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."

Tuesday, October 07, 2014

With The ABC’s Mental as Week Is On. It Is Important To Be Reminded What E-Mental Health Can Do.

This week the ABC is conducting a week of educational programmes on Mental Health and how it can be identified, managed and lived with much more satisfactorily.
Here is the link:
Interestingly there have been some articles appear on the topic and the blog has previously covered all sorts of interesting e-Mental Health initiatives.
Use the search function with “mental health” and there is heaps to find.
In the last week of so I have noticed the following:
First here:

Don’t get left behind, be a part of the new world

30th Sep 2014
GENERAL practice runs the risk of getting left behind if it does not keep up with the technology available to its patients.
Dr Jan Orman
GP Services Consultant, Black Dog Institute
E-mental health resources, especially online therapy, is an area GPs seem to know little about but will increasingly be expected to know about in the future. There’s a degree of scepticism but overall the problem is simply lack of knowledge of these resources and how to use them.
There’s no argument about the efficacy of online CBT for a variety of diagnoses in the mild to moderate stress, anxiety and depression categories. My experience is GPs acquainted with the evidence are generally convinced.
That hurdle overcome, the next is imagining where online therapy might fit.
The Better Outcomes in Mental Health initiative made face-to-face psychological therapy available to many who’d previously been unable to afford it, albeit in a limited way. We all know that isn’t nearly enough. 
 Lots more here:
And here:

Internet based or computerised CBT (iCBT or CCBT): depression and anxiety

About 85% of patients with depression have significant anxiety

Intervention

Internet-based or computerised cognitive behavioural therapy programs.
Cognitive behavioural therapy (CBT) is the main psychological treatment approach available as computer- or internet-based programs.

Indication

Depression and anxiety.
Treatment programs have been studied in patients with mild-to-moderate, moderate-to-severe and severe depression.
iCBT may be particularly useful for patients in rural and remote locations and for patients with mobility issues.
Lots more here with useful references:
Lastly the UK is pushing in the same direction:

Confed wants e-mental health strategy

2 October 2014   Lis Evenstad
The Department of Health and NHS England should create a national strategy for e-mental health and invest in a national programme to support this, says a report by NHS Confederation.
The report, entitled ‘The future’s digital - mental health and technology’, surveyed the members of the Confederation’s Mental Health Network about their current use and plans for utilising technology.
It found that although organisations were clear that technology could be used to improve patient care, there was a lack of a sense of “future vision and the right skills” in the workforce.
“Our existing ways of evaluating new products and services, and ensuring their safety, are too slow to enable our services to keep up with the pace of technological change we see all around us,” says the report.
It says that although there are “fantastic examples across the country”, these need to be learned from and adopted across the board.
“However, there are some common problems it makes sense to tackle at a national level, under the banner of the development of a national strategy for e-mental health,” it adds.
“We believe a national strategy for e-mental health, co-developed and co-owned by national bodies, should be developed in 2015-16.
More here:
All worth a browse. I especially think the self help services that are emerging may make a big difference.
Enjoy.
David.

Monday, October 06, 2014

Weekly Australian Health IT Links – 06th October, 2014.

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

Another quiet week with a lack of news on pretty much anything e-Health from the Government. In the private sector, however, all sorts of things are happening as witnessed by what follows.
If there were 2 themes this week they were security and interoperability / standards. Both are getting a good deal of attention all over and right now this seems more that warranted.

It is also good to see e-Mental Health getting more coverage and interest - as from trials it is clear that some of these interventions work very well indeed.
Enjoy the read.
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The start-up giving Telstra's HealthEngine a run for its money

In the summer of 2012, psychiatrist-turned novelist Benjamin Hurst was dreading the prospect of going home to Australia after living in the Big Apple for two years.  He was finishing off his first novel while attending classes in creative writing.
He was looking for a way to stay in the US and turned to his friends for advice. One of those friends told Hurst to apply for a job at ZocDoc, an online medical appointment booking service. 
He checked out the site and was immediately drawn to the business model, which allows patients to book medical appointments using a simple app on their smartphone. It also got his creative juices flowing. “This was a good idea that I could implement,” he told Technology Spectator. “It allows me to combine my creativity with my knowledge of the medical system.”
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Online medication blackmarket an 'increasing' problem: AMA WA

Date September 30, 2014 - 9:48AM

Aleisha Orr

Reporter, WA Today

An increasing number of Australians are trying to illegally sell prescription drugs online according to the Australian Medical Association WA.
AMA WA president Michael Gannon told Fairfax Media there "seems to be evidence of this increasing".
Last week a 48-year-old Perth mother was fined in Fremantle Magistrates Court after being found guilty of offering to sell her son's ADHD medication online.
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eHealth Interoperability Conference

Achieving Seamless Communications as part of an Interoperable eHealth system to enhance healthcare safety, quality and efficiency
Our 2nd Annual  eHealth Interoperability conference will offer the chance to hear the latest advancements in eHealth interoperability within Australia, combining presentations covering standardisation updates, achieving successful governance and security, updates on state-wide interoperability initiatives and case studies from in-hospital ehealth projects that have been deemed successful.
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Citizen hackers tinker with medical devices

  • Kate Linebaugh
  • The Wall Street Journal
  • September 29, 2014 8:25AM
JASON Adams, a business-development executive by day and a molecular biologist by training, had never considered himself a hacker. That changed when he discovered an off-label way to monitor his 8-year-old daughter’s blood-sugar levels from afar.
His daughter Ella has Type 1 diabetes and wears a glucose monitor made by Dexcom. The device measures her blood sugar every five minutes and displays it on a nearby receiver the size of a pager, a huge advantage in helping monitor her blood sugar for spikes and potentially fatal drops. But it can’t transmit the data to the internet, which meant Mr Adams never sent Ella to sleepovers for fear she could slip into a coma during the night.
Then Mr Adams found NightScout, a system cobbled together by a constellation of software engineers, many with diabetic children, who were frustrated by the limitations of current technology. The open-source system they developed essentially hacks the Dexcom device and uploads its data to the internet, which lets Mr Adams see Ella’s blood-sugar levels on his Pebble smartwatch wherever she is. It isn’t perfect. It drains cellphone batteries, can cut out at times and hasn’t been approved by the Food and Drug Administration. But for many, it has filled a gap.
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Privacy Commissioner battles Bash vulnerability

Government agencies, enterprises urged to protect IT systems against Bourne Again Shell (Bash) vulnerability
Hamish Barwick (Computerworld) on 30 September, 2014 16:06
Australian Privacy Commissioner Timothy Pilgrim is urging government agencies and businesses to protect their IT systems against the Bourne Again Shell (Bash) vulnerability.
Bash runs on many Unix-like operating systems, including Linux, that host websites.
“All entities covered by the Privacy Act must take reasonable steps to protect the personal information they hold. These obligations include regularly monitoring the operation and effectiveness of ICT security measures to ensure they remain responsive to changing threats, vulnerabilities and other issues that may impact the security of personal information,” he said in a statement.
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CSIRO's heart attack app proving a lifesaver

Date October 2, 2014 - 12:01AM

Hannah Francis

An Australian life-saving smartphone app is helping heart attack survivors stick to their rehabilitation program and avoid a fatal second bout.
The Cloud-based MoTER app, developed by the CSIRO's Australian e-Health Research Centre, takes the hassle out of staying healthy by allowing patients to follow tailored rehabilitation programs from home – or wherever they may be – rather than having to travel to an outpatient centre.
Cardiovascular disease is Australia's No.1 killer, with one person nearly every 12 minutes dying from a heart attack.
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New #FHIR Open License

Posted on September 30, 2014 by Grahame Grieve
Today, HL7 released an updated version of the FHIR™ Draft Standard, which is now covered under a Creative Commons License: No Rights Reserved. This marks the formal adoption of a recognized open license for the FHIR specification, and one that is truly open: this is an unencumbered license. Under the terms of the Creative Commons license, HL7:
… has dedicated the work to the public domain by waiving all of it’s rights to the work worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law. You can copy, modify, distribute and perform the work, even for commercial purposes, all without asking permission.
This is a truly open license – even more open than most open source projects, which usually require some form of attribution. However since FHIR is a standard, and many implementations will be required to implement it, it would be inappropriate to require acknowledgement of the specification. Note, though, that the reference implementations may require attribution – and most of them use a mix of BSD or Apache licenses that do.
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#FHIR Report from the Chicago meeting

Posted on September 27, 2014 by Grahame Grieve
Here’s a FHIR progress report from the HL7 working meeting in Chicago held the week before last.
General Progress
Overall, the hype about FHIR is astonishing, and I don’t see any evidence that it’s starting to slow. While we were in Chicago, Wes Rischel made some interesting comments about where FHIR is (though following his logic, our current task is to bring on the trough of disillusionment as soon as possible) . The FHIR project team is aware that there is a duality here: expectations and excitement about FHIR are high, but what we have published is still an early beta, and FHIR is not yet ready to meet the expectations that people have about it. We intend and expect to get there, but it is important that stakeholders and implementers understand that there’s still a lot of work to be done.
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Health interoperability standards are a pre-platform concept. Discuss.

There is a growing recognition that we need an open platform concept to solve e-health interoperability and reuse problems. Some evidence of this I noted in my recent post ‘What is an open platform’, including various US-based cross vendor platform alliances. The great value of a well-designed open platform is that it enables two things:
  • a growing platform-based economy of producers to collaborate technically while operating commercially and/or in an open source mode
  • adaptation to the constant stream of new requirements.
This is in contrast to the typical de jure standard based on a particular use case: it solves a locked down definition of the problem in a locked down way.
Within a platform, there are many interoperability points, and therefore many places where ‘standards’ might apply. However, the implication isn’t that you can just go and obtain a shopping basket of existing, separately developed, and possibly highly evolved standards and glue them together to get a platform.
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Don’t get left behind, be a part of the new world

30th Sep 2014
GENERAL practice runs the risk of getting left behind if it does not keep up with the technology available to its patients.
Dr Jan Orman
GP Services Consultant, Black Dog Institute
E-mental health resources, especially online therapy, is an area GPs seem to know little about but will increasingly be expected to know about in the future. There’s a degree of scepticism but overall the problem is simply lack of knowledge of these resources and how to use them.
There’s no argument about the efficacy of online CBT for a variety of diagnoses in the mild to moderate stress, anxiety and depression categories. My experience is GPs acquainted with the evidence are generally convinced.
That hurdle overcome, the next is imagining where online therapy might fit.
-----

Internet based or computerised CBT (iCBT or CCBT): depression and anxiety

About 85% of patients with depression have significant anxiety

Intervention

Internet-based or computerised cognitive behavioural therapy programs.
Cognitive behavioural therapy (CBT) is the main psychological treatment approach available as computer- or internet-based programs.

Indication

Depression and anxiety.
Treatment programs have been studied in patients with mild-to-moderate, moderate-to-severe and severe depression.
-----

Transcranial magnetic stimulation for depression?

30th Sep 2014
PSYCHIATRISTS are waiting on a decision from the Medicare Services Advisory Committee (MSAC) which may open up a whole new era in the treatment of depression in Australia.
Sydney psychiatrist Professor Colleen Loo says transcranial magnetic stimulation (TMS) has been in developmental use in Australia for 17 years and has been proven a safe and efficacious treatment for depression.
To date, outside of medical research institutes, it is available in Australia only at private hospitals.
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The AMT v3 Model Technical Implementation Guide is now available for download

Created on Monday, 29 September 2014
The AMT v3 Model Technical Implementation Guide is now available for download from the NEHTA website.
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BACKGROUNDER: Orion Health mulls pre-Xmas float

Friday, 3 October 2014, 3:49 pm
Article: BusinessDesk
by Fiona Rotherham
Oct. 3 (BusinessDesk) - Investor demand is expected to be strong locally and offshore, should health sector software company Orion Health proceed with its long-anticipated initial public offering before Christmas. It's expected to be one of the larger and classier floats this year.
Its prospectus has been designed, a top shelf chairman has been installed in the form of Fonterra boss Andrew Ferrier, and one of the busiest PR firms in the IPO area, Senescall Akers, is representing Orion.
It has talked about a float on the NZ stock exchange for the past two years and the window for doing so this year is within the next few weeks.
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Facebook plotting healthcare apps: sources

Date October 3, 2014 - 6:26PM

Christina Farr and Alexei Oreskovic

Facebook already knows who your friends are and the kind of things that grab your attention. Soon, it could also know the state of your health.
On the heels of fellow Silicon Valley technology companies Apple and Google, Facebook is plotting its first steps into the fertile field of healthcare, said three people familiar with the matter. The people requested anonymity as the plans are still in development.
The company is exploring creating online "support communities" that would connect Facebook users suffering from various ailments. A small team is also considering new "preventative care" applications that would help people improve their lifestyles.
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iPhone 6: Health app is watching you

Summary: The Healthkit initiative in iOS hasn't gone anywhere yet but your new iPhone is already tracking you.
By James Kendrick for Mobile News | September 29, 2014 -- 10:55 GMT (20:55 AEST)
Apple made a big deal about the Healthkit initiative kicked off in iOS 8. The goal is to have Healthkit work with third-party apps and accessories to track iPhone owners' health and fitness activities. Healthkit wasn't ready when iOS 8 was released but made it into the failed iOS 8.0.1 update. It's enabled in the current version of iOS (8.0.2).
The Health app in iOS is the hub for Healthkit. It gathers health and fitness data collected by third-party apps and accessories and displays it in one place. Apple says this data is encrypted on the iPhone to protect privacy.
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Aboriginal health centre Winnunga Nimmityjah offers new services as demand grows

Date September 28, 2014 - 11:30PM

Natasha Boddy

Canberra Times reporter

Canberra's only Aboriginal health centre has introduced new services, including a comprehensive child health clinic and triage system, to try and keep up with demand. 
Winnunga Nimmityjah Aboriginal Health Service has launched a child health e-clinic and triage system where all patients are  assessed by a nurse before seeing a doctor. 
Chief executive Julie Tongs said Winnunga was an extremely busy service, with 66 staff and five full-time GPs seeing about 130 patients a day.
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Power reflects on life, health and his Harvard windfall

 “It’s been a lot of fun,” reflects Patrick Power, as he looks back over his twenty plus years working in the IT healthcare industry.
Power, founder of PowerHealth Solutions and South Australia’s 2012 Entrepreneur of the Year, moved to Australia from Canada in 1994 on the back of a one-year contract implementing a healthcare IT system in the state.
Power recently won a scholarship via the Industry Leaders Fund that will see him attend leadership courses at Harvard, in the US, for three weeks each year for the next three years. He’s enthusiastic about the opportunities that will provide. “You get to do coursework, come back home and implement it, and then the following year you review, adjust and reenergise for another year - while bouncing-off some really smart people,” he says. “I am really looking forward to it.
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When a toddler asks Siri a question rather than daddy, it's time to put down our smartphones

Date October 4, 2014 - 10:40AM

Jane Scott

I've been a paediatrician for 20 years, and I thought I'd seen it all. But not long ago, when a father brought his two-year-old into my clinic, something happened that has me deeply concerned.
Upon entering my examining room, I found father and son sitting together, eyes downcast, each silently scrolling and tapping on smartphones. During my initial exam, the father directed most of my questions to his frowning toddler, who indicated that his ears hurt, and I quickly discovered that both eardrums were red and inflamed.
"Guess what?" I said to my small patient. "Your ears hurt because you have an ear infection. But we can give you medicine and make you better."
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Federal government accused of neglecting digital agenda

Date September 30, 2014 - 12:15AM

Sylvia Pennington

The Australian Information Industry Association (AIIA), the high tech sector's peak body, has accused the federal government of dragging its feet on the implementation of a raft of digital economy and e-government initiatives.
Detailed in the Coalition's policy for e-government and the digital economy of August 2013, the initiatives had not been enacted, more than a year on, AIIA chief executive Suzanne Campbell told IT Pro.
The government had failed to appoint an ICT advisory board, progress its plans to offer most government services online by 2017, produce a dashboard for government ICT performance and investment, improve the transparency of its technology spend or provide an update on teleworking targets, she said.
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One in five Australians not online: Broadband Commission

Australia excels on mobile broadband but lags on fixed
Adam Bender (Computerworld) on 25 September, 2014 11:04
Australia has ranked 21st in the world on Internet access, with 83 per cent of its people using the Internet, according to an annual report released by the Broadband Commission for Digital Development.
The commission was set up in May 2010 by the International Telecommunication Union and the United Nations Educational, Scientific and Cultural Organization (UNESCO). The ITU and OECD has defined broadband as a capacity of at least 256 kbps in the uplink or downlink speed.
Australia is one of 77 countries with more than half of their populations online, up from 70 in 2013, it said. The top ten countries for Internet use are all located in Europe. Iceland is ranked first in the world with 96.5 per cent of people online.
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Full Marx for Turnbull's NBN

Oh for a few years without revolution.
The past quarter century has seen the end of the Soviet era in 1989-90, a digital revolution straight after that via the world wide web,  revolutions in financial engineering that set markets rocketing up and then crashing down, and a sovereign debt crisis that is, frankly, still revolting.
To top all that off in 2014, religious fundamentalism is exploding in the Middle East and China’s economic miracle is perched atop a time-bomb stamped ‘Made in Hong Kong’.
Where to look for stability? Surely something must stay the same.
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No break-up of NBN Co – yet: Turnbull

Vertigan panel issues final report
Rohan Pearce (Computerworld) on 02 October, 2014 07:41
The government has indicated in its initial response to the third Vertigan panel report, which was released last night and includes an assessment of competition settings for the telco market, that it has no short-term plans to break up NBN Co.
“While disaggregation of NBN Co's business units (as the panel recommends) after the network is complete cannot be ruled out, now is not the time,” a statement issued by Communications Minister Malcolm Turnbull said
“Breaking up NBN Co would distract its management and delay the provision of high-speed broadband to all Australians.”
The third report (PDF) of the panel, which is known as the Vertigan panel after its chair Michael Vertigan and was appointed by the government to conduct a cost-benefit analysis of the National Broadband Network, includes 19 top-line recommendations.
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Microsoft announces Windows 10

Date October 1, 2014 - 6:28AM

Bill Rigby

Microsoft has announced its Windows 10 operating system to replace the largely unpopular Windows 8, skipping a number to mark a leap toward a new system aimed at unifying computing and mobile devices.
The next version of Microsoft's flagship product, which still runs the vast majority of personal computers, is aimed at recapturing the lucrative business market, which generally ignored the new-look Windows 8.
Windows 10 will be "our greatest enterprise platform ever," said Terry Myerson, Microsoft's head of operating systems, at an event in San Francisco. Only 20 per cent of organisations migrated to Windows 8, which was released two years ago, according to tech research firm Forrester.
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Enjoy!
David.

Updated Draft - The Standards Setting Processes In Australian E-Health Are Broken and No One Seems To Care.

Update is focused on Part 3 on the basis of feedback.

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Before discussing the present issues in Australian E-Health setting a little background in two areas seems justified. We can consider these issues by responding to two questions.
1. Why do Standards matter?
Standards are important in all industries to ensure the quality, safety and predictability of all goods and services. We have food Standards to help prevent food poisoning and building Standards to help ensure buildings are safe, fit for purpose and proof to reasonable environmental impacts (earthquake, bushfire etc.). Another vital function of standards is to permit safe interchangeability and interoperability, think of things like screw threads etc.
E-Health has, as its primary concern, the safe and secure transmission of clinical information between healthcare providers and between providers and their patients. To this end Standards have been developed covering such things as electronic health records, secure health communication, health data and information Standards and so on.
You can see the scope of the various Standards that have been developed for Australia (in association with the IT-14 Committee of Standards Australia) on this web-page:
 Interestingly the Australian Institute of Health and Welfare (AIHW - www.aihw.gov.au) also has a role in developing a range of data definitions and the National E-Health Transition Authority (NEHTA) has also had a role in clinical terminologies as well as attempting to manage / interfere with (depending on your perspective) the Standards development process over the last few years.
Before discussion processes it is also important to point out that Standards adoption by commercial and government entities can minimise risk and reduce the costs of bringing new services and products to market while also assisting in broadening the capabilities that may be offered. It is quite usual for companies to find that there are distinct advantages in Standards adoption and use - not the least in facilitating future-proofing development efforts. Of course, for some Standards adoption is compulsory and enforced by laws (e.g. food Standards).
2. What is the present process in Australia for their setting?
In ordinary times - and the last few years in e-Health can hardly be seen as ordinary - there was a stable and well thought out, consultative and inclusive process for e-Health Standards development. Work began seriously on the Health Informatics domain around 20 years ago with Standards Australia creating a steering committee (to become termed IT-14) to develop and implement a work plan. Key to this plan was to leverage all available international work (especially EU and USA) and to only develop new Standards if international approaches could not be reasonably adopted. The intent was to maximise the level of international engagement of the local development committees.
IT-14 has a range of sub-committees and a wide range of members. This page provides a useful collection of links:
Once a work plan is developed for a period the chairs of the various sub-committees - facilitated by Standards Australia staff convene meetings of volunteer experts representing a full range of stakeholders to develop a draft Standards document. The draft is then workshopped as needed and a balanced consensus document is developed. Only once this is fully agreed is an Australian Standard, Technical Report or Technical Standard published.
The keys to the process are seeking conscious involvement of as many interested parties and technical experts as possible and a consensual open way of working and document development.
3. What has changed and what has gone wrong?
By my reckoning the system of e-Health Standards setting was working relatively well until around 2010. Most needed Standards were being developed with reasonable speed and quality with the help of a large and expert volunteer workforce and reasonable support from Standards Australia.
This is not to say all was ideal, but in most areas some progress was being made, especially in terms of clinical messaging while - as in the rest of the world - many aspects in interoperability were being found complex and difficult. The whole area is recognised as being very complex as was well articulated in a blog by Thomas Beale in 2009. (http://wolandscat.net/2009/09/17/the-crisis-in-e-health-standards/). Only recently have we seen some steps to try and address these issues by initiatives such as HL7's FHIR (Fast Healthcare Interoperability Resources) initiative.
Also, the Commonwealth Department of Health was funding access to the relevant Standards for no charge and providing funds to ensure Australian experts were able to attend relevant major international meetings of bodies like HL7 and the ISO-TC-215 Committee so Australia was well linked into international trends and contributing where appropriate.
In 2010 the then Government announced it was going to implement a National Personally Controlled Electronic Record (PCEHR) and that it was going to be operational 1 July, 2012. In an attempt to have all the needed Standards in place well before the deadline (so they could be actually implemented)  many of the usual processes were abandoned with NEHTA led ‘Tiger Teams’ developing specifications which were then to be signed off by the volunteers. Not surprisingly there was considerable dissension and friction with many of the volunteers simply walking away and being replaced by NEHTA Staff. Additionally there was quite substantial funding provided by Government in this period to shape what activities were ramped up and what were deferred.
Also there were a range of quite fundamental technical directional choices where the was considerable disagreement between NEHTA staff and many of the volunteers and many of the volunteers felt they were being ignored and so became rather disillusioned.
To make matters worse NEHTA continued to pressure the acceptance of untested and unimplemented specifications which rather went against the usual standardisation approach of incremental development, testing and proof of concept and then implementation. Only when implementation was successful would further development take place. The failure to assess the quality of the various Standards proposals by way of formal evaluated implementation was, in my view pressured by artificial deadlines and a fatal flaw in what was being done by DoH and NEHTA.
In more recent times we have seen an accelerating loss of volunteers, failure to develop, agree and fund the 2014-2016 Work  Program for IT-14. As of the time of writing (Oct 2014) there has been no update of the Standards Australia e-Health site since May 2014 and most funding for meeting travel has been curtailed or cancelled.
Also, as of the time of writing, the fate and plans for the PCEHR are still in limbo with no outcome after a consultation period which closed late August 2014.
It would be fair to say, I believe, that for the present the Australian e-Health setting system is essentially ‘down for the count’. Whether it will ever recover in any useful form would have to be a completely open question. Essentially a largely working an valuable system has been damaged out of recognition by Government / NEHTA blundering, impatience and incompetence. Sad that!
As always it seems it is the quality of leadership and governance, along with the preparedness for honesty and appropriate introspection and insight, that offers the best hope. Right now these do not seem to be in place.

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David.

Sunday, October 05, 2014

There Is A Real Lesson Here Regarding Health IT Safety, Use And The Unanticipated Event.

The first US case of the Ebola Virus has caused a very interesting and educative event regarding a highly respected Hospital EHR System from Epic.
There is reporting here:

Scarier Than Ebola: Human Error

October 03, 2014
Texas Health Presbyterian Hospital in Dallas on Sept. 30
The Dallas hospital treating the first Ebola case diagnosed in the U.S. sent the patient, Thomas Duncan, home the first time he showed up because the doctors who saw him never learned that he’d just come from West Africa. The hospital has blamed a flaw in its electronic health records for keeping information collected by a nurse, including Duncan’s travel history, from being presented to the treating physician, who mistook Duncan’s symptoms for a low-level infection, on Sept. 25.
The apparent mistake meant Duncan was not admitted and isolated until Sept. 28. That increased the risk of infection for those he came in contact with while he was sick, including his family, who are now quarantined in their Dallas apartment. It also widened the circle of contacts that public health officials must trace and monitor for symptoms.
America’s risk of an Ebola epidemic remains vanishingly small. The country has the public health resources and hospital capacity to stop the spread of the infection, which is only transmitted through direct contact with bodily fluids after a patient exhibits symptoms. The misstep at Texas Health Presbyterian Hospital Dallas, though, indicates something patients should be spooked about: the very real chance that errors, oversights, or deviations from established procedures could kill them.
Lots more here:
Here is the release from the Hospital:

Ebola Update, Oct. 2, 8:35 p.m. CDT 10/02/2014

Texas Health Presbyterian Hospital Dallas

Report on Events Related to Ebola Diagnosis
Clarification: We would like to clarify a point made in the statement released earlier in the week. As a standard part of the nursing process, the patient's travel history was documented and available to the full care team in the electronic health record (EHR), including within the physician’s workflow. There was no flaw in the EHR in the way the physician and nursing portions interacted related to this event.
On September 29, the first case of Ebola Virus Disease in the United States was diagnosed at Texas Health Presbyterian Hospital Dallas. The doctors, nurses and other caregivers at Texas Health Dallas continue to provide compassionate intensive care to our patient, Mr. Thomas Duncan. Mr. Duncan remains in serious condition.
Texas Health Dallas is on alert for communicable diseases as we treat patients who visit our hospital, and particularly our emergency department. As a hospital, we have expertise in treating communicable diseases and have evidence-based screening processes in place. Texas Health Dallas strengthened and deployed updated communicable disease protocols on September 1, 2014.
In response to questions raised about Mr. Duncan’s first visit to the hospital emergency department on the night of September 25th, we have thoroughly reviewed the chain of events. In the interest of transparency, and because we want other U.S. hospitals and providers to learn from our experience, we are, with Mr. Duncan’s permission, releasing this information.
In diagnosing potential causes of infectious diseases like Ebola, Texas Health Dallas care teams are trained to look for multiple indicators, including the following:
1. Does the patient present with symptoms that indicate potential communicable disease?
  • Mr. Duncan presented with a temperature of 100.1F, abdominal pain for two days, a sharp headache, and decreased urination. These symptoms could be associated with many communicable diseases, as well as many other types of illness. When he was asked whether he had nausea, vomiting, or diarrhea, he said no. Additionally, Mr. Duncan’s symptoms were not severe at the time he first visited the hospital emergency department.
2. Has the patient been around anyone who has been ill?
  • When Mr. Duncan was asked if he had been around anyone who had been ill, he said that he had not.
3. Has the patient traveled outside the United States in the last four weeks?
  • Mr. Duncan was asked if he had traveled outside the United States in the last four weeks, and he said that he had been in Africa. The nurse entered that information in the nursing workflow of the electronic health record.
When patients visit the emergency department, they are first assessed by a triage nurse. Then an intake nurse conducts a more thorough screening process that includes:
  • vital signs;
  • general clinical assessment;
  • a neurological assessment; and
  • questions about major risk factors:
    • domestic violence;
    • tetanus status;
    • tuberculosis risk;
    • travel history outside the United States in the previous 4 weeks;
    • suicide risk assessment; and
    • falls risk assessment
Protocols were followed by both the physician and the nurses. However, we have identified a flaw in the way the physician and nursing portions of our electronic health records (EHR) interacted in this specific case. In our electronic health records, there are separate physician and nursing workflows.
The documentation of the travel history was located in the nursing workflow portion of the EHR, and was designed to provide a high reliability nursing process to allow for the administration of influenza vaccine under a physician-delegated standing order. As designed, the travel history would not automatically appear in the physician’s standard workflow.
As result of this discovery, Texas Health Dallas has relocated the travel history documentation to a portion of the EHR that is part of both workflows. It also has been modified to specifically reference Ebola-endemic regions in Africa. We have made this change to increase the visibility and documentation of the travel question in order to alert all providers. We feel that this change will improve the early identification of patients who may be at risk for communicable diseases, including Ebola.
Reading both these releases it seems clear that while the physicians tending the patient were able to access the nursing notes they were not forced to and so, when confronted with - on the second occasion - with an obviously ill man - there were other clinical priorities that needed to be addressed.
Given that it was possible to quickly remedy the display issue I think it is likely the way the system was operating was a configuration choice made during implementation.
What I take from to story is that this outcome provides a wonderful lesson on just how hard it can be to anticipate, in advance,  when such decisions might just provide harm and the possibility of major clinical consequences.
I also have no idea how to identify such subtle ‘black swan’ events in advance and so would suggest the best that can be done is to share what has happened widely so the lesson is learnt as widely as possible. Maybe a fix that allows any responsible clinician to flag a finding on any screen as needing to be seen by all carers to be highlighted on the entry screen might be worth considering.
The bottom line to me is that you can’t anticipate all contingencies so continual learning is crucial.
David.

AusHealthIT Poll Number 238 – Results – 5th October, 2014.

Here are the results of the poll.

Do You Believe It Is About Time The Future Of The PCEHR Is Clarified?

Yes 65% (155)

Neutral 22% (52)

No 12% (29)

I Have No Idea 1% (2)

Total votes: 238

This is a pretty clear and enthusiastic outcome. Most are sick of Government festination and failure to clarify what is happening.

Again, many, many thanks to all those that voted!

David.