An ID Card in all but Name – For Now!

Individual identity systems are a topic of great interest for this blog. The reason for this is that patient identification is a key requirement for any form of electronic health record and that NEHTA has been working to design a patient identity management system as one of the “building blocks” for e-health.

It now seems that Australia is to have an “access card” that will be needed to be presented when accessing all Commonwealth Government payment services (Medicare, Social Services and so on – in total 17 different services).

Interesting analysis and a range of opinions are available both here and here.

It is fair to say that denial that the proposed card is an ID card is disingenuous in the extreme and is to be condemned as an attempt at concealing the fact that this proposal goes much further that the publicly rejected Australia Card of the 1980’s in terms of potential for abuse and the scope of linkages being planned.

The claim the card is voluntary is equally a nonsense. If you choose to go without healthcare and social security benefits sure you could struggle on without it for a while at considerable expense – but how long will it be before it is needed to use State run services and finally private services. It will surely become all pervasive without firm legislative limitation – which has not been announced as far as I am aware.

The Government needs to come clean and be clear just what is proposed to manage scope creep and ID fraud before any one should support it.

Lastly it will be interesting to see how the proposed smartcard interacts with the proposed NEHTA patient ID proposal. Does this announcement pre-empt, support, interact with or have any other role in the development of the Australian EHR system.

This commentator will wait and wonder!

David.

Shared Electronic Health Records are Not Easy

A day or so an interesting report appeared in the web magazine ehiprimarycare.com revealing that the plans for the Shared Electronic Health Record (SEHR) for the NHS spine had been significantly scaled back. To quote the relevant section:

"Dr Gillian Braunold, one of CfH’s national clinical leads for general practice, said major diagnoses and major procedures will no longer be included in the initial upload to the spine, a change in policy from proposals issued by CfH in the autumn.

She told EHI Primary Care: “We feel it is sensible to limit the initial record to just prescriptions and allergies because we want to make sure each set of records is fully correct. The profession felt strongly that although globally a practice might feel its records were good it was important to look at each set of records before they went up.”

This outcome can only serve to remind us just how difficult it can be to come up with a useful SEHR and to ensure the accuracy and utility of the data held as well as address all the other issues that arise (privacy, security etc).

Australia’s effort in this regard, termed HealthConnect, presently has a rather ambiguous status. While it has not officially been killed off, it now seems highly likely that it will not be built as originally conceived. This conception was of a large centralised repository which held an initial patient record (with standardised content) and then a series of “event summaries” which were created each time an individual had an encounter with the health system. Over time the event summaries were to form a longitudinal health record which lasted the patient’s life.

The key barriers to success of this project would seem to have been:

1. The lack of clarity about just what the information contents of a summary records should be to meet the benefits objectives of the project.

2. The inability to clearly recognise the importance of, and the need to standardise, the client systems which were to be the sources of the information contents for the SEHR.

3. The lack of provider and client identifier approaches as well as the lack of an agreed clinical terminology. (the need for these is now recognised six years on – and they may be available in 2-3 years)

4. The lack of properly conducted, transparent, well funded trails of the various components required to reach the 2001/2 vision.

5. The difficulty in working through the privacy and legal issues, as well as the consent issues, associated with the whole concept.

6. The lack of a properly thought through and compelling business case for the overall project – leading to a lack of budgetary commitment for the whole enterprise.

7. The lack of recognition that the quality and sophistication of the client systems was crucial to the overall justification of the project.

8. An inability on the part of the sponsors of the project to develop political and public support for the implementation of HealthConnect.

It seems clear to me the UK has been sensible in scaling back what they are attempting and to approach the whole endeavour incrementally – hopefully learning as they go on. I am firmly of the belief “big bangs” are not the way to success in Health IT.

David

The More Things Change - The More They Remain the Same

The following is an article - unchanged - I wrote in late 1999. It is amazing to see how little has changed!

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

Opportunity Lost – Health Information Technology in Australia : 1970 – 1999

In 1986 I was walking home late at night from a large public hospital having just lost the battle to save the life of a young man whom my colleagues and I had been working on for a number of weeks. As I mourned the loss of this young life I, not unnaturally, wondered was there anything I should have done, I had omitted – or were there things I had done that had led to this sad ultimate outcome. A search for such certainty is a natural and appropriate activity for any responsible and caring clinician, but as I later came to realise, attainment of such certainty is ultimately not achievable, or even approachable, without automated help. As I walked I comforted myself by recalling that, while I was in charge of the Intensive Care Unit for that week, others had been in charge in previous weeks and they had all helped and offered advice and skills during the last few days. That the final outcome was not totally on my shoulders offered some comfort.

Why raise this story? The reason is that at the time of this story I was, as you might say, at the peak of my clinical powers. I had been trained for nineteen years since I had left school, had two clinical fellowships and a PhD and a little over a decade’s practical experience. But I was still unsure. As I reflected further I realised there were two elements forming my dilemma - firstly, that total certainty was impossible and secondly that the management of the knowledge of medicine, and especially its dissemination, was far less than perfect.

Move on to the present day – what do we see? We see a profession that has even less certainty and confidence than 15 years ago. There is evidence of a progressive loss of public confidence in the profession, the cost of medical professional indemnity insurance is soaring, professional satisfaction seems to be waning and all agree that the national public hospital system is in a mess. Worse still, thanks to the work of people in the field of clinical quality improvement , we now know for certain that the quality and consistency of care are far below what the ordinary man would see as acceptable levels. Indeed public expectation for perfection is now so high that when the College of Anaesthetists released their recent report on anaesthesia related deaths for the period 1994-1996 that showed some 135 deaths related to anaesthesia from over 8 million anaesthetics provided (1 per 63,000 procedures), there was intense media and public concern. That such an extraordinarily good outcome should be seen so negatively shows how far we have moved since the days, less than 50 years ago, when death rates of 1 per 2,000 procedures (Beecher & Todd, Annals of Surgery, 1954) were seen as totally unpreventable.

All this is made worse, as far as the ordinary doctor is concerned, by the escalating pressure from Government to take steps to improve quality and consistency, while reducing costs. Meanwhile, these doctors are not being provided with the supporting and enabling tools to achieve the desired outcome and are paid on a basis that provides very strong incentives to deliver quick care to maximise the doctor’s income.

In 1997, while working with the IBM Consulting Group on a study for the Commonwealth Health Department, a colleague and I analysed the benefits for the total health budget that could be realised if some small technology enabled improvements were to be implemented. We costed the impact of the fully funded introduction of a General Practice Clinicians Workbench with the sole function of providing electronic prescribing. (This involved using a computer to keep track of the medicines a patient was on and then, as required, producing prescriptions for that patient. The computer was able to both produce a neatly printed legible prescription while at the same time making sure what was being prescribed was both reasonable and safe – a side benefit for the doctor is that repeat prescriptions can be produced very quickly and easily). The cost was estimated to be in the order of $100 million over two years, with the direct cash benefits to the Government flowing from the reduction in prescribing errors and their sequelae of the order of $800 million over five years (the economic life of a desktop computer).

In addition to the benefits specifically related to Electronic Prescribing, there are a range of benefits which will flow as Electronic Prescribing is essentially the “pathfinder” application leading to the use of computers in other aspects of the patient consultation process. A now dated review (Sullivan F & Mitchell E, BMJ 311: 849 1995) of the worldwide experience, and the UK experience of the impact of the $A100+ Million the UK NHS spent almost five years ago on primary computing, reached the following conclusions based on a review of all available literature:

· On the downside, Use of a computer during consultations in the UK occurs in 55% of consultations and this use lengthens the consultation by between 48 and 90 seconds.

· But among the good news was that use of the computer improves immunisation rates between 8 and 18% and that;

· Use of a computer also improves the carrying out of other preventative tasks by up to 50% (eg mammography, Pap smears etc).

· Additionally it was found that use of the computer did not have a significant negative impact on patient satisfaction.

To obtain such major improvements in preventative activity would be of considerable importance in having Australia reach the goals set in the Health 2000 Initiative, and would represent immense overall value to the community as a whole (probably as important, if not more so, as the financial benefits identified above).

Sadly we find ourselves in a situation where, some four years after the study was given to Government, we are still moving at a glacial pace, nothing fundamental has happened and an opportunity cost of almost a billion dollars has been incurred through inaction. Even more worrying is that the present Federal Minister, Michael Wooldridge, has been saying publicly and privately that something needs to be done for at least three years and has been vociferously supported by both the AMA and the College of General Practice. Yet it appears that no coherent action has been taken or even planned.

If confirmation was required of the basic correctness of the general assertion that having doctors use computers to assist them deliver improved care, one has to look no further than the ‘Mother Country’. In the UK – a country not famous for being at the very forefront of IT Innovation – they have recently committed (September, 1998) through their strategy “Information for Health - An Information Strategy for the Modern NHS 1998 – 2005 ” to spend $A2.4 billion over seven years to achieve the following objectives:

· a lifelong Electronic Health Record for every person in the country.

· round-the-clock on-line access to patient records and support of best clinical practice, for all NHS clinicians.

· a National Electronic Library for Health to keep doctors and nurses, and other clinical professionals up to date with the latest clinical research and best practice at the time they need it.

· delivery of integrated seamless and properly co-ordinated care for patients through GPs, hospitals and community services sharing information across the NHS information highway.

· fast and convenient public access to information, advice and care through online information services and telemedicine.

· more effective use of NHS resources by providing NHS planners and managers with the information they need.

It is clear the UK sees this investment as a strategic move to dramatically upgrade the effectiveness of their national health system, and it is equally clear they would not be prepared to provide the scale of funding planned if they were not certain they would achieve major improvement both in financial and clinical outcome terms.

Back home, however, we find ourselves in a situation where we have an obvious and worsening problem – information overload for medical professionals, a ready solution in the form of automated clinical desktops, and the public in the middle are getting care of a quality and consistency considerably less than is possible. As a side issue, we also see spiralling health costs, related, in part, to a failure to leverage the efficiency and quality benefits obtainable from structured and properly planned implementation of appropriate technology. The fact that expenditure on technology to support the front line care givers may, on occasion, be dramatically more effective than simply hiring a few extra doctors, nurses or administrators, has clearly escaped many of the health system’s leaders.

So what, you may ask is actually going on, and why is the situation allowed to continue? The answer, I fear, is a combination of factors, but at the top of the list there must clearly be some degree of lack of professional and governmental leadership. Additionally, as is always the case there are some financial and structural issues as well as what may simply be termed the ‘well it doesn’t look too broke, so we won’t fix it yet’ attitude of those in the health system. This is despite the increasing concern of the public at large.

Let’s start with money. We have here an instant problem. Implementation of the systems and infrastructure to achieve the UK NHS goals would be quite expensive, probably $250+ million over 1-2 years. While a very compelling business case can be made that the money would be recovered many times over – no-one in authority seems to have a strong inclination to authorise that scale of investment. Sadly, even with an unassailable business case straightforward action in this area is not easy because of the Byzantine complexities of health funding in Australia, sourced as it isfrom federal, state, private and personal sources.

Easy you say, have each doctor pay for their computer etc as they are the user and all will be well. Maybe just sweeten it a bit with a payment or two for some specific computerised information on a monthly basis and they will all be off and running.

Think again – our health system – at the GP level – largely rewards not quality of care but rapidity of care – the faster you can get them through the more you make! Worse still, using a computer slows you down a little to boot. The final blow to GP enthusiasm for automation is, of course, that while there may be some small benefits to offset the inevitable slowdown caused by automation the major benefits derived from the system (e.g. less drug interactions caused, higher vaccination and screening rates etc) are for the Government and the patient. The doctor is no better off, except for the feeling of practising better medicine, and has all those ongoing costs – even if the initial leap, and expense, has been taken.

A third option might be to have the patient pay an extra 20 cents, or whatever, a visit to have the guarantee of being reminded when the next vaccination and screening procedures are due and being warned before taking potentially incompatible medicines.

Without denying that there are a number of GP’s who, for their own reasons, decided to computerise some aspects of their practice (50%+ with accounting and about 15% for some clinical functions), the step that will really make the difference is to ensure that there is a fair and equitable split of the benefit between Government, patient and GP. This can be most simply achieved, in my view, by developing a rebate for computerised activity on the part of the doctor and use of some appropriate federal funds to develop and appropriate secure health information network infrastructure (The Health Insurance Commission has wanted to do this for years –as have the telcos). An example may be an extra 50 cents rebate to the doctor for each patient encounter that is properly recorded in an approved computerised system. In this way the patient receives all the automated alerts and warning important for ensuring the quality of their care and the practitioner does not feel pressured to rush through the computerised parts of the consultation. As an inevitable side effect of this we reduce adverse drug events, improve vaccination and cancer screening rates, have prescriptions that pharmacists can read and have much enhanced medical record keeping which can later feed into research and teaching. I see this is a very small price to pay for a dramatic and sustained improvement in the quality and consistency of care in key priority areas.

In summary, Australia Health Information Technology is in a Mexican Standoff. Those who want the benefits don’t want to pay, for whatever reason, and those who need to use the technology for the good of their patients mostly won’t do so without some financial incentive to ensure their incomes are not reduced. The logjam needs to be cleared by some decisive leadership and development of a clear forward strategy that all stakeholders can be comfortable with and see is in their interests. Fortunately it is clear that there are a range of rational and effective national strategies that could be developed which would make all the stakeholders winners, and thus minimise implementation difficulties. The background work has all be done, it is clear the benefits are there to be had, all the pilot studies we need have been conducted and evaluated and the time for decisive coherent action has arrived. If ever my younger colleagues are to feel confident and sure of their capabilities to face the knowledge and information challenges of the new millennium the time to start is now. I hope someone will act soon, for all our sakes.

David G More – October, 1999

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

The only thing that has changed is that the evidence for all the claims made above is now vastly stronger!

David

David Brailer's Resignation - A Significant Loss

Today it has been announced that David Brailer has resigned his position as Head of the Office of the National Co-ordinator for Health Information Technology.

It seems to me this is a very significant loss, given the steady hand he has provided in the developments in this very important area in the United States.

There is no doubt the strategy he has developed to foster the use of Health IT has been largely sound and consistent with the constraints the operate in the US Healthcare sector. Inevitably some strands of the approach may need refinement going forward - especially in the area of the quality of the client EHRs that are to be implemented in physician offices and how best this transition can be managed and funded - but overall the approach of starting small and growing and linking as competencies build seems fundamentally sound.

Additionally his emphasis on the use of pragmatic proven standards -based on the CHI work undertaken in the period before his appointment - was also rational and appropriate.

However, I suspect his biggest contribution was the work he undertook in the year prior to his appointment where he as able to convince the West Wing and President Bush of the importance of the overall initiative and the potentially huge opportunity cost of inaction.

It is a pity Australia has not yet thrown up a similar individual who can weave the same magic on our Prime Minister. We need this prophet badly just at the moment!

David

Useful Standards Framework for Interoperation

In a very useful recent release the Californian Regional Health Information Organisation, or CalRHIO has released an interoperation standards framework along with a roadmap covering how they see these standards evolving over the next few years.

In their release they say they have worked to take account of all the prevailing standards initiatives in the US (from HL7, ONCHIT, Markle and so on) and have tried to form a clear direction forward.

This work is of interest in Australia because NEHTA is currently working to develop a standards catalogue, the work done here is a useful view, from other experts, on the way forward.

Notable to me was the use of the Californian HealthCare Foundation standard (ELINCS) for laboratory results communication and support of LOINC as the terminology used. This approach seems to support evolving the HL72.x standard in the same way is being developed in Australia. I hope this work can be jointly advanced until HL7 V3.0 is ready for prime time.

Also of interest were:

- The recognition that HL7 V3.0 is a little way off.

- The plan to use the HL7 (OMG) approach to Services.

- The non use of SNOMED CT in the Allergy Space where the is a developed subset already available for use.

- The planned phasing out of ASTM CCR by about 2010.

Australia could do worse than have discussions with the authors of this short (5 pages) framework to understand the rationale and motivations behind the recommended choices.

David

Back to the Future for E-Health

Last week CHIK Services conducted their annual Health IT conference (Health-e-Nation 2006). The slides and materials from this very useful gathering are now available on the web.

Of particular interest was one line in the presentation from Dr Ian Reineke (CEO, NEHTA). In this he says that the momentum for e-health is rising and that "The stage is set for Governments to consider a national system of electronic health records".

Reading this I must say I almost choked on my Wheaties. To my certain knowledge the stage for this was set in 1997 with a House of Representatives enquiry followed in 1999 by a large report recommending what eventually became HealthConnect in 2001/2.

Nine years into "consideration of national EHRs" we are now told the stage is set for what must be re-consideration, given the passage of almost a decade!

More than that we have the NEHTA Chairwoman (Ms Patricia Faulkner) tell us that we will all have a Shared EHR at some point in the future but that it will be six-eight years into the future.

What has happened to all the work done thus far and all the money spent. One can only assume very little since we are now to "re-consider".

The truths obvious from all this is are:

1. No national plan for Shared EHRs currently exists.

2. Those considering e-Health and Shared EHRs know they won't be around six to eight years from now to have to account for their level of success in delivery this time when what is happening now is reviewed.

3. Unless there are real funds to support develop the Shared EHR in next months Budget we can be sure "six to eight" years is an optimistic estimate of the likely time frames.

I look forward to being found to be wrong, but I doubt it.

David

RAND Corporation and the Value of Health IT

As a sign of its importance the Annals of Internal Medicine has published, a month in advance of its print date, an important systematic review of the Impact of Health Information Technology on Quality, Efficiency, and Costs of Medical Care. This is a crucial review and establishes that, at least in some circumstances, there are positive impacts on quality, efficiency and costs from the implementation of Health IT.

The evidence for such value in organisations with a high level of IT sophistication was very compelling indeed and given the expertise deployed in undertaking the review can be considered definitive. In the hands of experts Health IT makes a significant positive difference.

The less good news was that, while the value appeared to obviously be available to smaller and less advanced organisations, evidence this was actually the case was lacking.

The authors then go on to, very sensibly in my view, recommend more work to adduce the required evidence and ensure the business case for Health IT deployment is as robust as possible in all sensible settings - especially in the community ambulatory setting.

What this review and the body of evidence it collects shows is that Health IT works. It is now up to those with the relevant responsibilities to learn the lessons available from this work and move forward for the good of all of us.

David

An Important Release of Information from the U.S.

Late last week the Markle Foundation released its so called "Common Framework" for Secure Health Information Sharing. This framework offers Policy approaches to the protection of private health information and Technical approaches the effective and timely sharing of relevant information.

Importantly the "Common Framework" is not a pie in the sky specification but is a demonstrated set of policies and technology which has been shown to work between 3 major sites in Boston, Indiana and California.

The importance of these demonstrations ought not be underestimated - especially as it has been achieved in a standardised conventional way and the two special pieces of software developed to enable the information sharing have been made available in open source form.

With NEHTA saying they have a three year window in which to develop the required standards for Australia it seems clear the work Markle has done needs to be carefully reviewed here. It is interesting that the approach adopted is web services based - as is being recommended by NEHTA for Australia.

It is also important to note this US initiative has avoided any need for a universal patient identifier of the sort now under development - in some form - by NEHTA.

However, it is important to recognise that care is required with the wholesale adoption of Web Services approaches - as is made clear in a recent Computerworld article entitled "Researcher: Web services security risks largely ignored".

Secure and safe sharing of clinical information is a key to safe health services delivery. I hope the work done in the U.S. can help speed up the progress in Australia.

David