Failures to deliver on simple life-saving measures relating to Health IT usually don’t get similar attention. Just the other day, I attended an Electronic Health Record conference where the question was raised by one of the key-note speakers whether the benefits of a national EHR are sufficiently substantiated to warrant the breach of confidentiality that is introduced by a new law that enforces the use of a national EHR. Actually, according to a recent study, a majority of Dutch doctors thinks it is too early for a national EHR, citing security and privacy as the biggest risks.

The volumes of research available on this issue are apparently insufficient to convince and motivate the medical professionals or the community at large. The contribution by the Washington Post cited earlier in this blog is just another example. I suppose media, health professionals and administrators rather wash their hands of Health IT …

If you are aware of truly effective means to communicate life-threatening situations caused by a lack of adequate Health IT, please share them with us and with the community at large! It may help save your life …

The article (http://www.washingtonpost.com/wp-dyn/content/article/2009/05/15/AR2009051503667.html) starts with the following text:

"When President Obama won approval for his $787 billion stimulus package in February, large sections of the 407-page bill focused on a push for new technology that would not stimulate the economy for years.
The inclusion of as much as $36.5 billion in spending to create a nationwide network of electronic health records fulfilled one of Obama's key campaign promises -- to launch the reform of America's costly health-care system.
But it was more than a political victory for the new administration. It also represented a triumph for an influential trade group whose members now stand to gain billions in taxpayer dollars.
A Washington Post review found that the trade group, the Healthcare Information and Management Systems Society [HIMSS], had worked closely with technology vendors, researchers and other allies in a sophisticated, decade-long campaign to shape public opinion and win over Washington's political machinery."

Oh my! A group looking to improve healthcare through increased use of information technology...shear scandal. Clearly HIMSS and the Obama Administration must be wrong to promote moving health into the 21st century through the use of technology and bring healthcare in par with the service expectations of the general population and the use of technology in other industries is simply beyond reason...right?

What are they thinking about?

The article is absent of any relevant research about the issues of HIT, health interoperability, and the relevant benefits. There is no mention of the fact that most every government in the world is investing in the integration of health information. There is no mention of the fact that there are numerous cases where HIT is in fact improving the quality of care and while reducing the cost of care.

Anyone who has been in the industry knows that the use of HIT has been pursued for many years. We know also that the US is one of the few countries where the majority of the primary care providers (>80%) are providing care WITHOUT systems. These physicians have no systems to handle such basics as electronically recording the care provided, alerting doctors of conflicting treatments or prescriptions, reducing prescriptions errors due to poor hand writing, or simply reducing administrative cost associated with copying/sharing medical records. Of course the Post did not bother to consider these current condition.

HIT is surrounded by a vast number of complex issues, but the Post is simply proving again that they are just out to sell papers by raising a non-issue for the sake of creating controversy...not inform the public and support a change that must happen.

Today most information is accessed from a variety of “siloed” and disparate systems. The evolution points out standards have a greater impact now and a lot of good work is being done on interoperability.

In an environment with several hospitals and primary care units etc. with the same owner, public or private, the issue of common enterprise-wide data is becoming more important. Other sectors like Finance, Telecom and Retail have already experience of this, Master Data Management.

• Enterprise-wide data and facts describing key business entities


• Prerequisite for SOA


• A way to provide consistent, comprehensive core information across an enterprise


• Is captured once, on time, accurately, completely, correctly and consistently thus enabling master data quality


• Is stored in a way that guarantees integrity and a single place of reference


• Is made available to those who need it, whenever they need it, both internally and externally.

Results could be:
Effectiveness

• better information and leads to improved decision making

Efficiency

• Reduced time required for data cleansing


• Reduced time for data alignment across applications


• Reduce analyst time preparing and delivering reports

Standardization

• Multiple hierarchies can be managed efficiently


• New projects ramp up faster


• Time for data modifications is faster

Master Data could be one of the tools of combining standardized frameworks with individual creativity. Of course doctors must be like “pilots” but in some situations the “artist” must be allowed. An small example is using custom procedure trays and kits. A surgeon can chose individual trays within a Master Data frame.

1. The solution needs to be 'meaningful' to day-to-day activites (not just in terms of of what the government wants to see before they pay out the incentives).


2. An empty EHR/EMR is not really going to be helpful so rapid loading of current patient data will be essential to delivering value.


3. If there is some automation in place, you probably ought figure out how to use that in the overall solution because rip and replace is a flawed strategy (ask some of the participants in England's national program).


4. Dropping a solution into a practice is only the beginning. Support service needs to be included.


5. Clinical decision support will improve effectiveness of the practice and will become an essential requirement for improving experience for provider and patient.


6. Workflow support will improve efficiency for the practice.

NOTE: At HIMSS, there was a common fear that the new stimulus money will bring in new IT service providers and consultants who don't really understand these issues. If you are in the market for consulting assistance on these fronts, buyer beware.

• Clinical decision support
• Healthcare processes
• Workflow
• Unnecessary errors/mistakes in healthcare
• Patient Health Record

In World of HealthCare Congress – 2005 in Les Fontaines, Paris, Per Båtelson CEO Capio Group Sweden, talked about “Doctors should be like pilots, not artists” in the context of decreasing errors/mistakes in healthcare.
We have heard about horrible errors/mistakes in healthcare at WHCC and HIMSS every year there after. This year at HIMSS we heard Dennis Quaid, CEO Quaid Foundation, talking about his, and his family, experiences in healthcare.
The work, being done and the ongoing, about clinical pathways, process models, workflow and clinical decision support clearly points out the need and stress the fact that the number of unnecessary errors/mistakes must decrease.
As a complement to this the Patient Health Record likes HealthVault, Revolution Health, Google Health etc. engage people to be active in the process and able to follow the activities made by the Caregivers. Compare to the banking industry and the evolution of the internet bank.
When do we see the curve of unnecessary errors/mistakes in healthcare decline?

Over the last few weeks I have been engaging heavily in discussions with clinicians, health IT managers and managers of healthcare provider organizations. The topic was invariably on the Electronic Health Record (EHR), beit a regional health information exchange or a local EHR system for one institution. A common theme in these discussions is the necessity to take the perspective of benefits to the individual healthcare professional, to the patient and to the health system at large. Participants often feel they need to express their requirements of an EHR system in terms of functionality, security and performance, rather than focussing on the ways in which their daily lives can be improved using such a system.

One such example comes from a colleague who has been involved with an EHR for children's health. In the Netherlands we have a group of doctors visiting schools regularly to check up on all children there. They are used to carrying heavy cases of children's health records. Now that they are being equipped with a laptop and wireless 3G internet access, they don't have to struggle with the heavy load and don't have to worry about taking the right set of records anymore. Simple, effective and quite motivating.

Such benefits are a far cry from what is being constructed in business cases for getting approval for EHR projects, but they are equally (or even more) important in the adoption process and hence for the success of the EHR project. We are starting an inventory of simple individual motivators for change using an EHR solution. I am inviting you, especially if you are a doctor or a nurse, to contribute your daily benefits and the changes the EHR system has made in your working practices.

• Subject Attributes
Associated with a subject (E.g. identifier, name, job title, role….)
• Resource Attributes
Associated with a resource (E.g. metadata elements …)
• Environment Attributes
Describes the environment or context (E.g. current date, time, classifications…)

This Swedish initiative will be the world’s largest XACML 3.0 (OASIS) deployment.
I see the beauty of policy’s and the abilities in the Service Oriented perspectives but in the daily caregiver situation could the complexity making the policies be too high and leaving doors open accessing confidential electronic patient records?

One other thought on this topic of why is the Stimulus Package for HIT a good idea: has anyone thought that maybe there are other purposes for this increased flow of computable health data? While there are obvious benefits for the pharmaceuticals, the opportunity for more complete evidence based analysis over a larger population will likely give all-seeing payers the ability to identify which treatments are yielding the best clinical results. Will that lead to a new way to influence care? Will Medicare and Medicaid continue to pay for treatments that are not as effective as those that are deemed to be the best? Is the Obama Administration that clever?

Keep watch for those unintended consequences, that’s where it will be interesting. In the mean time, don’t hesitate to propose for those grant moneys and loans when they come available in 2010…assuming the economy has turned by then.

Current practice in treating cancer patients involves local, regional and national clinical networks and both local and specialist multidisciplinary teams (MDT). When a suspicion of a fairly rare type of cancer surfaces, clinical guidelines require the GP or surgeon in question to contact both the local and the specialist MDT to discuss the diagnostic results and treatment options. This means, among others, that diagnostic images are shared with a specialized cancer center and the patient may be referred to the specialist surgeon for further diagnostics and treatment.

Upon arrival in the specialist center, I was quite surprised to see the MRI images from the regional hospital already loaded in the local PACS system and available to the specialist surgeon, especially when I saw that the spelling of the patient's last name was all screwed up. Of course, in this case, the error was easily corrected, but it made me wonder.

How come we are discussing all sorts of complicated privacy issues about sharing patient information when in practice doctors and patients know quite well when and why pertinent data needs to be shared? How come, at the same time, simple issues like common and safe patient identification have not been realized yet? Should we focus more on the basics and tackle the more complex patient privacy matters in a more restricted clinical context, like cancer care? Both political an practical experiences are more than welcome!

But are the lessons of this successful manufacturing company applicable to hospitals? The hospital is a very professional universe, which is different from a factory for several reasons:

• Duties are various and non-hierarchical


• There is often little to no shared vision between the various participants in measuring the performance of the hospital


• The activity of the hospital applies to individual products: each patient with their particular needs


• The relationship of the staff to the patient is radically different from the relation of the worker to his product


• The professions are tighter in evolving and in the distribution of duties.

Despite these differences, Lean provides a new way of thinking that can be an asset to a hospital. For example:

• Lean endeavors to make the choice of the quality criteria for the patient a factor in motivating all the staff at the hospital in the procedure for progress.


• The governance of Lean projects reflect the diversity of the responsibilities and professions in the reorganization of the processes.

In the end, we see Lean contributing value to the hospital setting along three dimensions:

1. Expectations of patients at the center of the approach for improving the hospital (e.g., getting an appointment quickly, understanding the consequences of their treatment, knowing how long they will stay in hospital, being able to choose their meals, etc.). These become incentives for changing the organization of the hospital.


2. Focus on improving the quality of the product or service by rigorously analyzing the causes for failure and checking the procedures for continuous improvement. Far from being opposed to striving for efficiency this practice to improve the quality (as perceived by the patient) results in improving the performance of the hospital.


3. An approach supported by methodological tools which can be easily appropriated within the hospital by the various professions thereby pledging to the organization a commitment to perpetuate the new practice beyond an introductory project.

This project will develop a service package which will improve access of mobile citizens to healthcare provision in other Member States, based on a secure web service and its integration into developing European eHealth networks. Its key components include:

• pertinent information for citizens in their language at the point and time of treatment abroad
• instantaneous verification of insurance status
• electronification of reimbursement procedures across Member State borders
• assurance of interoperability.

Two European projects developing IT-based services for cross-border healthcare provision, TEN4Health and NetC@rds, have agreed on a common European web service specification supporting standardised messaging to link hospitals and other health care providers with health insurance organisations and with national healthcare IT infrastructure. The common web services are specified in WSDL and messaging is XML-based.

"With this agreement we are paving the way for a European standard supporting the necessary communication and data exchange processes for cross-border healthcare in Europe" said Pascal Collotte, project officer at the European Commission DG Information Society and Media

Are we looking at a upcoming de-facto standard driven from a insurance perspective that could be used in the public insurance perspective too? What do you think?

"Having a single-payer system also means that U.K. primary care physicians hold each patient's lifelong record, which includes a letter regarding every visit to a specialist [and/or hospital]. Virtually all primary care physicians use electronic medical records, and laboratories now generally download lab results directly into family practitioners' computer systems. Again, the government took advantage of having a single-payer system to define common standards to which all suppliers of electronic medical records must adhere."

While there are a great many problems with a government sponsored health system (just read of the tragedies in the UK press), the UK primary care capabilities are compelling (note: the government contracts with GPs, they are not government employees). Specific lessons learned for the US consideration include:

• Expanding the primary care workforce by utilizing care workers with training appropriate for the care service to be delivered


• Placing standardized EMR capabilities in the care setting where 80% of care is delivered;


• Standardizing transactions for exchanging electronic health information between GP EMR systems;


• Like the US, the UK has highly variable implementation of EMR capabilities in the hospital setting, but is addressing with their National Programme for IT (NPfIT).

• NHIN would draw on a larger repository of health information;


• Better information for outcome driven performance management & reimbursement;


• New generation of care workers who would be prepared for delivering care based on electronic health information (e.g., telemonitoring).

all talked about the important EC/EU actions taken and the roadmap ahead but
thinking of the EPSOS project and the importance of succeeding I find it a bit curious no one talks about the identity issues and the current problems around it.
Citizens must be able to have a lifetime identity including health records and be able to for example change nationality without loosing healthcare records etc.
The identity management is also an important bit in the puzzle to protect Medical Identity Theft and enable the Personal Health Records.
Do you see anything out there addressing this kind of issues?

There are numerous analogies to learn from. In the financial world, individual investors have had access to mutual fund rating models from organizations like Morningstar. In the food industry, nutrition labels, in their various forms around the world, have proven to be popular with individuals who are interested in knowing more about the health of the food they purchase.

What if such a label was available to individuals using PHRs and other health information portal services?

In the US, at the National Health Information Network demonstration project conference hosted by the Department of Health and Human Services, outgoing Secretary Mike Leavitt announced his idea for a comparable consumer information label for PHRs. HHS has made the related research available to the industry and for consumers of PHRs: http://www.os.dhhs.gov/healthit/privacy/notice.html

At this site you will find a draft blank model notice template and a draft completed model notice of a fictional health company offering a PHR.

What do you think of Secretary Leavitt's idea? Will the sample model work for you?

Do you have other ideas for helping individuals deal with the challenge of selecting trusted health information services?

Will this be sufficient as we see social services and health service become more aligned within the government sponsored entitlement programs?