Publication Date 01/06/2011         Volume. 3 No. 5   
Information to Pharmacists


From the desk of the editor

Well here we are in June, nearly the end of the financial year and the paperwork toil that comes with it.
Accompanied by some cold weather that I am finding it difficult to take.
This month we present with a range of very interesting articles, and what follows is a brief summary.

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Here we are! And the money goes to….?

Pat Gallagher

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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.

The Australian health informatics or e-health development situation is perhaps now at a point of soaring to a bright new world, or not.
Depending on how well ‘we’ spend, between now and June 2012, the $400 million allocated to the Wave 1 and Wave 2 PCEHR development and demonstration sites now under way.
If you are not across what Wave 1 and Wave 2 refer to - then please contact the saintly editor and we will point you to the information.
If you are not across PCEHR then you may as well stop reading now
In this context I was somewhat rocked by a report that came out of the UK on 18 May 2011.
It is a UK Government Audit Report
toThe National Programme for IT in the NHS; an update on the delivery of detailed care records system (click on link).

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This succinct 15 page report finds that ‘BP billions’ have been spent on a prestigious NHS project to convert paper based patient records to e-health platforms, and in short the attempt is failing.

The UK project managers, implementers and vendors have under delivered. Worse, the vendors are now asking for more money to deliver what they have failed to yet achieve.

The punch line is on page 13, in a paragraph titled:

Conclusion on value for money” – which says in part …

On this basis we conclude that the BP2.7 billion (say $A5 billion) spent on care records systems so far does not represent value for money, and we do not find grounds for confidence that the remaining planned spend of BP4.3 (about $8 billion) will be different”

Sends a shiver down the spine.

A sum of $5 billion is a lot of money to spend for what seems to be precious little benefit as a return on investment. It should remind us all that whenever any large project is proposed and before implementation starts, one of the many KPIs a project management team has to monitor and manage is to ‘follow the money”

That is - where is the money being spent and is the money being spent, as planned. In the UK case it was to save data capture, administration and data sharing time and effort of clinical care delivery to be recorded on patient records. So as to presumably change work practices gradually to the meet the many short, middle and long term goals of e-health platforms.

It was up to the UK project managers to keep asking what is it they were trying to do for the money. An overly simple prescription for effective change could be said to be – ‘remove the cost and improve the usefulness in the exchange of paper based information’.

And also, by removing the paper achieve process and practice time savings for care givers, reduce errors and attendant costs, in achieving care delivery improvements for patients.

Or in other words make it easier, faster, better, safer and useful for those working at the coal face as well as the receivers of care.

Clearly this is not yet the case in the UK. Therefore the lesson is stark and we should not ignore the warning that it could happen here as well. God knows we have had enough examples over the past decade in Australia to ram home the lessons-to-be learnt message.

Perhaps not, perhaps we might still blow it away and be asked to spend more money for the insult of suffering someone’s failure later in 2012.

What is the core warning?

My take is that everyone in the UK T1 and T2 loop, those who spent the money and those who received the money, are perfectly content with the state of affairs.

Meanwhile the people working where the money was needed to be spent are still under serviced and under supported. Ergo, only now by way of this follow-the-money post audit, from womb to tomb, does the result emerge - which is not a pretty picture.

First, foremost and simply the underlining goal of ‘e-health’ is to remove paper based transactions from as much of healthcare delivery and associated activities as possible; and do it when and where it is possible, affordably and usefully for all concerned.

To electronically reticulate this common information so that it can be shared up and down, across and throughout the three tiers of the health community: T1 - governance and policy (funding); T2 - ICT service providers and facilitators; and T3 - the coal face participants and taxpayers.

Once the project (s) start, the importance of the tiers of influence should be reversed in project management terms - so that those at the coal face become the main focus of attention.

The people who do the work will only accept and undertake change if it makes their world a better world. I said above that I suspect that every T1 and T2 player in the UK, who spent the money and got the money, thought they were doing a great job. In fact I would bet that they believed they had Plans, Specifications and ‘Standards’ that were world’s best and ‘perfect’ in being fit for purpose, theoretically.

However as we learn over and over again, in the real world, trying for theoretical perfection usually becomes the enemy of doing well. Thereby wasting money and frustrating the very people who should enjoy the fruits of the investment.

The associated factor here in Australia at present is wide spread ignorance.

Very few people employed in healthcare (Australia’s largest employer) understand the PCEHR issues as well as the relatively few insiders in T1 and T2 health informatics circles.

If you, as an informed or otherwise pharmacist, have any doubt about this matter please try it out for yourself and ask any GP, nurse, or Aged Care operator of your acquaintance, what they know of PCEHR.

The public are even more disconnected.

The public, as patients and taxpayers, do truly understand the burden of the huge cost in healthcare; yet have a contradictory view of what is good and bad. They believe that, in spite of all obstacles, on a whole we receive good care. The public are also certain that there is never enough money and what there is, is often, poorly used.

With this well established cynicism in place the need to ‘follow the money’ and not stuff up should be mission critical.

Keeping a few thousand insiders in a state of self appointed bliss will come to a sad end if the hundreds of thousands of coal face stakeholders and millions of patients and taxpayers see or even sense failure, like that in the UK.

There is at this time no informed mass demand for any e-health based change in Australia.

Therefore the first rule must be to keep the message simple and believable to sell a message that the eventual benefit is worth the national effort and the $400 million.

So far the PCEHR story is very much a blank page to the mass of any intended mass audience. This alone could hinder the ROI where money is spent on change and technologies, to and for people, who have no idea what is in store for them.

Any attempt to make big bang change, largely in the dark, will not work; it is the surest way to fail. So let’s hope that some of the $400 million is spent wisely on awareness and communication efforts to the T3 community.

In Australian healthcare interest groups we also have the tendency to purposefully design a perception of unique complexity into national projects. To always do this from the top down and often ignore the more tedious, boring and practical, small one at a time steps of a bottom up methodology. It is a cultural error. One that non-healthcare sectors inevitably do not do when making change happen effectively.

A thousand simple steps is a shorter journey than attempting huge implementation projects like that underway in the UK. This UK audit report illustrates that the big bang spending mindset delivers inglorious stuff ups which lead to a poor ROI outcome for the taxpayer.

Spending taxpayer’s money in this way is like giving alcohol to alcoholics, free reign on fees to bankers, speed cameras to public servants or unrestricted access to terrible web sites for pedophiles. Enough is never enough until the fan hits the doodo.

What is it we plan to do with the $400 million PCEHR investment between now and mid 2012 (let alone talking about the funding needed after 2012)?

Which pieces of paper will be removed as the catalyst for introducing a PCEHR hub as a national asset? One bit of paper or hundreds. One at a time, many at once or very few. Or, how many points of data capture are there where people obtain, store, retrieve and use shared information on paper that will need to be ‘changed’?

E-Prescriptions would be a radical place to start (I’m not kidding) as this touches more of the public, more often, than any other application – and is core patient record paperwork. But then so too are discharge summaries, referrals, tests, claims, payments and even the supply of what has been consumed, by and for, a patient.

Aside from an apology for a heavy pun, the best roll-out method for W1 and W2 will be to introduce change from the bottom up as viral phenomena. Get it started, get out of the way and then let harmonized evolution gain a natural momentum.

That said another factor that is still in play, takes me back to the analogy once used by a UK health sector writer: Comparing the huge infrastructure project in the 19thcentury to put sewer pipes under the streets of London and why that was relevant in a data sharing context.

I wrote a follow-up piece at the time for this newsletter (“The iffy smell of progress) that supported this example of sewer pipes and the information available in healthcare, with a dangerous lack of universal quality, to be pumped at the speed of light.

Message 1 being if the pipes and plumbing are a spaghetti mess of non-interoperable data networks, or databases and systems, then trouble awaits.

Message 2 is worse than interoperability. Unless the sources of core data are accurate and useful we risk spending money to merely pump crap. Or, to punch the point home, using the UK example, we must avoid spending a lot of money just to end up with a stinking mess.

Subtle? No, but eminently relevant

At the time I was saying, as was the original author of the ‘sewer’ opinion piece, we should leave the clinicians alone until the pipes, plumbing, standards and data sources (sewers of content) are cleaned up and are in place. Otherwise we are just interrupting their good work for no immediate purpose.

Today the question still remains: are the information sewers in our hospitals and wider healthcare community in good shape, or, even fit for purpose at all?

If not we will soon know as W1 and W2 sites and their taxpayer funded activities start to pump, exchange and re-use the existing content data.

Content data, let us not forget, starts with a clinical service person capturing data at the coal face. Regardless of how clean and accurate this data is, if the proposed changes do not save time, money and errors in the overall ambience of the data capture experience, then good data or not the project goals are very iffy indeed.

Who has been here before us?

Many pundits believe, as I do, that T1 and T2 health stakeholders rarely look for lessons-learnt of what works somewhere else. Think banking and insurance in terms of their technologies and procedural standards.

At no time did the broad financial sector introduce electronic transactions for online access and associated digital record keeping, along with personal identify protection, by selling the cleverness and complexity of the deep background technologies.

They just introduced simple changes at the point of interaction progressively and let mass demand gradually accept and then improve the value change proposition.

Simple steps tend to cost less in the long run. More importantly simple steps allow the people who are affected by significant change to stay in synch with the new world. No matter how much money is allocated it will fritter away and grow into black holes, unless people see and accept that the advertised benefits will be real and useful.

Finally a plug.

Let us do something very radical with the money go-round. Let us spend more than we ever have before on the local, usually smaller, IT and solution vendors.

The Australian ICT and health informatics vendors.

The vendors who have evolved and built products that work in Australia, for Australians. I suspect that the UK has blown a lot of dough converting very large systems that worked well in a vendor’s home country, to fit in with the Britishness of the NHS work practice model.

Let us get over this mindset we have that believes ‘big’ and foreign is always best. Where big and foreign inevitably translates to expensive.

More often than not the local solution is preferred by coalface practioners who sadly do not make the funding decisions and rarely get to say what they would prefer to use. If they were able to do so a whole level of costly change management hurt is removed in one simple stroke.

Our ‘big is safe’ cringe is something to behold when you think it through and look at the result of the spending and value evidence to date. If we follow the money spent since the announcement of ‘HealthConnect’, over the last decade, it shows much the same UK outcome, albeit at a slower, fragmented and in a more hidden manner.

Here we are and what should we do?

Wherever we are now, the question is where will be in June 2012 and beyond?

Maybe we could short circuit any risk of a penny dreadful result and engage the Auditor General now. Upfront, from the get-go, to be part of the ongoing T1 and T2 diligence effort.

In that way we will avoid any chance of it all ending badly – ending as badly as the UK model clearly shows could happen if someone does not - ‘follow the money’.


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