Tuesday, August 29, 2006

iSoft – A Problem for More than the NHS!

In November 2005, I had the opportunity to review, in some considerable detail, the Hospital Information System which was being offered to an international client as a solution to provide advanced computer services for a three hundred bed tertiary private hospital.

It was clear at that time that the iSoft Lorenzo software suite was little more than ‘foilware’. The system was a concocted blend of old and new components, was obviously un-integrated and lacked any common utility in its user interface.

Needless to say I recommended that no further engagement be had with iSoft and that alternative providers of the necessary HIS software be considered.

The following headlines from the London Financial Times over the last week say it all!

Isoft receives bid approaches
Isoft, the beleaguered software supplier to the £6.2bn National Health Service IT project in the UK, has received several informal approaches from both private equity firms and trade rivals.

Isoft refinances after posting £343.8m loss
Isoft, the troubled healthcare software company being investigated by the FSA for issuing potentially misleading statements, has reported a full year pre-tax loss of £343.8m.

Isoft duo present a catalogue of horrors
For the two men charged with delivering one of the most eagerly awaited earnings statements of the year, Isoft's John Weston and Gavin James appeared remarkably fresh...

Questions linger over plan to build electronic patient record
Ministers and officials yesterday breathed a collective sigh of relief that iSoft, one of the principal suppliers to the National Health Service's £12bn computer..

There is one crucial lesson to be learnt from this. That is that buying software futures is a fool’s game, especially with complex systems like a HIS. If you can’t see, touch and feel the software operating live in at least 2-3 reference sites, exactly as you need it to operate, then to make any purchase is folly!

In the Australian today Karen Dearne makes the point there are potential Australian implications.

Health group's fall may hit here
Karen Dearne
August 29, 2006

TROUBLED health software developer iSoft's shock loss of almost £400 million last year has destabilised Britain's £10 billion ($24.9 billion) Connecting for Health IT program and may hit local projects, including Victoria's $323 million HealthSmart.

While iSoft clutched a straw offered by its British bankers, the company faces investigations by financial regulators, problems with current implementations and questions over the long-promised Lorenzo web-based product.

The debacle has grabbed front-page attention in Britain, with reports that iSoft's three founders have become millionaires while the company's market value has plummeted from more than £1 billion at its peak to just £97 million.

Reports say the late Roger Dickens (iSoft chairman until late 2003), sold shares worth about £10 million; former chief executive Patrick Cryne received about £40 million; and Stephen Graham, currently suspended, about £30 million.

Former chief executive Tim Whiston resigned in June, reportedly with a golden handshake. The release of iSoft's results ended months of speculation over alleged accounting irregularities that saw its share price fall 90 per cent to just 40p last week.”

It looks to me that iSoft’s failure is inevitable, given the comments made a week or so ago in the audit of their progress in delivery of Lorenzo that they “lacked a credible plan” for its delivery any time in the next few years.

Additionally, there is no point holding obsolete software in escrow. All that does is provide a false sense of security that something can be done when iSoft fails. All that can be done with the escrowed software is maybe fix the occasional critical ‘bug’ while buying time to identify new software to replace the now doomed iSoft system.

Those in NSW and Victoria who have purchased iSoft software on the basis of future promises have clearly let their respective health systems down very badly and should consider their ongoing roles in their present positions. This is a huge mess both here and in the UK. Those in both the UK and Australia affected by this have my sympathy, but they should have known better.

David.

The Perfect Storm Intensifies!

Just when you thought it would not get much worse, it has. Added to the litany of computer assisted privacy violations perpetrated by Government custodians of “your personal information” we now find yet another and separate agency involved in more poor behaviour.

As Ben Woodhead reports in today’s Australian:

Tax office sacks 'spies'
Ben Woodhead
August 29, 2006

A SECOND government agency has been forced to sack staff for spying on client records, with the Australian Taxation Office taking action against 27 workers for breaches of privacy.

The tax office took action against 24 employees over inappropriate access to taxpayer files last financial year, with another three cases detected this year.
ATO first assistant commissioner for people and place, Anne Ellison, said 12 of the staff caught spying last year resigned on the spot. Four were sacked, two were fined and six had their salaries reduced or were demoted.

Two were ultimately prosecuted for breaches of the Tax Administration Act, with one sentenced to community service and the other fined."

The article then goes on to point out that there is considerable suspicion that leaked tax details of a range of celebrities may be linked to these unauthorised intrusions and searches.

Even more alarming are the comments from “Medicare Australia spokesman Peter Sexton said that agency had also had talks with Centrelink as part of a review of its privacy systems.

"We have engaged a consultant to review a number of our processes including audit logging, access profiles and risk assessments," Dr Sexton said. "There is swift disciplinary or legal action taken whenever a case of fraud or unauthorised access is detected."

This confirms what we already knew. Right now the security of your Medicare records (among others) is inadequate. Why else would consultants be asked to help and sort things out?

The points made in the earlier article are just confirmed. Public trust is on the way down and the effect of these ongoing problems not only confirms their right to be concerned but enhances it!

One has to ask why it is only now, with all these reviews having been underway for the last years, do we know what has been and continues to go on. The present system is clearly just not working.

If the public confidence in electronic health records is not going to be destroyed it seems time that a few of the senior managers of these “sticky beaks” who browse and leak information need to be faced with the ultimate disciplinary sanction and terminated. Maybe, then, we would see the cultural change that is so obviously required.

David

Saturday, August 26, 2006

Is Australian E-Health Facing a Perfect Storm?

Reference to Wikipedia describes a “Perfect Storm” as follows:

“The phrase perfect storm refers to a simultaneous occurrence of events which, taken individually, would be far less powerful than the result of their chance combination. Such occurrences are, by their very nature, rare, and so even a slight change in any one event contributing to a ‘perfect storm’ would be sufficient to lessen the overall power of the final event.”

In this short article I am suggesting that the future of e-Health may be facing just such a storm. Why? Because it seems there are a number of forces and events coalescing to greatly damage the progress of the implementation of e-Health nationally.

Firstly we have the revelations that following a two year investigation (one wonders why it took that long) some six hundred Centrelink staff have been found browsing Centrelink client records inappropriately – despite there being clear warnings to all stuff that such activity will be dealt with very harshly (over 100 apparently no longer work for the organisation).

It seems this is not the first incidence of such behaviour among public servants – with a major breach, rather worryingly, having occurred at the Commonwealth Child Support Agency a year or so back.

Secondly we have all sorts of incidents being reported from all over the world where patient details are being accidentally provided to third parties through everything from stolen laptops to web-based accidental patient information publication.

The most recent was reported a few days ago.

Laptop computer with home-care patient data stolen in Michigan

Beaumont Home Care on Tuesday asked the public to help it recover a laptop computer filled with three years worth of personal patient information that was stolen with an employee's car.

Beaumont said the information was encrypted and password-protected and is related only to home-health patients. Beaumont Hospital inpatients’ or outpatients' information was not included and centralized registration and medical records of Beaumont are not at risk. But the laptop belonged to a new employee who had stored the ID access code and password with the computer.

Home-care staff use laptop computers to document patient care. The stolen information included patients' names, addresses, birth dates and Social Security numbers. Medical- insurance and personal-health information was also included. Home-care patients have been apprised of the theft and Beaumont is arranging enrollment in a credit-reporting service as well, the Royal Oak, Mich.-based system said in a news release.

"We are taking aggressive measures to protect their personal and health information and to lessen the impact of the computer theft on them," said Chris Hengstebeck, security director at Beaumont in Troy, Mich. The hospital system is offering a reward for the recovery of the Dell Latitude D-400 laptop, serial No. 5MZ1F61, WBH Tag No. 218242.

Crain's Detroit Business”

Note that this problem would simply not have arisen without the records being computerised.

Third we have Minister Hockey, the minister for Centrelink, claiming the information held for the proposed Commonwealth Services Access SmartCard will be handled differently. How much credibility can such a claim have in the public’s mind?

Fourth we have NEHTA suggesting that the basis of its privacy approach is to be technologically agnostic. As I wrote a few months ago,

“talk of privacy neutrality is na├»ve. It is critically necessary to distinguish between conceptual privacy neutrality and practical (or privacy as it is actually implemented) neutrality. Preserving the privacy of a patient’s written record is a very different thing from preserving the privacy of a patient’s record when stored, typically with hundreds of others, in a computer system. The threats from leakage and exposure are different as are the methods of auditing access and use. These differences must be clearly recognised and effectively addressed. An example is the ease with which 10,000 records can be stolen on a USB key compared with the same ‘truck-requiring’ effort with paper records.”

The essence of my concern in all this is that unless public trust is manifestly justified, through leaks of sensitive personal information being made extraordinarily rare or non-existent, implementation of e-health technology and solutions will be effectively blocked by security and privacy concerns before it can even get underway.

It is up to those working, not only in health, but those handling all sorts of personally identifiable information (e.g. banks, insurance companies, diagnostic laboratories, police etc) to understand clearly that while mistakes will always happen, it requires a computer to really make a massive series of mistakes. In the wrong hands computer data-bases can disclose vast amounts of sensitive information far more quickly and efficiently than any paper based system can!

The key message is simple. To prevent there being great difficulty with the adoption of e-health technology and solutions, great care has to be taken to address, not only the technical, but also the cultural, human and organisational issues that permit un-authorised disclosure of private information. It is a problem for all of us!

David.

Interactive Electronic Decision Support Benefits - Keys to the Literature

As a follow-up to the material presented last week it seemed to me it would be useful to provide some references and abstracts from the current literature to confirm my views regarding the importance of interactive clinical decision support.

A very useful slightly earlier review by Professor Enrico Coiera, that is readily available on the web, can be found at the following URL.

http://www.coiera.com/aimd.htm

Four key recent references are as follows:
Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success
Kensaku Kawamoto , Caitlin A Houlihan , E Andrew Balas , David F Lobach
Objective: To identify features of clinical decision support systems critical for improving clinical practice.
Design: Systematic review of randomised controlled trials.
Data sources: Literature searches via Medline, CINAHL, and the Cochrane Controlled Trials Register up to 2003; and searches of reference lists of included studies and relevant reviews.
Study selection Studies had to evaluate the ability of decision support systems to improve clinical practice.
Data extraction: Studies were assessed for statistically and clinically significant improvement in clinical practice and for the presence of 15 decision support system features whose importance had been repeatedly suggested in the literature.
Results: Seventy studies were included. Decision support systems significantly improved clinical practice in 68% of trials. Univariate analyses revealed that, for five of the system features, interventions possessing the feature were significantly more likely to improve clinical practice than interventions lacking the feature. Multiple logistic regression analysis identified four features as independent predictors of improved clinical practice: automatic provision of decision support as part of clinician workflow (P<0.00001), provision of recommendations rather than just assessments (P=0.0187), provision of decision support at the time and location of decision making (P=0.0263), and computer based decision support (P=0.0294). Of 32 systems possessing all four features, 30 (94%) significantly improved clinical practice. Furthermore, direct experimental justification was found for providing periodic performance feedback, sharing recommendations with patients, and requesting documentation of reasons for not following recommendations.
Conclusions: Several features were closely correlated with decision support systems' ability to improve patient care significantly. Clinicians and other stakeholders should implement clinical decision support systems that incorporate these features whenever feasible and appropriate.

Source:
http://bmj.bmjjournals.com/cgi/content/abstract/bmj.38398.500764.8Fv1
BMJ, doi:10.1136/bmj.38398.500764.8F (published 14 March 2005)

Effects of Computerized Clinical Decision Support Systems on Practitioner Performance and Patient Outcomes
A Systematic Review
Amit X. Garg, MD; Neill K. J. Adhikari, MD; Heather McDonald, MSc; M. Patricia Rosas-Arellano, MD, PhD; P. J. Devereaux, MD; Joseph Beyene, PhD; Justina Sam, BHSc; R. Brian Haynes, MD, PhD
JAMA. 2005;293:1223-1238.

Context: Developers of health care software have attributed improvements in patient care to these applications. As with any health care intervention, such claims require confirmation in clinical trials.
Objectives: To review controlled trials assessing the effects of computerized clinical decision support systems (CDSSs) and to identify study characteristics predicting benefit.
Data Sources: We updated our earlier reviews by searching the MEDLINE, EMBASE, Cochrane Library, Inspec, and ISI databases and consulting reference lists through September 2004. Authors of 64 primary studies confirmed data or provided additional information.
Study Selection We included randomized and nonrandomized controlled trials that evaluated the effect of a CDSS compared with care provided without a CDSS on practitioner performance or patient outcomes.
Data Extraction: Teams of 2 reviewers independently abstracted data on methods, setting, CDSS and patient characteristics, and outcomes.
Data Synthesis One hundred studies met our inclusion criteria. The number and methodologic quality of studies improved over time. The CDSS improved practitioner performance in 62 (64%) of the 97 studies assessing this outcome, including 4 (40%) of 10 diagnostic systems, 16 (76%) of 21 reminder systems, 23 (62%) of 37 disease management systems, and 19 (66%) of 29 drug-dosing or prescribing systems. Fifty-two trials assessed 1 or more patient outcomes, of which 7 trials (13%) reported improvements. Improved practitioner performance was associated with CDSSs that automatically prompted users compared with requiring users to activate the system (success in 73% of trials vs 47%; P = .02) and studies in which the authors also developed the CDSS software compared with studies in which the authors were not the developers (74% success vs 28%; respectively, P = .001).
Conclusions: Many CDSSs improve practitioner performance. To date, the effects on patient outcomes remain understudied and, when studied, inconsistent.

Source:
http://jama.ama-assn.org/cgi/content/abstract/293/10/1223

Systematic Review: Impact of Health Information Technology on Quality, Efficiency, and Costs of Medical Care
Basit Chaudhry, MD; Jerome Wang, MD; Shinyi Wu, PhD; Margaret Maglione, MPP; Walter Mojica, MD; Elizabeth Roth, MA; Sally C. Morton, PhD; and Paul G. Shekelle, MD, PhD

16 May 2006 | Volume 144 Issue 10 | Pages 742-752
Background: Experts consider health information technology key to improving efficiency and quality of health care.
Purpose: To systematically review evidence on the effect of health information technology on quality, efficiency, and costs of health care.
Data Sources: The authors systematically searched the English-language literature indexed in MEDLINE (1995 to January 2004), the Cochrane Central Register of Controlled Trials, the Cochrane Database of Abstracts of Reviews of Effects, and the Periodical Abstracts Database. We also added studies identified by experts up to April 2005.
Study Selection: Descriptive and comparative studies and systematic reviews of health information technology.
Data Extraction: Two reviewers independently extracted information on system capabilities, design, effects on quality, system acquisition, implementation context, and costs.
Data Synthesis: 257 studies met the inclusion criteria. Most studies addressed decision support systems or electronic health records. Approximately 25% of the studies were from 4 academic institutions that implemented internally developed systems; only 9 studies evaluated multifunctional, commercially developed systems. Three major benefits on quality were demonstrated: increased adherence to guideline-based care, enhanced surveillance and monitoring, and decreased medication errors. The primary domain of improvement was preventive health. The major efficiency benefit shown was decreased utilization of care. Data on another efficiency measure, time utilization, were mixed. Empirical cost data were limited.
Limitations: Available quantitative research was limited and was done by a small number of institutions. Systems were heterogeneous and sometimes incompletely described. Available financial and contextual data were limited.
Conclusions: Four benchmark institutions have demonstrated the efficacy of health information technologies in improving quality and efficiency. Whether and how other institutions can achieve similar benefits, and at what costs, are unclear.

Source:
http://www.annals.org/cgi/content/short/144/10/742

Costs and Benefits of Health Information Technology.
Shekelle PG, Morton SC, Keeler EB.
Evidence Report/Technology Assessment No. 132. (Prepared by the Southern California Evidence-based Practice Center under Contract No. 290-02-0003.) AHRQ Publication No. 06-E006. Rockville, MD: Agency for Healthcare Research and Quality. April 2006.

Abstract

Objectives: An evidence report was prepared to assess the evidence base regarding benefits and costs of health information technology (HIT) systems, that is, the value of discrete HIT functions and systems in various healthcare settings, particularly those providing pediatric care.

Data Sources: PubMed®, the Cochrane Controlled Clinical Trials Register, and the Cochrane Database of Reviews of Effectiveness (DARE) were electronically searched for articles published since 1995. Several reports prepared by private industry were also reviewed.
Review Methods: Of 855 studies screened, 256 were included in the final analyses. These included systematic reviews, meta-analyses, studies that tested a hypothesis, and predictive analyses. Each article was reviewed independently by two reviewers; disagreement was resolved by consensus.

Results: Of the 256 studies, 156 concerned decision support, 84 assessed the electronic medical record, and 30 were about computerized physician order entry (categories are not mutually exclusive). One hundred twenty four of the studies assessed the effect of the HIT system in the outpatient or ambulatory setting; 82 assessed its use in the hospital or inpatient setting. Ninety seven studies used a randomized design. There were 11 other controlled clinical trials, 33 studies using a pre-post design, and 20 studies using a time series. Another 17 were case studies with a concurrent control. Of the 211 hypothesis-testing studies, 82 contained at least some cost data.

We identified no study or collection of studies, outside of those from a handful of HIT leaders, that would allow a reader to make a determination about the generalizable knowledge of the study’s reported benefit. Beside these studies from HIT leaders, no other research assessed HIT systems that had comprehensive functionality and included data on costs, relevant information on organizational context and process change, and data on implementation.

A small body of literature supports a role for HIT in improving the quality of pediatric care. Insufficient data were available on the costs or cost-effectiveness of implementing such systems.
The ability of Electronic Health Records (EHRs) to improve the quality of care in ambulatory care settings was demonstrated in a small series of studies conducted at four sites (three U.S. medical centers and one in the Netherlands). The studies demonstrated improvements in provider performance when clinical information management and decision support tools were made available within an EHR system, particularly when the EHRs had the capacity to store data with high fidelity, to make those data readily accessible, and to help translate them into context specific information that can empower providers in their work.

Despite the heterogeneity in the analytic methods used, all cost-benefit analyses predicted substantial savings from EHR (and health care information exchange and interoperability) implementation: The quantifiable benefits are projected to outweigh the investment costs.

However, the predicted time needed to break even varied from three to as many as 13 years.
Conclusions: HIT has the potential to enable a dramatic transformation in the delivery of health care, making it safer, more effective, and more efficient. Some organizations have already realized major gains through the implementation of multifunctional, interoperable HIT systems built around an EHR. However, widespread implementation of HIT has been limited by a lack of generalizable knowledge about what types of HIT and implementation methods will improve care and manage costs for specific health organizations. The reporting of HIT development and implementation requires fuller descriptions of both the intervention and the organizational/economic environment in which it is implemented.

Note: This abstract is for the full report, which was summarised in the Annals of Internal Medicine article above which was published at close to the same time.

Source:
http://www.ahrq.gov/downloads/pub/evidence/pdf/hitsyscosts/hitsys.pdf

Taken together these review provide compelling evidence for the key importance of interactive CDS

Note: a Google search for (benefits "clinical decision support") yields 158,000 English language pages. That of itself says something!

David.

Sunday, August 20, 2006

Paths to Benefits – A Clearway or Not?

We have a new document from NEHTA. It is entitled “PATHS TO BENEFITS. NEHTA’s approach to modelling the benefits of investment in national e-health infrastructure - Version 1.0 — 20 August 2006 - For Comment”

According to the document’s introduction “The purpose of this document is to describe the approach NEHTA is using to model the benefits realisable from investment in national e-health infrastructure. In order to model the benefits realisable from national e-health infrastructure investment, it is necessary to examine both the most likely approaches to developing Australia's e-health infrastructure and the quality of evidence supporting these approaches. The document also outlines the technical approach to modelling costs and benefits being used by NEHTA for the Benefits Realisation Study.”

I have endeavoured to approach this document with a positive mind-set and in the hope that something useful will come from the modelling and associated efforts outlined. Sadly the more I have read, the more I am concerned.

The first issue that occurs to me concerns the second sentence of the introduction quoted above and relates to the admission that NEHTA does not know what the national e-health infrastructure approach is and so it is going to model some likely approaches. NEHTA has been in existence for just over two years having been authorised by Health Ministers on July 29, 2004 to commence immediate operations. For NEHTA to still not know the approach that will be adopted to the establishment of a National E-Health Infrastructure two years after its founding would be hilarious if it were not so dreadfully serious. What on earth are they being paid to do?

It is clear that what is needed, before benefits analysis is undertaken, let alone before benefits realisation is undertaken, is a clear statement of the technology and e-health functionality assumptions and directions being assessed. Appendix 1 suggests there are eighteen NEHTA initiatives & deliverables that “Contributes to >0.5 Billion annual benefit”. Such assertions are simply not credible unless there is a clear articulation of just what is referred to in each and (hopefully) what the cost of each might be. It is just not possible to model the cost-benefit of system Y or infrastructure X without knowing, in some functional and technical detail, what it is!

Secondly there is to me a fundamental issue with the context of this document. Benefits Realisation is a process that is undertaken as part of the planning of and implementation of new business processes and supporting or enabling computer systems. Before it begins there are a few prior steps which NEHTA has omitted which render the present document problematic. These prior steps include identification of problems to be addressed, development of a strategy to address the problems and the subsequent development of a business case (with costs and benefits) to justify the planned investments and activity. Only once this is agreed should implementation planning and business realisation (of the identified benefits) be undertaken. The work covered here, in the absence of the pre-work, is clearly a cart put much before the horse.

It should be noted that in the US (ONCHIT Plans), the UK (Information for Health) and Canada (Health Infoway) the national plan and approach has been developed first and costed and analysed for benefits before implementation is begun. In Australia a plan (HealthConnect) was in development for five years, but having not been funded has largely gone nowhere, while we now see NEHTA making infrastructure investments without either a National Plan or a National Business Case and in the absence of a clear view of what is being built towards!.

A third concern relates to the nature of Business Cases for Infrastructure Investment. In developing the various identification initiatives and SNOMED CT, it seems to me NEHTA is adopting a “build it and they will come” mentality, which may or may not turn out to be true. Additionally it is widely recognised that there is seldom a business case for infrastructure development that, of itself, is positive. Building a railway can only be justified when one knows how many trains of what type will use it and what they can be charged. The same with NEHTA infrastructure. NEHTA does not know who (GPs, Specialists, Hospitals, Pathologists etc) will use its planned infrastructure, what their needs will be and how much they are prepared to pay. The central issue is that while NEHTA has some understanding of the needs of the Jurisdictions which own it, it would seem to have little information and understanding of the needs of the private sectors comprising GP, Specialist and Private Hospitals. Any approach to examining the benefits of e-Healthand to developing a business case for investment, must review the Health Sector as a whole and not serve just the sectoral concerns of NEHTA’s owners.

Fourthly it is clear that the lack of interest in, and understanding of, the office practice needs and requirements has led to substantial imbalance in the benefits being sought and a denial that anything needs to be done in these areas. An example is the discussion of decision support (Section 3.2.1)

"3.2.1 Role of decision support

The diagram highlights the important role of decision support in the realisation of quantifiable clinical benefits. Information from the shared electronic health record, clinical evidence and evidence arising from the monitoring of health services utilisation (such as the monitoring of the under use or overuse of specific medications, trends in laboratory results and regional variation in access to specific elective procedures) are used to present to both health consumers and healthcare providers sophisticated decision support tools designed to assist health consumers and healthcare providers make better decisions when choosing to access specific healthcare services.(13)

In the case of health consumers, decision support is primarily designed to assist self management of clinical conditions and to assist a health consumer in making choices concerning the most appropriate healthcare services to meet their needs, given their clinical, cultural and geographical context.(14) Decision support for healthcare providers is primarily targeted at improving the appropriateness of prescribing and referral for specific consultations, procedures or investigations in order to reduce misuse, overuse and under use of individual healthcare services. (15-18)”

It is well known that the key driver of Health Sector costs are medical activities. These activities are notoriously difficult to change and the only good evidence for causing change in behaviour centres around decision support and alerts provided at the point of clinical decision making. Non-interactive reporting back to doctors, weeks or months later, of what they were doing inappropriately runs a very poor second in effectiveness – yet this is really the only type explored in the report. Why one asks? NEHTA simply does not want to address the issues of quality and functionality of the client systems which may use its infrastructure. This is a real “head in the sand” approach which means any assessment of benefits will be pure guesswork without explicit assumptions as to the capabilities of the client systems being modelled.

Let us be quite clear on this – it is interactive, point of care, advanced clinical decision support and alert systems that offer the largest opportunity for benefit realisation from e-health. The fact this point is not emphasised in this report provides evidence that the document is lacking an appropriate direction and focus.

Next the report notes, without giving adequate emphasis, the issue of the distribution of benefits and the place of incentives in obtaining the adoption and use of Health IT. This issue has been explored in a previous note (Who pays the Piper? May 28,2006) but the essential truth is that small business people (as GPs and Specialists are) will not adopt any technology that reduces their net income. Time and time again it has been demonstrated altruism is not enough and it won’t be here as well. Any modelling will need to carefully analyse the source and recipients of the benefits. NEHTA would be well advised to workshop the suggested provider benefits with a range of practitioners as I know few who would see many of the claimed benefits affecting them and many who could foresee much increased cost and time expenses.

A mystifying omission from the potential benefits of secure messaging is the use of such a service for the transmission of Specialist’s Letters. If ever there is a considered reliable document produced regarding a patient it is such letters (much more so than discharge summaries) and priority should be given to their communication. Their omission is another reflection of the lack of a whole-of-health system perspective in the document.

Another concern is that many of the benefits are predicated on a Shared EHR that is not yet being built, is not funded and in the present climate, realistically, never will be. It is mentioned in the document that NEHTA has recently published a “Concept of Operations” document for the SEHR. This document has been under development for over a year and has yet to see the public “light of day”. It would be useful if this were made available as soon as possible to assist in providing comments to NEHTA on the present document.

It is this commentators belief that the key benefits that can be derived from e-Health will occur from the provision of quality information and advice at the point of clinical care. To not focus on the high quality delivery of these services is a major strategic omission from both this report and NEHTA’s overall agenda.

Lastly the following from Section 7.1 is telling. “It is intended to circulate, for comment, a Study findings document outlining the major Study findings prior to completion of the final Study report. In reporting the findings, it is intended to group benefits (and costs) for NEHTA’s current COAG funded initiatives, (foundation services, identifiers and clinical information structure/terminologies) separately from the shared electronic health record benefits.” It may be that NEHTA is hoping to provide the basis of a business case for the SEHR in a form which will be accepted by Government for funding. If so it will be crucial to address the issues raised here. Benefits studies for HealthConnect have been done previously and have been ignored, one can hope maybe this one won’t be ignored but I for one will not be holding my breath.

In summary this project is the wrong project at the wrong time with the wrong scope. What is needed is a National e-Health Strategy and Business Plan (covering the whole Health Sector) based on the modelling of a considered, agreed and realistic implementation approach. The benefits realisation comes after we have decided to invest and implement and want to ensure success.

David.

Small Nits Appendix:

1. Why is the document so badly formatted?

2. Why is the role of the private sector in Health Services Delivery so underplayed?

3. Is the ASTM Clinical Care Record (rather than HL7 CDA) now on the NEHTA agenda?

Enquiring minds would like to know!

Note - the original report is found at:

http://www.nehta.gov.au/component/option,com_docman/task,cat_view/gid,141/Itemid,139/

D.

Sunday, August 13, 2006

Mr Howard Announces Electronic Medicare Claiming – A Good Thing?

Today the following press release appeared on the Prime Ministers Web Site.

ELECTRONIC MEDICARE CLAIMING

I am pleased to announce that the Australian Government will be introducing new arrangements to make it easier for people to claim their Medicare rebate.

We will be formally engaging the private sector to manage the introduction of a system for patients to directly claim a Medicare rebate into their bank account with the swipe of a Medicare card at their doctor’s surgery.

This streamlined claiming process demonstrates the Coalition Government’s commitment to Medicare. It will be a huge benefit for families, avoiding the queue at a Medicare office, filling in forms or waiting for cheques.

Through these arrangements, patients will pay for a doctor’s visit and then swipe their Medicare card and EFTPOS card to receive their rebate back directly into their bank account. It is expected the new claiming system, via the EFTPOS network, will be available in the second half of next year.

The new claiming process will not affect bulk billed patients, although it will mean their doctor will receive payment from Medicare more quickly for providing the bulk billed service. This will be a major improvement in the way we pay doctors for bulk billed services.

Each day 80,000 people queue at a Medicare office to claim their rebate. Access Economics estimates that the average cost in time and resources to make that claim is $10.
The private sector has indicated it can provide this technology simply and quickly and the Australian Medical Association has given its support for the proposal.

It will provide real time checking for Medicare and concession status.

Medicare offices, easy-claim booths and other current claiming processes will remain in place while the new system is introduced.

13 August 2006”

On the face of it this all seems to be a great idea. Mr Howard is to be commended in trying to reduce the frustration felt by those queuing at Medicare offices in their lunch time as well as speeding up the payment of claims by practitioners.

The devil, however, is in the detail (again) and there are certainly a number of issues raised by this release.

Before discussing these I guess it is pretty clear the motivation for such a system can be seen in the figures provided by the costs of the Medicare queues. $800,000 per day is a large cost when multiplied by the 260 working days of each year ($208 Million p.a.). Sadly it will be impossible, except in the broadest community sense, to recover that possible benefit as it is largely to be found in the time spent by individuals who could be doing more productive things than queuing with their time. Savings will largely only come as Medicare offices are shrunk and closed - to the disadvantage of all those not fully enrolled in the electronic world. Depending on how much the banks charge for their services there may also be some reduction in the $3.50 spent on processing each transaction.

The larger issues from my perspective include the following:

Firstly this system is obviously designed to be a co-payment collection system for doctors who do not bulk bill. Those who are bulk billed are explicitly not affected according to the release. The impact of the prompt return of the Medicare rebate, and electronic payment of the residual via EFTPOS, will make it easier for doctors to raise their co-payment level and avoid the customer “sticker shock”.

Rather than strengthening Medicare this looks like another piece of sleight of hand to make it easier to reduce the role Medicare plays in paying for GP services.

Secondly, one is forced to wonder just how secure and fraud free a payment system based on the use of the Medicare Card will be. It is well known these cards are widely forged and that the number on issue exceeds by a considerable margin the number of eligible families and individuals – hence the enthusiasm from Mr Abbott (the health minister) to replace them with a smartcard, a much more robust system, as announced a year or so ago (Jul, 2004).

The HealthConnect web site makes the importance of accurate identification clear.

Health Identifiers

Another significant issue for HealthConnect is the need for a foolproof system of identification to prevent people receiving incorrect treatments. It is vital to have such a system in the transfer of clinical information. Without it, health care providers cannot be certain that the information held in HealthConnect belongs to the individual being treated.

As in every hospital in Australia, HealthConnect local level patient health identifiers are being used in HealthConnect trials to ensure a consumer's medical information is unambiguously linked to that person. Identification arrangements for the whole of state implementation of HealthConnect are still being investigated, but could include a health smartcard.

Longer-term identification arrangements for HealthConnect will need to take into consideration work underway through the National Health Information Group to investigate options for a national health identifier together with appropriate and robust privacy safeguards.” Current as of 23/02/2006 (It should be noted I am pretty sure the NHIG does not know it is doing this! I can’t check as the AHIC Web Site is currently down!)

The policy confusion regarding patient identification issues just continues to deteriorate. We are now planning, it seems, to introduce a payment system based on the Medicare card by the end of 2007. At the same time the Government plans to introduce its Access Card from 2008 on! (This is not mentioned in the PM’s press release – one wonders why - as presumably the Medicare Card is to be replaced by the Access Card!) Of course we also have NEHTA developing its own Individual Health Identifier for patients to also be available in 2008 or so! We can only wonder will this be used as a basis for payments too!

Next there are some real privacy issues that will inevitably emerge unless there is very clear regulation (and possibly legislation) to ensure all the claims information handled by the bank network is kept totally separate from other banking details. For example, would the payment show the doctor providing the service and the date of service? At first glance it will need to have some information of this type. If it does the person’s bank statement may contain information the patient does not wish to appear on their statement (consider the issue of joint accounts, children operating on parent’s accounts and so on).

Further the press release says the AMA and the banks are in favour. Of course they are. For very little additional cost it means, for the AMA easier access to higher co-payments, and for the banks incremental revenue from transaction fees.

Lastly, it seems that as the electronic payments become the norm, the Medicare office is certain to be wound back to realise additional savings. Who will be inconvenienced? Those without an EFTPOS card and those older and typically more infirm who have not mastered the electronic world and still write a cheque or pay cash for things. Again Medicare is hardly being strengthened.

Before concluding it should also be noted there will be a range of practicalities around implementation of this plan that will need very careful planning. How many practices have EFTPOS terminals? What paper trails are required to avoid and detect possible fraud? What will be the impact on current practice workflows? What information will be required to be held by the practice to identify that an EFT refund has been requested and what will be the costs of providing such interfaces into GP computers? A moment of reflection, I am sure, will identify many more issues to be resolved.

I fear what we have here is a proposal which may very well weaken Medicare, increase fraud, violate at least some people’s privacy, disadvantage the old and be very complex to actually implement. It is also curious why this was announced by the PM rather than by the Health and Human Services Ministers given they have been talking about fixing this problem for a good while now.

I will look forward to understanding how the implementation of this proposal will avoid all these apparent risks. It is not clear to this observer that all the un-intended consequences have been properly analysed.

David.

Tuesday, August 08, 2006

E-Health Excitement in the Apple Isle

Another day, yet another HealthConnect Newsletter – this time from HealthConnect Tasmania. The news provided however is a little less than earth shattering.

From page one we learn that the Project Director is to return from a secondment and that the acting director has left. We also learn, it seems, most of the support staff have day jobs elsewhere and are part time with the project at best.

Next we learn that the Canberra Office of HealthConnect is to manage all engagement with Health System Vendors and that all the senior people had a visit to Katherine in the Northern Territory to share experiences.

Additionally we learn that a project to record ambulance patient transport and clinical information is being recorded on toughened lap-tops rather than paper. This is grandly described as Electronic Patient Care Record Project (ePCR).

From page two we learn that some new projects are to be undertaken. They cover e-mail transfer of triage and discharge medication information and, for the hundredth time, an investigation of the use of a computer to assist in management of warfarin therapy.

We also learn that HealthConnect is alive and well, despite disappearing from the Federal Budget and having totally lost its way as far as Shared Electronic Records are concerned.

I was so overwhelmed by all this I responded to a Tasmanian colleague in the following terms after I was sent the newsletter.

===================================================

Hi You Lucky Tasmanian,

I am just thrilled about the wonderful progress being reported in e-health in Tasmania update from the HealthConnect team. Pity about mislaying their acting project director.

You must be really happy to be in a place where all the action is!

It is good to see e-mail is being used effectively and that for the 20th time someone is using a computer to manage warfarin therapy.

Seems we are probably only a decade (or two) away from the HealthConnect vision of real Shared Electronic Health Records. .but you do have to master the technology first I guess (using a PC, sending e-mail etc) before you can move on.

I look forward to the next instalment with ever growing anticipation and excitement.

Cheers

David.

==================================================

Frankly this newsletter is, just like the other recent HealthConnect newsletters from Canberra and South Australia, a hoax on the Australian people. Truth telling about the terminal fate of the original HealthConnect vision seems to be impossible for the creators of these deliberately deceptive documents. I have no idea why they can’t just tell the plain truth that every observer of the e-Health agenda knows to be true, and move on.

David

Monday, August 07, 2006

E-Prescribing - Part 2

Just when I thought the e-prescribing initiative was settling down for a few weeks, a very useful contribution to knowledge and the state of play comes from the Commonwealth Department of Health and Aging (DoHA).

A statement was circulated today clarifying last week's AHMAC announcement. It said (in full).

Electronic Prescribing of Medicines

Last week in Brisbane, Health Ministers signalled their intent to remove legislative barriers to electronic prescribing.

Commonwealth Minister for Health and Ageing, Tony Abbott told the Health Ministers meeting on 27 July 2006 that his Government would amend the National Health (Pharmaceutical Benefits) Regulation 1960 to remove a requirement that Pharmaceutical Benefits can only be paid for prescriptions that carry a doctor's signature.

The amendments, which will come into effect on 1 March 2007 will allow for all stages of the prescribing process to be completed electronically and provide an alternative to the present paper prescriptions system. Scripts will be able to be created electronically by prescribers, electronically signed, then transmitted securely and uploaded into the pharmacist's system without the need for re-keying. This will ease the burden created by paper-based prescription processes, allow healthcare professionals to spend more time with patients and reduce the risks of errors and lost prescriptions.

According to the Australian Council for Safety and Quality in Health Care's Second National Report on Patient Safety an estimated 400,000 adverse drug incidents occur in Australia each year. Electronic prescribing will help eliminate those incidents that occur due to poorly handwritten paper prescriptions and transcription errors. It will also support longer term moves to reduce waste in the PBS and improve patient safety stemming from duplicate prescriptions and adverse interactions between different medicines.

While the changes announced last week remove one of the main barriers to electronic prescribing, there are a number of additional steps that will need to be taken before the vision becomes a reality.

States and Territories will first need to examine their own legislation and make any amendments that are necessary to bring it into line with the amended National Health (Pharmaceutical Benefits) Regulation 1960.

Then, governments will need to work with Medicare Australia, the National E-Health Transition Authority, IT suppliers and professional bodies representing doctors and pharmacists to put in place arrangements to ensure the successful operation of electronic prescribing. Key considerations to be addressed will include:-
• the need to ensure security of prescribing information and protect patient confidentiality;
• procedures to validate the identity of prescribers;
• mechanisms to allow patients choice over where and when they have their medicines dispensed;
• integration with doctors' and pharmacists' existing computer systems; and
• arrangements for secure archiving of prescription details.

Given the scale and nature of the practical challenges in any large-scale move to electronic prescribing it may be some time before it is widely adopted. Nevertheless, last week's announcement by the Federal Health Minister is an important move which will yield substantial long-term benefits to patients and health professionals throughout Australia.

Regards

Tam Shepherd
Assistant Secretary
eHealth Branch
Australian Government Department of Health and Ageing”

As far as this goes this is excellent and recognises – as mentioned in my initial comments – that there is considerable work to be done in a range of areas before this can all come to fruition.

However it is also important to note what is not covered in this briefing.

First the strategic and e-health context in which the planning for e-prescribing is to be undertaken remains vague if not totally opaque.

Second there is no target time-line (except a long one) of any sort provided – leading to at least some scepticism about just how serious this actually is.

Third there are a number of Standards related issues that NEHTA is yet to address, as well as the need for consultation with the all relevant stakeholders to see just where this fits in the overall e-health priority list.

Fourth – yet again - the issue of quality of GP and Specialist prescribing decision support and its importance (and indeed the issue of the quality of the GP computer systems in general) is not recognised. To contemplate e-prescribing without fully and carefully addressing this area is folly. I believe that unless we have certified systems with current knowledge bases that provide consistent, evidence based, interactive, point of care advice the business case to e-prescribing is hard to build.

Fifth it is important to note that prescribing information data bases are presently a significant issue with the SA HealthConnect SEHR initiative choosing not to use the database sponsored by NEHTA according to their web-site.

The bottom line is that prescribing error in the absence of quality information is much more of a risk than transcription errors for the patient.

I look forward to further refinement of the e-prescribing plans and indeed a clear outline of the overarching e-health framework into which this initiative fits.

David.

Who Is Kidding Who in NSW?

Sometimes one hears something that stretches credulity, but the plans just announced by the NSW Commerce Department’s Office of the Chief Government Information Office truly “take the biscuit”!

A plan entitled People First – A new direction for ICT in NSW which is said to be the NSW Government ICT Strategic Plan was announced at 9.00am on Thursday 27th July 2006 by the NSW Minister for Commerce, John Della Bosca

It is said that this is “an innovative Government ICT Plan that sets the framework for a coordinated government-wide approach to planning, expenditure and allocation of ICT resources.

It represents a major change in ICT policy direction and will pave the way for a new and more effective way of service delivery for the NSW Government.

The Plan provides a strategic framework to make better use of technology to improve the efficiency and effectiveness of services and systems, both within government and the wider community.

It will allow NSW Government Agencies to work together within a coordinated strategic framework to aggregate ICT initiatives to minimise costs and maximise the use of common applications, infrastructure and processes.

Savings will be redirected to key frontline services such as health, education, policing, disability services and information.”

The claims made in the body of the plan are that it: -

• Will be implemented over 4 years, commencing July 2006.

• Targets initiatives that are inevitable, which no one agency can do singularly, that are common and repeatable between agencies and which provide strategic value.

• Removes the technological barriers that inhibit both the reform of government and e-government initiatives.

• Results in savings of over half a billion dollars over four years.

The claim is made in the detailed document that the plan:

“Directs ICT savings to key front-line services such as health, education, policing, disability services, home and community care, transport and housing.”

Excellent one thinks – a bit more for the areas that need it. But read on. Then we find the following:

“ICT capital expenditure will be reduced by $350 million and recurrent ICT expenditure reduced by $215 million over four years.”

So not only is there no extra money for the front line – worse $565 million over four years is being pulled out the NSW Public Sector IT Budget.

If you believe this will provide improvements in health service delivery, the police and transport systems and so on – you are clearly a believer in the tooth fairy!

On the basis of what is written in this document the whole plan is nothing more than a money saving initiative wrapped up in a collection of pretty A3 charts.

What a pathetic farce!

David.

Saturday, August 05, 2006

Oh HealthConnect! – You Have Done it Again!

A few days ago I was told that the South Australian HealthConnect Project has suddenly burst into life after a period of relative inactivity. Intrigued I thought I should have a look and see what was going on and I found that recent activity was indeed in evidence.

Those who have been following the HealthConnect saga will be aware that it has been Tasmania, the Northern Territory and South Australia where projects have been initiated. In South Australia (SA) there are two streams of activity. The first is an extension of the Broadband for Health Project for SA with some extra support on implementation of security.

The second, and more interesting, is the planning of a project (to go live in November 2006) to provide a basic Shared Electronic Health Record (SEHR) (accessible by the GP, Patient and other Carers) to assist in the communication and sharing of patient specific health information to better co-ordinate and deliver care.

The SEHR and messaging environment is to be provided by Ozdocsonline. They can be found at Ozdocsonline.com.au.

What a very good idea I hear the loud cries – and I cannot but agree. As always, however, the devil is in the detail.

Before discussing that detail, let us briefly consider what attributes we would expect from a Commonwealth / State Government funded Shared EHR Project. I suggest we would expect at least:

1. The use of an open, rather than proprietary, SEHR and messaging platform.

2. Adherence to the national technological standards directions being defined by NEHTA.

3. Interoperability and synchronisation between the GPs local Electronic Health Record and the SEHR record to the extent that both contain the same information to ensure patient safety.

4. At least a HeSA level of security for information flows between the systems of the various users of the SEHR to ensure clear accountability on the part of all users regarding the information stored in the SEHR.

5. Use of the necessary coding and terminology sets to ensure information was captured in a comparable and computable form.

6. Access to the service would be free to the patient (ideally).

What is proposed is that the Ozdocsonline portal will become the central, and proprietary, access point from which patients and their carers will contribute and retrieve information – largely in the form of free uncoded text. The shared record will consist of some key demographic information and then a series of entries (which are either unstructured encounter documentation or itemised action plans) which, it is hoped, over time will become a useful record.

Now, while I am a long time supporter of the idea that progress will only be made in e-health if the various actors just get on with it - this proposal frankly seems a bridge to little!

Among the issues I also see around the planned operation of this proposal are:

1. The patient is apparently charged a fee every time they leave the practitioner a question, prescription repeat request and so on. (Ozdocsonline collects the funds and remits to the GP monthly).

2. The practitioner will need to record information twice – in their computer system and in the on-line system. This may slow the GP down just a little and lead to quite slow adoption.

3. The use of clear text e-mail to let the various actors in the operation know the other has made a referral, a change or whatever. This has the possibility of leading to a deluge of e-mail and further delay for the GP, as well as providing some information, some may not want disclosed, to others.

4. The proposal does not meet the expectations for a publicly funded SEHR trial given the learnings already made in this area so far (e.g the importance of information coding, the importance of client GP systems etc).

It is clear to me that this plan – as presently evolved – is seriously underdeveloped and quite inconsistent with even the broadest outlines of where e-health in Australia should be heading.

I find it amazing that the funding for Development of the Web Based Community Care Plan Management Tool Ozdocsonline is coming from the iTOL program in the Department of Communications, Information Technology and the Arts, rather than the Commonwealth Department of Health. Maybe that explains why the special health privacy and standards issues have not been addressed as one might have hoped.

The motivation for this project is excellent, and if well executed it could make a difference. However, sadly the currently plan for its conduct is, I believe, badly flawed and needs serious review.

David

Thursday, August 03, 2006

Danish Nirvana – Happiness and e-Health

A few days ago the University of Leicester published the following survey of some 80,000 people from around the world. Participants in the various studies were asked questions related to happiness and satisfaction with life. The Leicester study also looked at health, wealth and access to education. The results were as follows:

The 10 happiest nations in the world are:

1 – Denmark
2 - Switzerland
3 - Austria
4 - Iceland
5 - The Bahamas
6 - Finland
7 - Sweden
8 - Bhutan
9 - Brunei
10 – Canada

They also reported that Burundi, Zimbabwe and the Democratic Republic of the Congo are the unhappiest nations on the planet.

As a matter of pure co-incidence I had been researching e-Health interoperability and had come across a report on the status of e-health in the very same Denmark.

See the following site for details and a copy of the full documentation covering many countries (including Australia – which receives a report suggesting much planning but little actual delivery as of May 2006.) http://www.srdc.metu.edu.tr/webpage/projects/ride/

I now know why the Danes are so happy (other than having our Princess Mary and a new prince) and why Australia (and the US) do not make it into the top 20. Their e-Health works!

A few statistics make the point pretty clearly.

1. 97% of general practitioners now use EDI, and almost all hospitals are now able to send electronic X-ray results and hospital discharge letters. This is unique coverage unknown in any other country.

2. Electronic patient referrals for hospital treatment and to specialists have not yet been used on a massive scale, nor has the use of laboratory requests so far become particularly widespread. However, in the local-authority area, the number of local authorities that exchange EDI with the hospitals has risen from 12 to 92 during the course of the MedCom IV period (2002-2005).

3. The range of services used by 80+% of GPs include:

• Discharge Letters and Reports
• Outpatient Letters and Reports
• Casualty Letters and Reports
• Image Diagnostic Letters and Reports
• Admission and Radiology Referrals
• Pathology Results (All types)
• GP Prescribing
• Billing (Most Services)

Referrals are now being progressively rolled out.

At present the network (termed MedCom) is EDI based but it is being migrated to an XML based web services environment over 2006.

It seems to me this is proven technology that works and would make a huge difference to clinical care in this country. It would also be easily replicable in a sensible time frame and would be consistent with what is known of NEHTA’s planned directions.

Someone from the Government needs to undertake a detailed study visit (it’s a nice place in Autumn) and then get on with actually doing something here!

David.