Tuesday, June 12, 2012

Good Heavens - It Seems The NEHRS Will Be Like The Old Scanned Electronic Record Systems Where Search-ability , Decision Support and Discrete Data Is Out The Window.

The following appeared a while ago - and I missed it for a while.
MAY 2012 | Published by RCPA
Issue #014

Pathology results will miss this year’s eHealth debut

The long-anticipated eHealth initiative will make its debut on July 1 this year, and it’s been a long journey to date. But the journey’s not over yet, especially for pathology which won’t be included in this year’s eHealth rollout. It’s not a case of omitting pathology from eHealth, but more a case of advocates such as the Royal College of Pathologists of Australasia (RCPA) ensuring that pathology results are uploaded and viewed in the safest possible way.
“The RCPA have been working cooperatively with the National E-Health Transition Authority (NeHTA) on this project,” explains Dr Bronwen Ross, Deputy CEO of the RCPA. “However, patient safety is paramount so we have been making sure pathology results will be uploaded into eHealth records in a way that ensures their complexity and context are not lost in the transition.”
The official title of this new eHealth patient record is the National Electronic Health Record System (NEHRS), although older information may refer to it as a Personally Controlled Electronic Health Record (PCEHR). Whatever its name, Professor Michael Legg from the Centre for Health Informatics and eHealth Research at the University of Wollongong says the roll out will be slow with the initial benefits mostly favouring people who are outside of their normal caring group of health practitioners.
“There’s a good example of this in action on the eHealth information website1 which gives the example of Kelvin’s eHealth journey to demonstrate its usefulness in this situation.”
Prof Legg, who is also a Fellow of the Faculty of Science of the RCPA, says eHealth is an important initiative but he also shares Dr Ross’ concerns about the risks of uploading pathology results in a fragmented way.
“If you grab bits of a pathology report and cut and paste it into an eHealth record then it can lose its context, especially if there are differences in the units and reference ranges used by different laboratories.”
Dr Ross says the RCPA is working on standardising certain aspects of pathology reports, but like any major project it will take time.
“Pathology results are not just a group of numbers or a commodity that can be put wherever people like,” she stresses. “There is medical analysis by a pathologist behind them and that’s one of the reasons why they must be represented in context. For example, microbiology is one area where uploading fragmented information can have serious consequences because the reports deal with different organisms and cultures as well as specific recommendations by pathologists.”
Dr Ross says a group of pathology stakeholders have agreed on a model where the results will be uploaded into the eHealth record in a PDF format so the report is viewed in full. This has the added advantage of enabling treating practitioners to view additional information such as who wrote the report as well as the laboratory’s contact details.
More explanation and details are found here:
Further on we also find the target date for result availability is a year after the NEHRS was meant to go live for large pathology providers and a year later for smaller ones.
It seems that while discrete pathology results (as well as those in PIT format) have been provided by a range of secure message providers for years that we are now going to settle for the foreseeable future on a ‘data lump’ format for the NEHRS.
What needs to be quite explicit here is that this problem has been known about for years by NEHTA. It has always been the intent that the new Secure Messaging standards from NEHTA would support proper interoperability.
Here is a title page from an old presentation. (Not surprisingly Google does not now find it!)
NEHTA

Moving to Interoperability in eHealth

12 July 2006
Andy Bond
General Manager Interoperability
----- End Extract.
Page 14 of the presentation makes it clear that not only e-Results but also e-Ordering are to come. Six years later - Oops missed that one and it will now take a few more years.
I will leave it to others to explain why so much has been spent on NEHTA and why this work still isn’t done. It beats me.
That we have not reached agreement on how to provide discrete information to clinical systems is really a very sad outcome - given the how ‘blob’ formats make things like clinical decision support that much harder.
Use of .pdf files is really such a technically poor outcome that one only wonder why more work has not been done to get a better outcome by those involved - RCPA, NEHTA and DoHA.  Why do I get the feeling there is more than technology involved here - turf preservation or politics maybe? Maybe a careful rethink with the interests of clinicians and patients might be a good idea?
Remember that, of course, once second best gets established - how long will it be before a new improved version emerges? Your guess is as good as mine!
David.

7 comments:

Anonymous said...

My guess is the political agenda has always been for Government funded agencies to control all aspects of the 'national' electronic health record.

NEHTA is the mechanism to achieve that goal. The corollary is therefore that any organisation which looks as though it is making progress in those spaces targeted by NEHTA must be blocked from doing so until such time as NEHTA has established and deployed a series of national repositories relating to the three major domains of pathology, imaging and medications.

That's why we have seen so little progress. Because as NEHTA continues floundering it continues obstructing progress elsewhere by others more competent than itself. In effect it blocks market progress and innovation.

Remove the block and progress will be made. Nothing is more certain. But, the Catch22 is that to remove the block NEHTA must first be neutralized.

Anonymous said...

There should be no misunderstanding about this issue - the inclusion of pathology results in the PCEHR/NEHR in PDF format (only) is a major backward step in eHealth and no amount of spin and noble-sounding words can make it otherwise.

Pathology results are available as "atomic" data today in HL7 V2 messages - from almost every laboratory in the country. This allows the health sector (through automated systems) to provide essential health information analysis and reporting to clinicians. There is no excuse for not continuing to provide results in this format to the PCEHR/NEHR; CDA (HL7 V3) supports atomic data AND a report format (if the latter is considered useful for presentation to clinicians).

The previous comment has interpreted this correctly. The focus on centralised control of the PCEHR/NEHR has never been clearer, despite previous ministerial commitments to a non-centralised solution. NEHTA and DOHA have spent the last six months actively discouraging any eHealth initiative that would offer an alternative to national components of the the PCEHR/NEHR program, including, for example, conformant repositories. The only logical reasons for this are that other solution providers might a) deliver more value than the national infrastructure operator and b) deliver more cost-effective,timely, better engineered solutions that the national infrastructure operator.

We couldn't have that, could we ...

Michael Legg said...

David,

Rendered reports were seen by Pathology Practices as the safest way to make pathology reports available to the Government health record that is still being specified and built. This also goes some way to explaining the timing under the pathology agreement for participation in the PCEHR/NEHRS.

Your readers may be interested to know that AS4700.2, the Australian Standard for radiology and pathology messages (for atomic results), first published in 1998 and now in its fourth iteration, is currently out for public comment on the Standards Australia website. PIT by the way is deprecated in this version of the Standard.

Pathology practices, public and private, see atomic results being provided point-to-point using this Standard for the foreseeable future and this is acknowledged in NEHTA's 'Standards Catalogue'. It was envisaged that any authorised person that wanted atomic results after seeing them in the PCEHR would get them this way - allowing the reports to be incorporated in their Practice Medical Record System in the usual manner and used in decision support if that is available. This also allows the Laboratory to fulfill its responsibilities in terms of audit and to provide report corrections and updates if necessary.

The pathology profession, led by the RCPA is not moving backwards in eHealth, rather there are increased efforts at standardisation of terminology, units and structured reporting with more than a hundred pathologists, informaticians, scientists and other clinicians working on two significant projects currently. They are the Stuctured Reporting of Cancers and Pathology Units and Terminology Standardisation Projects. More information on these is available from the RCPA website.

Anonymous said...

This is all very familar to those who have been involved on the clinical, non - ICT/ ehealth side of the so called QH "the viewer" project.

Which just won a major industry award - some considerable years after it was meant to materialise.

In particular, there has been a discounting of concerns about the clinical safety as more data it pulled into the repository without the neceseary infrastructure services sorted.

The utility and safety of a repository of pdf based non atomised data has been one the IT departments and professionals have avoided taking responsibility for as it threatens their capacity to stand up and say they have actually delivered something.

Who is legally responsible for a mistake caused through viewing the QH "the viewer" or data in the previously named PCEHR - what is the value of a repository of dumb or near dumb documents - least of all that it wastes valueable clinican time and resources?

Anonymous said...

This is so typical of government eHealth programs. They ignore the expertise and existing standards and march in saying get out of the way because we are going to fix it and you are the problem. After a few billion dollars and untold damage to the industry they realise they are way out of their dept and scale down their efforts to this weak anaemic excuse for eHealth and try and sell it as a major advance. Its just a waste of taxpayers money and its time they were called to account. It's time to stop. The only way we are going to get decent eHealth is to support whats proven to work now with small rewards for compliance with standards. The government is the problem.

Anonymous said...

David I am surprised you missed this announcement from NEHTA. http://www.nehta.gov.au/media-centre/nehta-news/985-nash-delay-will-not-impact-consumer-registration-for-pcehr-

If the rumors are correct, then the executive responsible for NASH and his manager have both resigned. I also hear that the man in charge if the non-delivery of the PCEHR will take over. This puts projects such as continuity of care, prescriptions, pathology under this idiot’s direction and what ever disaster elements he brings across from PCEHR.
I guess we can expect three things for NEHTA in the next 12 months:
1. Clinical perspective and needs further sidelined
2. Accenture will play a bigger role in these fields with an of the shelf non-solution
3. The Silo approach will continue to isolate the various projects; resulting in specifications that are not really much use once you start to use them.

Have they gone through so much of Australia talent that they have little or no options left to them.

Dr David More MB PhD FACHI said...

Fear not - covered later today in detail....

David.