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Welcome to the May 2012 homepage edition of i2P-Information to Pharmacists. Rollo Manning has been having some time out having staples removed from the site of his open heart surgery.He is now at home recuperating in Darwin, having arrived home last Friday, beating a cold and hasty retreat from Canberra.We all wish him a speedy recovery and hopefully, he will be fit enough to contribute by next month.
This month, Pharmedia discusses the toll that is taken when someone complains about you to an authority without good cause. Well, the good news is that you can now take action to protect yourself if such a complaint is made, and that may even include action for defamation. Read about a recent case involving two doctors, with Mark Coleman drawing on personal experience to illustrate.

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Advancing to garbage at the speed of light

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Pat Gallagher articles by this author...

Patrick Gallagher is well known in Information Technology circles. He has a vital interest in e-health, particularly in the area of shared records and e-prescriptions, also supply chain issues. He maintains a very clear vision of what ought to be, but he and many others in the IT field, are frustrated by government agencies full of experts who have never actually worked in a professional health setting. So we see ongoing wastage, astronomical spends and "top down" systems that are never going to work. Patrick needs to be listened to.

I am going to preach to you dear reader.
So what is new with that you will say?
Plenty, because I truly do believe in this creed, which is the belief that without rigorous control of core data integrity the whole e-health plot is flawed.
This boring subject has been raised in these pages several times and there is no doubt the message has sort of got through, but ‘sort of’ is way, way too far from being acceptable. You see this mishmash problem in the pharmacy daily as you use different PDE numbers for the same product when you buy from more than one wholesaler.
You cope with different proprietary product identification and then use the GS1 barcode, on the product pack, to close the sale at the POS (you do, you do use that barcode don’t you!).
All of this means you have to use the wetware technology tool to interpret and map information from one system to another; and the minute you introduce wetware you introduce errors.

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As I have said here before, using more than one single, unique product identifier defeats the upside of the technology’s ability to automatically reticulate common, error free transactions. All the hardware, middleware, software and broadbandware come to grief holistically when wetware gets involved.

You do understand this?

No - well, wetware is a euphemism for people – you, your staff, catalogue managers, anyone who is going to enter or use multiple systems (interoperability) and multiple identifications to manually exchange information about the same things. Wetware basically dilutes the value of the technology mix enormously.

The two technologies that combine to deliver a level of garbage data are wetware and paper – put them together and errors are assured.

The elementary discipline of a data alignment and integrity practice 101 is to ensure one accurate identification number for any one data item is the rule that rules the world of automatic data exchange.

Yet, there is always a yet, and that normally comes before the but, in Australia we still do not have a single source of product data electronically feeding and linking the working catalogues and data files. Files that today are being used by prescribers, dispensers, suppliers and hospitals to exchange common product data electronically. All based on the belief that it will all be without risk.

This is not referring to a financial risk; this is referring to a clinical risk. As in unintentionally substituting 50mg for 0.5 mg, because that is what the ‘computer’ said ‘to do’. The descriptor that best fits this linking of clinical and product data is: “every clinical decision is a procurement decision”

Is there truly a risk that we can introduce harm faster and more ‘efficiently’?

Surely not?

Sorry, the answer is - yes we can and yes we will

Driving to work this week I caught a garbled snatch on the radio along the lines of: “electronic prescriptions threaten safety due to an increase in errors” (sic).

C’mon! How crazy is that?
The act of replacing handwritten scripts with clearly printed forms must be a huge improvement.

And, of course that is certainly, to a degree, the case.

When a script is printed it is easier to read, as the ink on *paper is clearly readable. The question is all about how reliable is the information and how much work is required to routinely interpret that description, on the paper form, and ‘get it right’ for the patient.

(* Paper! Of course the whole e-health framework is based on saying bye-bye to paper in all its inefficient, time consuming, error inducing and costly, pun intended, printed forms. Easy to say, very hard to do and a subject too big to digress with here today)

Imagine this scenario if (and when) the process is totally electronic.

That is, all data is exchanged by machine-to-machine transactions whereby, over time, the inclination is to rely more on the middleware than the wetware and then discover that mistakes occurred due to the source of the data being less that 100% accurate.

The prescriber used a faulty file and the dispenser’s file didn’t mismatch and the process was concluded, in error.

It can, will and does happen.

This was all researched exhaustively in 2001/2002 by a committee of over thirty stakeholders and the report urging total compliance for the Australian e-health industry of a single data repository, was tabled to the then Health Minister.

Yet, here we are in mid-2009 and (and no buts) it still has not been put in place.
It is useful to have a snapshot of what this model is designed to look like without soaring to nosebleed country of complex mind maps and PowerPoint jargon.

 1. First we should have the small core repository or database with only static identification data in it:

• Only the manufacturer or supplier (as is the TGA requirement) can add, delete or alter any product data centrally;

• Because they own the identification (GS1/GTIN barcode) data and as such must take responsibility for its accuracy - ‘relying’ on second hand or third parties to do this work will introduce errors;

• Even worse, introducing proprietary numbers, not used by the manufacturer or supplier, as a high order ‘number plate’ to link to product information, is sacrilegious;

• Like we do for the TGA, and to limit the workload and maintain enthusiasm and cooperation, the data fields for this central repository should be the minimum required to ensure total, risk free, accuracy of the information, to be electronically shared between users;

• In Europe and the USA, in respecting this barrier of potential and real non-cooperation, the rule is that a supplier can start to become compliant by entering a mere seven (7) fields – the maximum being forty (40) fields of commonly required information;

• The obvious benefit to a manufacturer/supplier is that they are only doing this information task once for thousands to share, and not a thousand times for one user to be reached; and

• This asset would be administered and operated, in terms of QA and service delivery , by an accredited agency who would triple check the data before releasing it to ‘working’ catalogues

2. What is a working catalogue?
It is the business level where different disciplines and professions use the core data seamlessly and then add the dynamic fields of data they require (and by definition) are not required by other users.
One such group is the clinical users:

• Prescribing software vendors and their clients;

• Dispensing software vendors and their clients;

• Hospital clinical software vendors and their clients;

• Clinical service software vendors and their clients; and

• Clinical date exchange hubs and gateways

Whereby these accredited users then add their ten (10), twenty (20), thirty (30), or whatever, fields of data that only they use and need for their catalogue

3 And then we have the supply chain community as a second group of catalogue users:

• Pharmacy, hospital and other health sector procurement and other buying entities;

• Wholesalers - that by association will feed into your computer inventory files that, ergo, will be identical to your dispensing files that came from the clinical group;

• Please think carefully about the future consequences of having or not having your POS and Dispensing system aligned; and

• Transport, logistics and other support service providers

These wholesale enablers and other users would add their ten (10), twenty (20), thirty (30) odd fields of supply and packaging data; such as: a) packs in a carton; b) cartons an a pallet, c) weight and dimension; d) pricing and all that good stuff for the guys in supply that no clinician ever wants to see, needs to see or should see.

4. And then there would be and are ‘other’ types of combined users, like accounts, record keepers, researchers and academics - which we will call group 3.
And they too can happily add their unique data field requirements that the supply tribe do not need nor do the group 1 clinical people as a general rule.

Summary: this model will suit all users, who are disparate in their own requirements, but share a common need for the same core, static data. In doing so they will never make a mistake with the core data and thereby never endanger any patient due to human induced of otherwise undetected, errors

If a price is wrong, or a weight is wrong, or a delivery instruction is wrong, then the cost is financial or inconvenient; but the error will not kill or harm anyone

Secondly, the other big point is they should only receive, store and use the minimum data set required to do their job. Only store and pay for transacting ‘X megabytes’ of data and not the unnecessary total set of ‘Y megabytes of data.
So compellingly, so sensible, logical and usable that even an Einstein could understand and accept it.

To the background tune of ‘Advance Australia Fair” let us review what has happened, more or less, in the lucky country since 2002.

We have the NPC (National Product Catalogue) and the NBN (National Broadband Network). Yippee?

Nope – neither is in place.

The latter is not that critical because most of us have reasonable access to reasonable broadband; so the people most likely to benefit from the rainmaking, of such a huge investment, is the ICT sector. While they might be panting in lustful anticipation, I for one am a sceptic.

I do not believe the NBN financial numbers will pan out so that investors will get a return on their money; of course if the comrades decide that we the taxpayer noddys will pay, then we will see the NBN roll on to a MFP (Multi Function Polis) result.
If you don’t compute the MFP thing, just think of a black, failed, wet dream.

I think we can forget about advancing society of ‘girt by broadband’ being in place anytime soon. For example, last weekend the press reported that the Tasmanian effort seems likely to deliver a whimpish 22% take up at $20,000 per household. Gee, isn’t that just grand. I think I will put my dough into pork belly futures.

What about the NPC?

Deep, mournful sigh and silent gnashing of teeth.

I said above - ‘sort of’. The powers to be, or not to be, or not yet seen to be, as whatever is the case, took the concept mentioned above and decided to improve it (I am being unusually polite).

How can they improve it? Well make it uncomplicated. Dissolve the four tier model, briefly outlined above, and just have one gigantic, one-size-fits-all edifice to out-do any comparable effort anywhere in the entire world. Advance Australia – where?

Breathtaking isn’t it?
I can’t help but say we’ll be ‘girt by data’ and loving it all, I’m sure (not).

In advancing Australia’s e-health capability this means that the manufacturers/suppliers will be asked (I do agree with the ’M’ word by the way) to mandatorily enter not seven (7), not forty (40), not one hundred (100) but one hundred and fifty plus (150+) fields of data. Can you imagine the thousands of SME suppliers going - whoopee, where do I start?

Sure, the cynics out there will say that there are only 500 real important suppliers and they have the staff to manage the work load. Perhaps, and then perhaps not.

That isn’t the point.
This is healthcare.
Near enough is not good enough.
All the metaphors about ‘for the want of nail’ or the ‘weakest link’ are more than true in this context. Any gap, any error, any omission will potentially do harm, faster than we now do harm.

And then we have you the pharmacist – you the data user.
You as a buyer of products and you as a dispenser of product.
Girt by data indeed.
You will be swimming in data – 150+ bloody fields of useful and useless data.
Makes you wonder whether this brilliance came out of a gaggle of undergraduate MBAs trying to impress the Professor after happy hour.

What is certain is that the authors of this concept have not worked in all of the various and separate communities they are attempting to service with this one big bang bubble.

And, to date that is what it is – a bubble. A handful of suppliers, a few thousand products and no clinical users.
What clinical users?

Well, there are now three if not more e-script hubs up and running.
Where and how is the common data being aligned, synchronized and otherwise safely presented to a prescriber and dispenser - huh?

We can now send a script from point A to point B at warp speed. The question is - is sending data at the speed of light the benefit we are looking for, or is it merely the carrier component? Rhetorical question and you are welcome to answer it.

What if, one-in-one thousand, or one-in-a-million even, has wrong data?
Who are you going to blame?
Girt is a silly word, garbage is a nasty word, but they seem made for each other.

The lucky country is advancing fairly amateurishly to a collective oh, oh moment of - ‘how did we girt into this nasty mess’

Seeya

PS

Can’t help myself - again. In the movie ‘Kenny’ there is a wonderful gag about ‘Advance Australia Fair’. He confesses that at school he always thought the line was;

"Let us meet Joyce"

rather than

"Let us rejoice"

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