complications from overtreatment. According to the group, the database portal will allow men with slow-growing forms of the disease to track it in a secure, interactive environment.
"Recently, new research has estimated that as many as 50 percent of newly diagnosed prostate cancer patients have a form of the disease that is so slow-growing that it often does not pose a threat to the life or long term health of the patient," said Stuart Holden, M.D., director of Cedars-Sinai’s Louis Warschaw Prostate Cancer Center and medical director for the Prostate Cancer Foundation, said in a statement. “As a result, a growing number of prostate cancer patients are deciding that the best course of action for them may be to defer initial treatment until it can be determined whether they, in fact, have the more aggressive or less aggressive form of the disease.”
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  • October 22, 2012, 7:20 p.m. ET

Physician, Steel Thyself for Electronic Records

Who's got time to listen to patients when the government demands 'meaningful' data entry?

By ANNE MARIE VALINOTI

There is a new television show on Fox this fall called "The Mob Doctor." Its heroine, Dr. Grace Devlin, is a surgeon who, in order to help settle her brother's gambling debt, agrees to serve as a one-woman HMO for Chicago's underworld. This would include everything from tending to the wounds of the nearly-whacked to treating the strep throats of gangsters' children.
While this professional track would have its unique occupational hazards, one appealing advantage makes up for the downsides: You can bet that no one is making Dr. Devlin use an electronic medical-record system.
The electronic medical record, or EMR, is a computerized system that allows physicians to record patient information electronically instead of using paper records. Test results can be reviewed through the system, and prescriptions can be emailed straight to the pharmacy. You can order medical tests and medications worth thousands of dollars with just a few mouse clicks.
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Why Can’t We Solve Big Problems?

On July 21, 1969, Buzz Aldrin climbed gingerly out of Eagle, Apollo 11's lunar module, and joined Neil Armstrong on the Sea of Tranquility. Looking up, he said, "Beautiful, beautiful, magnificent desolation." They were alone; but their presence on the moon's silent, gray surface was the culmination of a convulsive collective effort.
Eight years before, President John F. Kennedy had asked the United States Congress to "commit itself to achieving the goal, before this decade is out, of landing a man on the moon and returning him safely to the Earth." His challenge disturbed the National Aeronautics and Space Administration's original plan for a stepped, multi-generational strategy: Wernher von Braun, NASA's chief of rocketry, had thought the agency would first send men into Earth's orbit, then build a space station, then fly to the moon, then build a lunar colony. A century hence, perhaps, humans would travel to Mars. Kennedy's goal was also absurdly ambitious. A few weeks before his speech, NASA had strapped an astronaut into a tiny capsule atop a converted military rocket and shot him into space on a ballistic trajectory, as if he were a circus clown; but no American had orbited the planet. The agency didn't really know if what the president asked could be done in the time he allowed, but it accepted the call. 
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Electronic standing orders in EHRs improve preventive care

October 23, 2012 | By Marla Durben Hirsch
Utilizing electronic standing orders in electronic health records improves patient treatment, according to a new study published in the Journal of the American Board of Family Medicine.  
Standing orders are useful since they enable nurses and other ancillary staff to carry out medical orders without a physician's examination. The 21-month pilot demonstration study, conducted by researchers from the Medical University of South Carolina in Charleston, studied eight primary care physician practices in eight states. The practices ranged from two to 25 clinicians per practice. The standing orders were applied to 15 measures involving screenings, immunizations and diabetes care, such as flu shots, cholesterol checks and bone mineral density.  
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Hospital execs slow to measure technology ROI

By Mike Miliard, Managing Editor
Created 10/25/2012
WEYMOUTH, MA – Most healthcare C-suite members are dissatisfied with their organizations' efforts to measure return-on-investment from clinical IT systems, according to a new report from Beacon Partners.
The survey, "Finding the ROI in Clinical IT Systems," polled more than 300 healthcare executives, including CEOs, CIOs, CMIOs and CFOs. Beacon Partners, a healthcare management consulting firm, sought to analyze how hospitals and care delivery organizations use clinical system performance measures as a way to calculate the ROI of electronic medical record (EMR) systems.
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Docs: CPOE doesn't improve care or increase productivity

October 25, 2012 | By Julie Bird
While computerized physician order entry remains largely unpopular with doctors and nurses, a new study finds, over time nurses become more accepting of CPOE.
In a study published online today by the Journal of the American Medical Informatics Association, researchers from the University of Wisconsin-Madison reported that users were "moderately satisfied" with CPOE. That level of satisfaction didn't change over time for "ordering providers," or doctors, but improved significantly for nurses.
Nurses started out less happy with CPOE than doctors, the research found, but after a year their level of satisfaction matched that of doctors.
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Death by defibrillator: FDA called to address hacking risk

By Brian Alexander, NBC News Contributor
It sounds like a scenario out of a James Bond movie: a villain spots his quarry and uses a small device to hack into the official’s heart defibrillator, sending a signal for mayhem. There’s chest grabbing, and a collapse, and alarms, but the bad guy walks free because there’s no gun, knife, poison dart -- no evidence at all a murder has been committed.
According to a recent report by the Government Accountability Office (GAO), a non-partisan agency that works for Congress, not only is such a scenario possible, there’s a growing danger that grandpa’s heart rhythm device, or, say, a child’s insulin pump – any implantable device that can be accessed remotely --  could be susceptible to hacking.
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The Kiss of Death for Meaningful Use Efforts

OCT 24, 2012 11:54am ET
The kiss of death to an electronic health records meaningful use effort is boiling down the criteria to a checklist of to-do items for physicians. That’s the word from Jeff Loughlin, project manager at the Massachusetts eHealth Collaborative and executive director of the Regional Extension Center of New Hampshire.
“Physicians hate lists and once you think of meaningful use as a list, you are doomed to failure,” Loughlin said at the MGMA Conference in San Antonio. The program does provide qualification criteria in list format, he acknowledged, but the way to streamline adoption of meaningful use is to describe the criteria not as discrete tasks, but rather as steps that are part of any practice’s given workflow.
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CMS Staffer Says Stage 2 Patient Engagement Criteria Not Set in Stone

OCT 24, 2012 11:56am ET
Stage 2 electronic health record meaningful use requirements that at least five percent of patients conduct secure messaging with physicians, and view, download, or transmit their ambulatory and inpatient data came at the insistence of HHS Secretary Kathleen Sebelius. And those requirements might not be set in stone.
That’s the word from Travis Broome, a health insurance specialist at the Centers for Medicare and Medicaid Services, during a presentation of the Stage 2 rules at the MGMA Conference in San Antonio.  He devoted most of the presentation to rehashing the rules, but the tedium quickly dissipated during the question and answer period. It was dominated by concerns around requirements for patient access to a portal, government auditing of incentive payments, and the program’s longevity in face of recent Republican questions about its effectiveness.
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What Scares Healthcare CIOs

Scott Mace, for HealthLeaders Media , October 23, 2012

We now know the extent of the HHS Office of Inspector General (OIG)'s fraud and abuse fishing expedition regarding electronic health records, which came to light in the CHIME Fall CIO Forum in Palm Springs, CA, last week.
According to the American Hospital Association, the OIG letter went to all hospitals that received an incentive payment between Jan. 1, 2011 and March 31, 2012, directed specifically to the CEO's or administrator's office. The letter requests that responses be submitted by this Friday—one week from issuance.
The AHA says OIG will use the information from the survey as part of a report expected out next year. OIG staff informed the AHA that hospitals may take additional time to respond to the survey if needed. In addition, OIG will allow a health system to file a single response for all facilities, where the survey responses would be the same for each entity in the system.
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Blogging helps chronic pain patients feel less isolated

October 24, 2012 | By Dan Bowman
For patients suffering from chronic pain or illness, blogging about their condition can help to decrease feelings of isolation and increase their sense of usefulness, according to a study published this week in the Journal of Medical Internet Research.
Of of the 230 respondents, most (88 percent) had blogs that were public and searchable online, and 64 percent used their own names on their posts.
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Recent OIG report reignites call for CMS to drop SSNs from Medicare IDs

October 24, 2012 | By Julie Bird
Citing a report issued earlier this month by the U.S. Department of Health & Human Services' Office of Inspector General, Republican leaders of two key subcommittees of the House Ways and Means Committee are urging the Centers for Medicare & Medicaid Services to stop using Social Security numbers in identifying Medicare patients.
U.S. Reps. Sam Johnson (Texas), chairman of the Social Security subcommittee, and Wally Herger (California), chairman of the health subcommittee, made the argument in a letter dated Oct. 22.
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Healthcare system hackers usually after financial info

October 24, 2012 | By Susan D. Hall
Despite reports of efforts to blackmail patients and the possibility of hacking pacemakers, healthcare data breaches in the end are similar to other cyber crimes, according to a new report from Verizon. In an examination of approximately 60 confirmed data breaches over the past two years, the report concludes that those who attack healthcare systems primarily look for information from which they can make a profit.
"POS [point-of-sale] systems and desktops were at the forefront of breaches in the healthcare sector," according to the report's authors. "At first glance, this may seem counterintuitive, since electronic health records would almost certainly be stored in a file or database server, and surely this is what the criminals are after. But this likely represents an incorrect assumption; most cybercriminals are more interested in accessing your bank account and applying for loans in your name than they are the details of your last medical exam."
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Open source GP project takes off

18 October 2012   Rebecca Todd
A locum GP is co-directing a project to develop an open source GP clinical system to allow "true interoperability" with other healthcare systems.
Dr Marcus Baw told EHI Primary Care the idea of an open source primary care system has been “knocking around for years” amongst GPs that code.
“The open source model fits in very neatly with the NHS model because it’s about the sharing of ideas and the ideology of the NHS is essentially about sharing the risk of illness.”
Dr Baw introduced the idea at an NHS Hack Day held in September where he got an enthusiastic response.
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Health 2.0 Showcases More Clinician-Friendly Apps

Software developers show products that are more useful and relevant than ever at this year's Health 2.0 Conference.
Most of the breakout sessions at last week's annual Health 2.0 Conference event in San Francisco featured rapid-fire product demonstrations, and venture capitalists were out in force to view the latest fads. Attendees saw that mobile apps and other health tools are moving past the novelty stage and beyond the limited consumer realm in healthcare to become increasingly useful in clinical settings. Some developers are even taking steps to integrate their apps into clinician workflow.
Ringful Health, a small company based in Austin, Texas, delivers interactive clinical content to patients on mobile devices to help improve outcomes and reduce hospital readmissions. It demonstrated a tablet-based clinical decision support tool for nurses that also can be used for patient engagement. The idea is to reduce risk for major in-hospital adverse events, while fitting the nursing workflow, CEO Michael Yuan said. AdTech Ad
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Tuesday, October 23, 2012

Q3 2012 Saw Surge of Federal Health IT Activity

by Helen R. Pfister, Susan R. Ingargiola and Christine D. Chang, Manatt Health Solutions
The federal government continued to implement the Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as part of the American Recovery and Reinvestment Act (ARRA), during the third quarter of 2012.  Below is a summary of key developments and milestones achieved between July 1 and Sept. 30.
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Medication barcoding reduces errors, ushers big savings

By Erin McCann, Associate Editor
Created 10/22/2012
TROY, MI – A newly implemented medication barcoding system at the Michigan-based Beaumont Health System helped the organization prevent some 23,500 possible drug errors within a six-month time period, officials announced Friday.
With an estimated 400,000 preventable drug-related injuries in hospitals resulting in $3.5 billion in unnecessary medical costs each year, Beaumont officials wanted to make medication error prevention a strategic imperative for improving patient safety, quality and cost across its three hospitals.
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Study Pegs Cost of Medical Errors Near $1 Trillion Annually

OCT 19, 2012 5:24pm ET
A study in the Journal of Health Care Finance from Wolters Kluwer finds medical errors in the U.S. may cost up to $1 trillion per year.
That figure includes measuring the cost of lost human potential and contributions, making the overall cost from errors considerably higher than shown in previous research. Study authors used Quality-Adjusted Life Years (QALY) to get a more  complete accounting of the economic affect when a person dies from a preventable medical error. They took calculations on measures from multiple previous reports, including the 1998 benchmark figure from the Institute of Medicine of 98,000 deaths caused annually from medical errors.
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WHO, ITU Launch mHealth Initiative

October 19, 2012
The World Health Organization (WHO) and International Telecommunication Union (ITU) are launching a global mobile health (mHealth) initiative, aimed at using text messaging and apps to combat noncommunicable diseases (NCDs) such as diabetes, cancer, cardiovascular diseases and chronic respiratory diseases.
With the initiative, ITU and WHO promise to provide evidence-based and operational guidance for various worldwide entities, especially governments, to implement mHealth interventions to prevent NCDs. According to WHO, NCDs contribute to an estimated 36 million deaths every year, including 14 million people dying between the ages of 30 and 70. WHO predicts mHealth can save lives, reduce illness and disability, and reduce healthcare costs significantly.
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Bioinformatics called critical to next-generation DNA sequencing

October 22, 2012 | By Julie Bird
Laboratories that want to run next-generation sequencing (NGS) of DNA will need extraordinarily robust bioinformatics infrastructure to fully leverage research and diagnostic opportunities, the Association for Molecular Pathology reports in the November issue of the Journal of Molecular Diagnostics.
"The power of NGS to generate hundreds of millions to multigigabase levels of sequence in a single instrument run, while having opened a diversity of research and diagnostic avenues, is concomitantly stretching our ability to process data," according to the report, "Opportunities and Challenges Associated with Clinical Diagnostic Genome Sequencing."
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Database finds docs actively use Twitter

October 22, 2012 | By Susan D. Hall
A new database of physician tweets aims to gain insight into how doctors use Twitter.
San Francisco-based WCG, an independent strategic communications firm, created a database of nearly 1,400 U.S. doctors on Twitter and linked them to their National Provider Identifier, the 10-digit identification number issued by the Centers for Medicare & Medicaid Services.
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Study: High-risk teens open to online health records

October 22, 2012 | By Susan D. Hall
High-risk teens could benefit from online records and the ability to share their health information, according to a study published at Pediatrics.
Teens in a California juvenile detention center were overwhelmingly interested in being able to access their health records online, according to research that surprised Stanford researchers.
The teens tended to engage in high-risk behaviors, and the researchers assumed they would pay little heed to their health. The subjects often had no adult keeping a record of immunizations and other medical conditions, including sexually transmitted infections, mental illnesses and substance abuse. This could pose problems for them, even into adulthood, according to senior author Arash Anoshiravani, who pointed out that such teens generally are not considered in the discussion of how to better engage patients in their health.
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Enjoy!
David.

Friday, November 02, 2012

A Little Follow Up From A Post Two Weeks Ago. Not Really Good Enough.

Dr Hannan passed on an update from our frustrated physician and would be PCEHR User.

Hi Terry,

I thought I should let you know that I still have not been able to put my Advance Medical Directive, or my own medical history summary into this medical record. I have phoned up the contact number twice, the first time got the message they were having trouble and call back please. The next time the contact person seemed to have little insight and was not used to handling people, and if I had not been persistent would have been put off.

It seems, at least according to her, that there is no capacity to put in one's advance medical directive or personal medical history, that must be put in by ones doctor.

If that is the case, then it is really useless and this is not what all the promotional material says.

Indeed, in attempting to even find where to log in or searching for PCEHR on the internet one is bombarded about just how good it is and how one can input personal data.

When pressing the contact individual about how important it was to get one's advance medical directive in, they were confused, and directed me to the field for entering the custodian's details who may hold my medical record.

That is useless in the real world as they may not be home or be able to find it.

One still cannot put in personal documents.

I seems to me that if it were modelled on Facebook (plus securities) the system may work.

Best wishes,

John

Maybe we could sit down together over a computer one day and go through this together so you will know what I mean

Dr.J.M.Sands

Email: doxanz at nixanz.com

Pretty sad I reckon.

David.

Thursday, November 01, 2012

This Is Really A Totally Astonishing Figure. Could It Be True?

The following appeared a few days ago:

Study Pegs Cost of Medical Errors Near $1 Trillion Annually

OCT 19, 2012 5:24pm ET
A study in the Journal of Health Care Finance from Wolters Kluwer finds medical errors in the U.S. may cost up to $1 trillion per year.
That figure includes measuring the cost of lost human potential and contributions, making the overall cost from errors considerably higher than shown in previous research. Study authors used Quality-Adjusted Life Years (QALY) to get a more  complete accounting of the economic affect when a person dies from a preventable medical error. They took calculations on measures from multiple previous reports, including the 1998 benchmark figure from the Institute of Medicine of 98,000 deaths caused annually from medical errors.
More here:
Here is the abstract of the paper (free full text available from same link)

The Economics of Health Care Quality and Medical Errors

Article from Journal of Health Care Finance, Vol. 39, No. 1, Fall 2012, published by Wolters Kluwer Law & Business

Charles Andel, Stephen L. Davidow, Mark Hollander, and David A. Moreno


Hospitals have been looking for ways to improve quality and operational efficiency and cut costs for nearly three decades, using a variety of quality improvement strategies. However, based on recent reports, approximately 200,000 Americans die from preventable medical errors including facility-acquired conditions and millions may experience errors. In 2008, medical errors cost the United States $19.5 billion. About 87 percent or $17 billion were directly associated with additional medical cost, including: ancillary services, prescription drug services, and inpatient and outpatient care, according to a study sponsored by the Society for Actuaries and conducted by Milliman in 2010. Additional costs of $1.4 billion were attributed to increased mortality rates with $1.1 billion or 10 million days of lost productivity from missed work based on short-term disability claims. The authors estimate that the economic impact is much higher, perhaps nearly $1 trillion annually when quality-adjusted life years (QALYs) are applied to those that die. Using the Institute of Medicine’s (IOM) estimate of 98,000 deaths due to preventable medical errors annually in its 1998 report, To Err Is Human, and an average of ten lost years of life at $75,000 to $100,000 per year, there is a loss of $73.5 billion to $98 billion in QALYs for those deaths―conservatively. These numbers are much greater than those we cite from studies that explore the direct costs of medical errors. And if the estimate of a recent Health Affairs article is correct―preventable death being ten times the IOM estimate―the cost is $735 billion to $980 billion. Quality care is less expensive care. It is better, more efficient, and by definition, less wasteful. It is the right care, at the right time, every time. It should mean that far fewer patients are harmed or injured. Obviously, quality care is not being delivered consistently throughout US hospitals. Whatever the measure, poor quality is costing payers and society a great deal. However, health care leaders and professionals are focusing on quality and patient safety in ways they never have before because the economics of quality have changed substantially.
Key words: medical errors, quality, patient safety, quality-adjusted life year, QALY, Joint Commission, Institute of Medicine, Society of Actuaries, Milliman, efficiency, Medicare, accountable care organizations (ACOs), facility-acquired condition, cost savings.
Full text link here:
The conclusion sentence or two of the paper says it all

Conclusion

“Quality care is less expensive care. It is better, more efficient, and by definition, less wasteful. It is the right care, at the right time, every time. It should mean that far fewer patients are harmed or injured.”
What is interesting is the implications for Australia.
On a population basis 22/315 Million = about 7% = $70 Billion ($US)
On a GDP basis it is 1.4/15 (Trillion $) = about 9.5% = $95 Billion ($US)
Now while all this cannot be got rid of - even small percentage improvements can thus make a huge difference.
Properly implemented e-Health can be part of this story. Seems like there is an opportunity here!
Pity that isn’t the focus of present e-Health rather than the unproven PCEHR.
David.

Compulsory Retrenchments At NEHTA Are Rumoured - Anyone Have Some Facts?

All sorts of people are telling me there has been a rather messy 'staff detachment process' occur in the last few days at NEHTA (No executives, just staff) and that is has been rather less than well handled.

Does anyone have a fact or two to put on the table about numbers, potential impact on workplans, worker impact etc?

David.

Wednesday, October 31, 2012

Ministerial Speech To RACGP Last Week. It Will Be Interesting To See What Comes Of All This.

Here is the text of the speech. I have marked the e-Health Component in italics.
Speech - Royal Australian College of General Practitioners Conference GP12: Leading Primary Care - Gold Coast Convention and Exhibition Centre - Broadbeach, Queensland, 25 October 2012
Federal Health Minister - Tanya Plibersek.
Thank you for inviting me to be with you here today.
I’d like to begin by acknowledging the traditional custodians of the land on which we meet, the Kombumerri People, and pay my respects to their Elders past and present.
I would also like to recognise:
    • Dr Elizabeth Marles, the RACGP’s brand new President;
    • Professor Claire Jackson, immediate past President of the RACGP;
    • Dr Zena Burgess, the CEO of the RACGP; and
    • today’s keynote speaker, Professor Clare Gerada, Chair of the Royal College of General Practitioners in the United Kingdom.

Introduction

I’m delighted to be able to acknowledge international delegates from an impressive 16 countries. Welcome to Australia and the beautiful Gold Coast.
Your presence underscores the importance of the Royal College and the high esteem in which this conference is held.
Primary care and GPs: the heart of our health system
For most Australians, visiting a GP is their first, and often their main contact with our health system.
And you’re a popular bunch – with GPs always amongst the handful of professions at the top of our ‘most trusted professions’ lists.
But I know that trust is hard-earned.
Earned through the caring relationships you develop with your patients, and in your practices, each and every day.
And it’s those relationships that mean GPs are the ones best placed to make decisions with their patients, based on their unique circumstances and needs.
Today I’d like to talk about what I think are three key roles for government in the primary healthcare system.
Firstly, about how we can support local decision making, especially by GPs.
Secondly, about collecting, analysing and reporting honest, transparent information about our performance in primary healthcare.
And thirdly, about using that information to help guide investment and drive continuous improvement across the system.
Supporting local decision making in primary care
The international evidence tells us, loud and clear, that health systems with strong primary healthcare are more efficient, have lower rates of hospitalisation, fewer health inequalities and better health outcomes.
The World Health Report in 2008 found that where countries at the same level of economic development are compared, those that were organised around the tenets of primary healthcare produced better health outcomes for the same investment.
We have also seen how care coordination in the primary healthcare sector has been demonstrated to have a significant impact on reducing avoidable hospitalisations.
A randomised control trial conducted by GP Partners in north Brisbane provided clear evidence that a model including dedicated care coordinators, and GP-led care planning leads to lower service utilisation and better health outcomes for patients. The randomised control trial was carried out over three years and involved more than 3000 participants, 179 GPs from 108 practices, as well as 16 care coordinators. The evaluation showed that after 12 months the intervention participants had better general health, and enjoyed a higher quality of life compared to the control group. And after 18 months of care coordination, the intervention participants accounted for an incredible 25% less hospital admissions than the control group.
And another nationally representative study from the United States showed that patients who had a family GP, rather than a paediatrician or sub-specialist, as their regular doctor had:
    • a lower annual cost of care;
    • made fewer visits;
    • had 25% fewer prescriptions;
    • and reported less difficulty in accessing care…
...even after controlling for case-mix, and demographic characteristics.
As a Government we are taking this evidence seriously.
We are shifting the centre of gravity in the Australian system away from acute care in hospitals to primary care.
And as you’d all be aware that’s what we’ve be doing through the establishment of Medicare Locals...
...and more flexible funding and decision-making arrangements to allow GPs and their colleagues to better respond to local needs.
But now Medicare Locals have been established, what we are looking at is what other responsibilities we might sensibly think about devolving to a community level, including to GPs.
At the end of the day, our goal is to have more decisions made locally by GPs, rather than by bureaucrats in Canberra.
The potential of patient-centred medical homes, and better integrated team-care arrangements are some of things already on my list for further exploration.
But I’ll be talking to the RACGP about their vision for how that could look. And I’m very excited by potential of things like eHealth to help realise that vision.
I’ve been working closely with the RACGP on eHealth and I am confident it will help empower you, as GPs, to make even better decisions for your patients…
...decisions based on more comprehensive, more integrated information than ever before.
The statistics tell me that in any week, one in three Australian GPs see a patient for whom they have no current information. And more than one in five GPs face this situation every day.
That really serves to reinforce how central GPs will be to the system – which is why today I am pleased to announce the Government will invest around $2.55 million for the RACGP to lead some new work to assist general practice engage with the Personally Controlled Electronic Health Record.
The College will develop an eHealth syllabus and education modules for use by the Australian General Practice Training Program. And that will be done in collaboration with the Australian College of Rural and Remote Medicine – with the final program earning Continuing Professional Development points for GPs with either College.
This will help ensure GPs can access professional training in eHealth so care can be confidently delivered in a shared electronic environment.
As well, the College will manage a program of GP to GP support – again in collaboration with the College of Rural and Remote Medicine.
The program will employ around 30 GPs with expertise in the PCEHR to speak to their colleagues in around 200 locations across Australia.
The program will engage GPs on the clinical utility of the PCEHR and help prepare general practice for e-readiness and PCEHR compliance. Of course, this will complement the practical support offered to GPs by practice liaison officers under the Medicare Locals eHealth readiness program.
As the PCEHR rolls out, we will be keeping a close eye on the impact it has on the primary healthcare system, as well as the system as a whole.
But to help us better understand impacts like these we need honest and transparent information about our performance.
Honest and transparent information about our performance in primary healthcare
I’m sure everyone here is well acquainted with the health performance information agenda being progressed through the council of health ministers.
And you’d know we have established the National Health Performance Authority to help manage that work.
But today I wanted to touch on some of the things the Authority will be looking at across the primary care system.
Initially the focus will be on information about local health systems – so we can better understand the relationship between hospitals and primary care systems in local communities.
People often tell me they feel a little 'in the dark' about primary care, particularly in terms of understanding its success in keeping patients out of the acute system.
So what the Performance Authority will do is pull together comparable data to paint us a more accurate picture of how we’re doing – to help us explain variation in health outcomes across different communities by exploring the link between primary care and things like avoidable admissions, and length of stays in hospitals.
This is the kind of information that should be valuable for discussions between GPs, Medicare Locals and hospitals.
It will inform your work to ensure that patients get the right care in the right location.
In terms of nationally consistent information on local communities, the Authority will present information in such a way that communities can meaningfully compare experiences with healthcare. The Authority is already working with the Australian Bureau of Statistics to create ‘comparable communities’ so that Medicare Local regions can compare their results with other regions in Australia that face similar social, economic and geographic issues.
And most importantly for everyone here today, the Authority’s first report will include information on use and experiences with primary healthcare – and GPs in particular.
Using information to drive continuous improvement across the primary healthcare system
But all the information in the world is for nought if as a government you don’t look at it, analyse it, and act on it.
The examples I touched on earlier really highlight the power information has to describe how the primary care system is doing, and to identify the things that really work.
For Government, it helps to guide our investment towards what the evidence shows to work, and away from the things that don’t.
It will mean we can make even better use of every precious health dollar.
For instance, research has suggested that in Australian general practice only about half of patients with chronic diseases such as asthma, type 2 diabetes and hypertension received recommended care. And as well as that, there was variation across the country. In NSW for example, the rate of hospitalisation for medical conditions such as asthma and diabetes between local government areas varies by nearly three times.
What is needed is a better understanding of the extent and reasons for this variation in care. The Australian Commission on Safety and Quality in Healthcare is leading Australia’s involvement with the OECD in a project to consider clinical variation within a number of countries for a range of conditions. The Commission is also working to understand further the degree of clinical variation experienced by patients across the country and plans to describe such variation in clinical care.
The next important step will be to understand how best to reduce any unwarranted variation. We know that when patients are given clear and accurate information about treatment, their choices begin to change.
Collaborative work is also underway through the Australian Primary Care Collaboratives, with participation by some 1100 GP practices Australia-wide. The Collaboratives have worked closely with divisions and now with Medicare Locals to look at continuous improvement in practices. That work includes reducing variation in key areas such as diabetes prevention and treatment, chronic obstructive pulmonary disease, and coronary heart disease.
It is important that the medical profession, and in particular the College, is given a leadership role in the work to understand the reasons for this variation in care, and in taking action to reduce unnecessary variation.
This will help to ensure that more people get the right care, at the right time and in the right place.

Conclusion

In closing, I want to take this opportunity, here, amongst her colleagues, to thank Professor Claire Jackson for her fine work as President of the RACGP over the past two years.
On Claire’s watch, the College’s membership has grown to an impressive record of 21,500 practitioners.
Claire has displayed great leadership on issues from eHealth, to general practice funding streams, chronic disease management, and after-hours arrangements.
Her work has also set the stage for the College to continue to develop and support the next generation of GPs.
And on a personal note, Claire, I want to thank you for your wise and honest counsel to me as Minister. I know you will continue to make a significant contribution to your profession, and to the Australian health sector.
Just as I know your successor, Dr Elizabeth Marles, will continue to represent the RACGP admirably.
I look forward to working with you, Dr Marles, to better support GPs, and to use the evidence about our performance to drive continuous improvement in the Australian primary healthcare system.
Thank you.
The text of the speech is found here:
I really wonder just how most GPs will see all this.
Consider this statement:
“The statistics tell me that in any week, one in three Australian GPs see a patient for whom they have no current information. And more than one in five GPs face this situation every day.”
Surely this means that, for the vast majority of patients GPs see, they do have information?
What I see in all this is an expanding set of requirements and demands for measurement and performance assessment of GPs from the Commonwealth Government and what I am not seeing is the evidence that the profession has decided that this is the way they want to profession to proceed.
It is also not entirely clear just how much evidence there is that such an approach - without a lot of support, education and clinical leadership - actually works.
What I find quite interesting is that there has been recognition for a very, very long time (going back to the work done at Intermountain Healthcare by Brent James (going back to 1988) of the importance of limiting variation in practice
See here:
In this paper the authors specifically say that they “did not try to control physicians’ practice behaviour by top down command and control...Instead we relied on solid process and outcome data, professional values that focused on patients’ needs and a shared culture of high quality”.
Brent James is widely recognised as probably the world expert in the area of clinical quality improvement so I hope the Ministerial Advisors are making sure they are going about their attempts to obtain quality improvement the right way that we know works and not just measuring for the sake of measuring without relevant clinical buy in and understanding. The information that will make a difference needs to be relevant and solid as well a locally credible.
The Collaboratives program mentioned later in the speech certainly seem to be heading in a sensible direction and by being more locally driven and clinically led. This program is, of course, hard work and needs continuing support to reach the wider clinical community.
Canberra bureaucrats can be a long way from the GP clinical work face!
Of course the best source of information on which to base quality improvement is that from local live systems used daily by GPs. Hardly what the NEHRS is providing sadly.
David.

Tuesday, October 30, 2012

There Is Governance Management Chaos Loose With The NEHRS. What A Nonsensical Fiasco.

The following amazing diagram crossed my path the other day and I felt an urgent need to share.

This diagram is described as the PCEHR Governance Context and really makes alphabet soup sound like an understatement.

Click To Enlarge


The issue with all this is that it virtually guarantees decision making paralysis. Additionally it guarantees that absolutely no-one will ever be held accountable or responsible for anything.

There is a prize being offered - an opportunity to post a guest blog - for the person who can correctly say what each of these acronyms stand for. Many of them are clearly secret as no one seems to have heard of them except the members!

Imagine the hours that could be happily wasted and the frequent flyer points that could be accumulated attending all these!

Wanders off holding sore head in hands. What utter nonsense!

Last - while I have your attention - I hear rumours of all sorts of things happening at NEHTA. Stay tuned as they say.

David.

Monday, October 29, 2012

Weekly Australian Health IT Links – 29th October, 2012.

Here are a few I have come across the last week or so.
Note: Each link is followed by a title and a few paragraphs. For the full article click on the link above title of the article. Note also that full access to some links may require site registration or subscription payment.

General Comment

Quite a busy week with the Health Minister out talking up the PCEHR and then offering a trivial sum to have some clinicians talk it up while thinking that GPs are all going to be able to turn on  a technological dime and make it all work - supported by vendors who are still not entirely clear about how it will all hung together and how much disruption lies ahead.
The remarks made at Senate Estimates last week have finally been noticed and we have seen a lot of reporting - even internationally - on the cancellation of an IBM contract. Speculation that this will wind up in the courts is rife - but I suspect it will be sorted long before it gets to that. No one wins when the lawyers get involved!
Of course Windows 8 also hit the shelves this week. It is certainly a bit different so it will be interesting to see how it plays out in terms of adoption over time.  
It was good to see that all was well logging in to the NEHRS today. That’s twice in a row it has worked. The odd thing is that the Australia.gov.au login screen looks quite distorted - no idea why but has been the same for a couple of week. Go figure (using Firefox as browser).
This is a useful link if you want to keep an idea on outages and so on.
Can see how the NEHRS is going from there via a link.
Quote of the week from DoHA on the messed up graphic which had ovaries as kidneys etc:
“During a Senate estimates hearing on Friday, health department Assistant Secretary Adam Davey said the error occurred after the poster was sent back to the graphic designer with amendments and an old file version was accidentally used.
"The department does have processes in place to ensure the accuracy of our communications. On this occasion they were not followed," Mr Davey said.”
Oh really?
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Software ePIP update put practices behind

23rd Oct 2012
AN ePIP software update that crippled some practices using the most popular practice software has sparked concerns about looming disruption from the upcoming e-health record rollout.
Some practices using Medical Director were forced to return to paper records and cut consult times after the software’s latest update drastically slowed their IT systems.
Medical Director owner Health Communication Network (HCN), a Primary Health Care subsidiary, confirmed it issued a new version of the program, aimed at ensuring practices would qualify for the e-health Practice Incentives Program payment (ePIP), to its 17,000 users in September, with a follow-up patch to fix bugs earlier this month.
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State not sold on tracking

Date October 23, 2012

Josh Gordon

THE Baillieu government has not signed up to a new national ''real time'' prescription tracking system to prevent the growing abuse of painkillers, warning it is not a ''magic bullet''.
With mounting concern about the misuse of drugs such as fentanyl and oxycodone, the Royal Australian College of General Practitioners and the federal government are pushing for a nationwide electronic system that would allow pharmacists, doctors and state health authorities to monitor the prescribing and dispensing of addictive drugs.
The plan, which is being funded by the federal government and trialled in Tasmania, would allow health authorities and professionals to check up on people suspected of ''doctor-shopping'', forging prescriptions and trafficking painkillers using a national database.
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Online program to help GPs manage pain

26 October, 2012 Megan Reynolds
Access to the latest skills and research on acute and chronic pain management will be provided to GPs through an Australian-first online learning tool launched at the GP12 conference yesterday.
The innovative Active Learning Module (ALM) pain management program developed by the Faculty of Pain Medicine (FPM) of the Australian and New Zealand College of Anaesthetists (ANZCA), the RACGP, and the Bupa Health Foundation will give primary healthcare professionals immediate access to the latest evidence-based research and skills to help prevent transition from acute to chronic pain and improve their patients’ quality of life.
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GPs to play key role in e-health: minister

2:24pm October 25, 2012
General practitioners will play a vital role in the establishment of Australia's e-health system, according to federal Health Minister Tanya Plibersek.
Speaking at the opening of the Royal Australian College of General Practitioners (RACGP) annual conference on the Gold Coast, Ms Plibersek said the government was investing $2.55 million to develop training programs aimed at GPs.
The minister said the RACGP, in consultation with the Australian College of Rural and Remote Medicine, will use the funds to develop an e-health syllabus and education modules.
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Government increases focus on GP performance

26 October, 2012 Julie Robotham
The primary care sector can expect escalating government scrutiny of patients’ health outcomes, the federal health minister, Tanya Plibersek, foreshadowed yesterday.
Opening the GP12 conference on the Gold Coast, Ms Plibersek said the Health Performance Authority was working with the Australian Bureau of Statistics to find ways to compare geographically and socially similar regions.
This would identify regions with high rates of potentially avoidable admissions or prolonged hospital stays, and highlight “how to best reduce any unwarranted variation,” Ms Plibersek said.
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Government pledges ehealth funding for GPs

26 October, 2012 Nick O'Donoghue
GPs are set to get $2.55 million in Federal Government support to help them engage with the Personally Controlled eHealth Record (PCEHR) system.
Tanya Plibersek, Minister for Health and Ageing, announced the funding at the Royal College of General Practitioners (RACGP) Conference on the Gold Coast yesterday.
Recently, in a column in Pharmacy News, Kos Sclavos, Pharmacy Guild of Australia national president, expressed disappointment at the roll-out of the PCEHR.
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GPs gain PCEHR training and support boost

GPs will have access to peer support and online education tools under a new ehealth plan announced today by federal health minister Tanya Plibersek.
Under the $2.55 million funding agreement, The Royal Australian College of General Practitioners (RACGP) will train a cohort of 30 “GP advocates” to deliver peer-to-peer ehealth support and education via a seminar program delivered at up to 200 sites around Australia.
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IBM loses key e-health contract

Human Services steps in as provider.

The National E-Health Transition Authority (NEHTA) has sacked IBM as provider of the National Authentication Service for Health (NASH) after it failed to deliver the service on time.
The NASH service designed and built by IBM was intended to provide a secure means for clinicians to connect with the Federal Government’s $467 million Personally Controlled Electronic Healthcare Record (PCEHR) system.
IBM won the $23.6 million NASH contract in March 2011 and was due to deliver the system on 26 June 2012.
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IBM’s NASH deal gets terminated

news The National E-Health Transition Authority and IBM this afternoon confirmed Big Blue’s $23.6 million contract to build a key component of the Federal Government’s Personally Controlled Electronic Health Record project had been “terminated”, just 18 months after the contract was initially inked. However, it is unclear where culpability lies in the situation.
As part of a $466.7 million investment in the e-health records announced in September 2010 by the Federal Government, the nation’s peak e-health body NEHTA chose IBM in March 2011 to build and manage its new National Authentication Service for Health (NASH) system, which aims at establishing a nationwide secure and authenticated service for both healthcare organisations and personnel that have to exchange e-health information.
At the time, NEHTA chief executive Peter Fleming said NASH would improve healthcare for both professionals and patients. “Our agreement with IBM enables NEHTA to build a system that will give healthcare professionals timely and secure access to appropriate patient information,” he said in a statement. “In turn, the NASH program will take us one step closer to broader healthcare access for all Australians.”
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IBM loses $23 million contract for Australian EHR system

October 24, 2012 | Anthony Brino, Associate Editor
The Australian federal government has terminated a contract with IBM to build the National Authentication Service for Health (NASH), a key security component for the country's national health IT system.
The Australian National E-Health Transition Authority (NEHTA) has terminated the $23 million contract with IBM, citing missed deadlines and delays.
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Lawyers crawl over NASH debacle

The collapse of the $24 million contract to develop a National Authentication Service for Health (NASH) is now in the hands of lawyers following IBM being stripped of the project.
The National E-health Transition Authority, Nehta, awarded IBM the $23.6 million NASH contract in March 2011. IBM was charged with developing an access authentication framework using Public Key Infrastructure (PKI) and secure tokens to manage access to information stored in PCEHRs (Personally Controlled Electronic Health Records).
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Legal woes for IBM's e-health contract

Summary: The end of a key AU$24 million contract with the Australian government's e-health agency appears to be bound for the courts.
By Josh Taylor | October 25, 2012 -- 06:14 GMT (17:14 AEST)
IBM's AU$23.6 million contract with the National E-Health Transition Authority (NEHTA) is in tatters, and both sides have brought the lawyers in as the government implements an interim National Authentication Service for Health (NASH) system.
The deal was first signed in 2011 for delivery by June 30, 2012. IBM was tasked to develop a system that would use public key infrastructure and secure tokens, such as smart cards, in order to provide an authenticated service. This is so that healthcare personnel and providers can exchange e-health information, including referrals, prescriptions, and personally controlled electronic health records (PCEHRs).
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Patient sign-up to PCEHR steady

23 October, 2012 Kate Aubusson
Uptake of Australia’s new e-health system is gradually increasing, with more than 12,500 people signed up for a personally controlled electronic health record by mid-October.
However, the number is still a long way short of the 500,000 target the Federal Government has set for 1 July 2013.
There are also 68 individual health practitioners and 86 health organisations — including hospitals and practices — signed up to access the e-health system, launched on 1 July.
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Telehealth cut as PHI targeted in mid-year budget

22nd Oct 2012
GP telehealth rebates will be restricted to people in designated areas of need and after hours video conferencing restricted to people in aged care facilities as the federal government clings to its forecast budget surplus.
The private health insurance rebate, which was already means tested in the last budget, will now be reduced, Treasurer Wayne Swan said today as he blamed global economic conditions for across the board spending cuts in his Mid-Year Economic and Fiscal Outlook (MYEFO) statement.
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SA office to manage $485m ehealth spend

SA Health is establishing a body to oversee its $485 million investment into statewide ehealth transformation.
According to government documents released this week, the new eHealth Program Management Office’s (ePMO) primary role will be ensuring successful delivery of the $408 million Enterprise Patient Administration System (EPAS) and the associated statewide e-pathology ($30.4 million), imaging ($22 million) and financial and supply chain systems ($25 million).
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Medical agency blocks request for report's release

THE Department of Health and Ageing has refused to release details of a crucial risk-assessment study conducted by Ernst & Young on the personally controlled e-health record system.
The department's e-health division head, Matthew Corkhill, ruled that it was against the public interest to release the 21-page report, Assessment of PCEHR Information Security Threat and Risk Assessments, in response to a Freedom of Information request lodged by The Australian in July.
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No risk guarantee on e-health

THE Department of Health and Ageing has refused to guarantee that its much vaunted e-health record system is risk-free after more than 140 risks were identified before it went live on July 1.
The Gillard government's personally controlled e-health record system, developed by Accenture, contained a staggering 142 risks of which 32 were rated extreme, 77 high and 33 medium.
The detailed risk assessment study, obtained by The Australian, was prepared by the National E-Health Transition Authority (Nehta) and submitted to the Health Department and other relevant parties about two months before the July go-live date.
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IBM says it “successfully delivered” Qld Health payroll

news Global technology giant IBM has written to the new LNP Queensland Government claiming it “successfully delivered” against milestones agreed with the previous Labor administration with respect to the disastrous payroll systems overhaul at Queensland Health, which has already cost the state $417 million and will need another $837 million to fix over the next five years.
The project was first kicked off in late 2007, when Queensland Health determined there was a need to look at a new payroll platform to replace the previous platform, based on Lattice and ESP software, which had been progressively implemented from 1996. Partially as a result of the fact that the state had decided to standardise on SAP’s ECC5 and Infor’s Workbrain software across its whole of government operations, those same platforms were picked for the Queensland Health implementation.
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Date validation for exchanged data

Posted on October 21, 2012 by Grahame Grieve
A question arose in the PCEHR program: is the date 00010101 a valid date in CDA, and if not, what is the valid date range allowed?
Well, firstly, as far as the TS data type is concerned, 00010101 is a valid date – the 1/1/01, the nominal year of Jesus’ birth (only he wasn’t born that year). But just because it’s legal according to the type doesn’t mean that it makes sense – especially as the date of onset of a patient’s problem. This caused some discussion about what dates the national program should accept for clinical dates – what should be valid? When I looked around, I discovered remarkably little good information about the general subject of what dates are reasonable to accept in clinical records.
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Top health diagnosis apps

Date October 21, 2012
Jenneth Orantia reviews the best apps for helping - not replacing - your doctor's opinion.
iBGStar Diabetes Manager
iPhone
Free
The iBGStar Diabetes Manager helps monitor blood glucose levels for those with Type 1 or 2 diabetes. A small accessory for taking blood samples clips to your iPhone (the iPhone 5 isn't supported), alerting you when your blood sugar is out of range.
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Putting medical apps through their paces

APP NAME: SWAP It
PUBLISHER: Department of Health and Ageing.
COST: Free.
PLATFORM: iPhone.
PURPOSE: Gives tips on what food items and activities people can swap to achieve a healthier lifestyle.
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IT service found 'corrupt'

THE state-owned centre for information technology excellence in Victoria was undermined by corrupt behaviour, botched procurement systems and sham contracting, the acting Ombudsman has found.
Acting Victorian Ombudsman John Taylor said CenITex breached procurement policies and guidelines and accused it of nepotism and favouritism. He found some appointments were made on the basis of fabricated or false documentation and staff deeply compromised by conflicts of interest. "Serious improper conduct did occur," he found.
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NBN backlog in greenfields to take eight months to clear

Up to 3800 homes are waiting to be connected to the NBN in new housing estates.
NBN Co has admitted that its roll out of the National Broadband Network (NBN) is not keeping pace with demand in new housing estates, with 3800 premises waiting to be connected.
7:30 reported last night that NBN Co as said it would take until the middle of next year to clear this backlog in new developments.
The program reported several residents in new developments who have been unable to connect a fixed phone line or broadband services due to fibre not being rolled out in their new housing estate yet.
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Microsoft's big gamble with Windows 8

Date October 26, 2012

James Manning

Technology reporter

Microsoft has thrown down the gauntlet to Apple with the official launch of Windows 8, a new operating system that focuses largely on tablet and mobile devices.
As consumers increasingly turn to smartphones and tablets for their computing needs, sales of PCs are expected to decline this year for the first time in 11 years, says research firm IHS iSuppli.
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How Windows 8 changes the game for PC security

Date October 23, 2012 - 9:33AM

Lance Ulanoff

Windows 8 changes the security game in ways that attempt to push aside security software giants such as Norton and Symantec.
Security, or lack thereof, has dogged Microsoft Windows since the mid 1990s. This was bad news for consumers who were fond of risky practices such as sharing 3.5-inch floppies and downloading unknown files from services like AOL, UseNet Groups and, later, the web and file-sharing services. It was a boon, though, for a legion of security software companies that all dove into the breach to protect us from a vulnerable operating system and ourselves.
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Gartner: 10 critical IT trends for the next five years

ORLANDO -- Trying to stay ahead of the curve when it comes to IT issues is not a job for the faint of heart. That point was driven home at Gartner's IT annual IT Symposium fest here where analyst David Cappuccio outlined what he called "new forces that are not easily controlled by IT are pushing themselves to the forefront of IT spending."
The forces of cloud computing, social media/networking, mobility and information management are all evolving at a rapid pace. These evolutions are largely happening despite the controls that IT normally places on the use of technologies, Cappuccio stated. "IT was forced to support tablets, and end users forced them to support IM and wireless networks a few years ago. And more such technologies are on the horizon," he said.
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Enjoy!
David.

AusHealthIT Poll Number 142 – Results – 29th October, 2012.

The question was:
With The Contract For NASH With IBM Being Cancelled (See Senate Estimates) Will We Ever See NASH Actually Delivered As Intended?
Yes - Pretty Soon 16%
Yes - But Much Later 7%
Yes - But Very Much Later 7%
No 47%
I Have No Idea 23%
Total votes: 43
Very interesting.  Close to ½ think it will never happen and quite a few don’t know or are thinking later!
Again, many thanks to those that voted!
David.