Editorial

From the desk of the editor

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.

read more
open full screen

Columns

Recent Comments

Click here to read...

Past Editions

Volume 1 Number 1
Volume 1 Number 2
Volume 1 Number 3
Volume 1 Number 4
Volume 1 Number 5
Volume 1 Number 6
Volume 1 Number 7
Volume 2 Number 1
Volume 2 Number 2
Volume 2 Number 3
Volume 2 Number 4
Volume 2 Number 5
Volume 2 Number 6
Volume 2 Number 7
Volume 2 Number 8
Volume 2 Number 9
Volume 2 Number 10
Volume 2 Number 11
Volume 3 Number 1
Volume 3 Number 2
Volume 3 Number 3
Volume 3 Number 4
Volume 3 Number 5
Volume 3 Number 6
Volume 3 Number 7
Volume 3 Number 8
Volume 3 Number 9
Volume 3 Number 10
Volume 3 Number 11
Volume 4 Number 1
Volume 4 Number 2
Volume 4 Number 3
Volume 4 Number 4

i2P Archives

EPublications

Click here for a list of epublications

Username: *

Password: *

• Request new password

Man bites dog – mongrel rules needed

• Printer-friendly version
• Send to friend
• PDF version
• Share

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.

Here I am.
Back from another lengthy and self enforced break and reporting in i2P on things and matters with ICT in pharmacy-land and health generally.
It is not that I am lazy.
It is that there hasn’t been much ‘news’ happening worth getting our knickers in a knot.
It is all the same old; same old in e-health playing field and that is rather uninspiring to say the least. So I have taken the view that if there is nothing positive to say it’s best to stay stum.
But now as 2011 is coming to a rattling death perhaps there are some things worth saying, usefully or otherwise.
What is a snapshot of some of the year’s achievements in the e-health community?
Hard to say that the world is on fire with overwhelming success, but a summary of the activities that might interest the i2P reader, in some order of oomph are:

open this article full screen

* The Wave 1 PCEHR demonstration or development sites were created;

* The Wave 2 PCEHR demonstration or development  sites were created;

* The $400 million Health Identifier Service is in play;

* The PCEHR project is on everyone’s lips;

* The NPC (you should know the acronym) is being created;

* The ETP (ditto this acronym) specification is nearly ready for peer review by the standards community and consisted of six separate documents totaling  over 1000 pages;

* We still have work to do in secure messaging; and

* Nothing has actually worked (half empty), or failed (half full) to proceed, yet

Having more than my share of self nurtured cynicism it is rather easy to be a pot-shooter at the way ‘we’ are going about implementing e-health in Australia. I would prefer though to use cannon and say that we have spent over a $1billion and there isn’t much to see in terms of real world change.

It is over ten years since the National E-Health Summit was held. Over five years since NEHTA came into being. During the past three years we have had several hard hitting and very detailed reports with oodles of sensible recommendations and yet, as we approach 2012, we still have a very large inverted pyramid, teetering on a very narrow point of balance at the workplace level.

The upside base of that $1 billion pyramid is wide and deep with top down activity, with little coal face demonstrable change.

That is not to say that there aren’t islands of commercial success. Independent sites were the vendors and users have just got on and made things better, without any big brother involvement, because it makes business sense to do so.

To get a reasonable snapshot of this overall situation take a look at the NeHTA website and read the latest Annual Report published just this month. Without wishing to influence your take-away after reading the document I will say that it reads, still, like a prospectus. Flashy, eye catching, promising a lot with lots of fine print; but is there a scorecard to indicate actual change? Nope.

Let’s take a look at the landscape.

The most promising activity we have today, that involves process and practice change, is the Wave site concept. As with all my contributions I will keep it brief and expect you to ask if you do not know what (a Wave site) is.  Fingers crossed they deliver. Because they are closer to impacting on the real world than anything that has happened over the last ten years.

During my data capture business career, introducing technology-based change management outcomes, there were two words we never used to describe a new project that was (say) replacing order books with bar-coded data capture.

One was ‘pilot’ and the other ‘trial’.

That was because it was never the technology that was in question; the technology mostly proved itself to be ‘better’ – it was the people factor. Where people had to accept and embrace a work practice change. If the project was introduced as a pilot or as trial there was an instant reaction of –

“Oh well, it isn’t really going to happen, so why bother”.

Apathy and/or fear are always a powerful and constant barrier to success. 

The Wave sites, thank goodness, have been implementated as ‘demonstration’ sites’. Thereby giving a platform to road test and gradually define change and its inevitable tweaking as an ongoing shared experience between implementers and users. 

So we can give higher scoring points for the Wave sites than is usually the case and hopefully they might just deliver valuable and harmonized benefits.

It must also be said that a welcome and rare benefit is that some of the local SME vendors got a Wave site guernsey. This is not the norm. So for a really good change these vendor battlers got a (small) seat at the funding trough, err table, or dare I say gravy train.

Identifiers! I said above ‘in play’ and that’s pretty much the case. As we are all too aware technology and ‘machines’ need unique identifiers to process data. In health, as in most situations, that includes the who, the where, the what and the *why.

We need to identify people; both patients as well as service deliverers and care givers. Your pharmacy, a surgery or a hospital has to be known for electronic transactions and processing. That the transaction is a prescription or a discharge summary needs to be known and finally why a service is being delivered, which comes down to how is the claim going to be *paid and by whom.

Older readers will remember the ‘Australia card’ hullabaloo. All readers understand the MediCare numbering system. But how many Australians realize that we now all have been issued with an IHI; an Individual Health Identifier? Well we have and yet few of the hoi polloi have the faintest idea what this means. 

This problem clearly is that, outside the Wave sites, us Prols do not know that the new individual personal number will ‘soon’ replace the existing, generally family structured, Medicare number system. And this IHI will be used for all healthcare services and importantly, the subsequent health records.

It should be a concern that this planned ‘rollout’ is still much of an insider’s wet dream. Until we can all be electronically identified not much can happen – for good or for naught – and until we all have an IHI in play we are not yet on the starting blocks, at best.

Which leads to the PCEHR?

When I think of a PCEHR, in terms of my experience and prejudices, I hear an old joke. Whereby a certain community of a flavour of Christianity believes that sex is bad, because it might lead to dancing.

Perhaps this PCEHR, as we know it, offers a similar reverse analogy – dancing to this music may lead to an unintentional bad end

The first thing to know is that the ‘plan’ calls for the IHI to start becoming a real rollout event by 1 July, 2012. A little over six months away. As we are over 21 million people and counting, the scenario of all having an IHI ‘in time’ seems very remote. Before you ask, is ‘in time’ by 2013 or 2015? I don’t know.

Moreover the funding stops at the end of June 2012 and what happens next is not public knowledge. 

The thing to focus on here is the E, the H and the R words (I’ll come to the P and the C, below).

Electronic (E) processing mandatorily requires a machine to machine identification number; no number, no transaction. And, this needs to be the high end identifier on each and every transaction.

Then we have what was delivered (H). Who got the script, what were the test results, who was discharged, who is being referred and of course who just died.

Lastly we have the ongoing history and list of (R) events. Not much is usefully available for listing without an IHI to tie it to.

Of course, somewhat similar to the pilot/trail failure phenomena above, those who don’t like (whatever) is happening can use the IHI as a powerful weapon to prevent or to slow down change. The words they use are of course ‘security’, ‘privacy’ and not forgetting variations of the big bad bogie man.

To get around this formidable obstacle, the governors, the committees, the leaders, the directors or whoever is calling the shots, decided to introduce P and C as a high order identifying solution to allay all fears and robust hand braking.

What isn’t clear is the fear of failure stronger than the fear of success?

Perhaps there is too much twee going on. Someone, somewhere, needs to get a dose of mongrel into the process or we might all drown in work-around plots and pussy-footing.

It is just too easy to replace Personal with Political and Controlled with Correct to explain what has happened. It does, and it does explain regardless whether you are a cynic like me or not. It is easy to see that the loading of the P and the C soothers in front of EHR is just a lot of lead in the saddle bags of any simply effective and understandable (by said Prols) EHR development.

A reasonable person can swap ‘lead in the saddle bags’ for ‘complex’ if that is the polite way to explain the problem.

Essentially here is the simple rub. The patient entity has an opt-in, or opt-out option and that simply means you, me, him and her are in charge. We, not an authority of any kind, will decide whether there will be a (PC) EHR at all and whether the PCEHR will be complete. The immediate effect is to dilute and devalue the vital intention of delivering the benefits of e-health. If it isn’t complete, well, it isn’t complete enough to be used reliably.

To oil the wheels and accomplish this PC safety net there are rules and methods that I struggle to understand (and I attended two days of conferencing the issues); to assume that all levels of Australian society will understand, let alone embrace, a (PC) EHR is very questionable. But dear reader that isn’t the real problem.

The real problem is that beside the less contentious right to opt-in or opt-out, is the right to ‘control’ the system. The patient has the right to allow or disallow the recording of any or all personal medical activity. In simple terms; allow the recording of the script for Diabex but delete the record of any prescription for Viagra, as an example.

This subject matter is worthy of a lengthy article on its own but as this is a brief overview let me close on why this PCEHR barrier won’t go away.

Just as you would not (well would you?) allow a patient to decide what is, or isn’t recorded on their medication record within your dispensary system (think about it), the anecdotal view of the average GPs take on the patient control factor is a strong forgetaboutit. As they author prescriptions it is a very serious factor.

That the records will  be incomplete, for various reasons, is the #1 issue for GPs. Issue #2 then leads, reasonably in my view, that any diagnosis that cannot rely on the veracity and completeness of the patient’s record is ‘dangerous’. Not just in the obvious clinical meaning of dangerous but also the medico-legal meaning of dangerous.

So much then for any likely wins for anyone much in this space. As no one has asked me or many others for advice I will refrain from boring you with where the answer lies.  (Just think – keep it simple, deliver user benefits and work from the bottom up, one step at a time).

One place to look, and not to put the boot in any harder than necessary, is the UK. If you have been in any way across the e-heath ‘news’ you will know the UK has just dumped, after many years and $billions, their similar EHR plans. We can only hope our governors with this PCEHR responsibility have spent a lot of time in the UK benchmarking what happened there, with what is planned, to happen here.

What fun. Not.

Like an IHI regime being in place, the total e-health journey, from supply to consumption, to records (your medication records and into other EHR platforms) requires there is one, single, reliable, harmonized and available PRODUCT identifier, or any EHR is going to be flawed.

Way back in 2002 this was addressed by the Medicine Coding Council of Australia. Today it’s the MCCA presence has morphed into the NPC (oh, all right – the National Product Catalouge).

Unfortunately this is not the only product source data catalogue in use. Moreover the NPC is not in use for the EHR application – just the supply chain function. And therefore this is a huge flaw in the plan to rollout a PCEHR starting in July 2012.

Put simply it is a lengthy subject to understand properly, in the meantime we should remember this clue:

“every clinical decision is a procurement decision’’.

Meaning the decision to prescribe, is the decision to then use and trigger the ordering and resupply of a product. Because we are transacting in an ‘E’ world, and not with human interpretive and translated data, we must have one, single identifier, from womb to tomb, that does not require re-keying. And for efficiency sake the number should be barcode readable

What do we have?

Most of the dispensary systems use proprietary databases maintained by the system vendors. Nothing wrong with that. Then there is the use of the PBS codes where applicable and mandatory. Fully understandable as well.

These numbers are not machine-readable; nor aligned or electronically useful for an EHR. The proprietary numbers are not uniquely suitable for a cross-referenced EHR, and the PBS number isn’t usable for non-PBS items.

Then we have the AMT (Australian Medical Terminology) which has been developed for clinical purposes; it fails to automatically link the three elements in the data reticulation chain – supply, clinical and records – because it won’t be used in supply functions, nor is machine readable, the AMT will therefore need to be mapped or re-worked in some manner. It has a place but is not the practical answer.

Adding to this are the two (of many) Australian databases that can help solve the problem. One is the NPC. The other is the TGA. Neither is perfect. One has to be perfect for e-health and for PCEHR to deliver timely, accurate and usefully reliable, product related patient records.

The sooner we merge or deliver a perfect version of one catalouge the sooner the EHR records can be reliably and usefully populated.

Oh and what number should be used? Long standing readers will know I have covered this matter many times in i2P to the point of becoming a caricature of a nagger.

There are many on offer. The three that matter as I said above are: a) PBS; b) AMT; and c) GS1 (GTIN). Only one says ‘yes’ more often and that is the GTIN.

A compelling reason is that the GTIN is the responsibility of the source manufacturer/supplier to maintain (no third party) and is the only number that is barcode printed on the packaging. Happy to discuss. Because otherwise mapping is needed and that means re-working source data and that means errors.

Above I also added in the bullet of - ‘secure messaging’.

As obvious as this is dear friend we are not necessarily on the same technology page with the rest of the ICT world. It is very true that if we can’t rely on data, identifying us as patients and what clinical events have befallen us, all being used in a secure and private manner, then good night nurse. No need to keep on dancing, is there?

Here is the rub. One of  the perennial faults of the health community is the mantra that as health is especially complex (sic) and precious (sic) there needs to be clean sheet and we need to reinvent and ignore the developments from elsewhere in the ICT world. This, with the exception of HL7 and similar standards that are fit for purpose, is more or less rubbish. There needs to be more learn-and-use and less - ‘we know better’ - when it comes to technology that crosses IM ‘borders’.

This island mindset says that the ATO, the banks, the insurance and financial industries and may I say Defence, have not developed suitable methodologies to protect data content over the web so that the transaction is vulnerable to misadventure.

A case in point is a PKI; a digital signature. Surely we can surf off the rest of the web-based world here?  But no, we are designing a (well two actually) separate health only version (s) for what is a globally standard tool – the mongrel in me asks - why this is so?

An oldie to remember in this context is this statement:

“The past is a rehearsal for the future’;

All the necessary web security tools exist. We merely have to put them in place, with perhaps some modification for the nuances in the health community.

But no siree, we have organizations writing new specifications, organisations setting new standards and others inventing rules and regulations that are not seamlessly interoperable to all other platforms of secure, private and sensitive ICT/web based exchange systems. Give me strength. GGRRRRR!

Let me repeat, it will be better for all if we merely modified what the world is already using, rather than add time, complexity, cost and interoperability barriers to a practical outcome. Meanwhile be in no doubt that there are many participants that will argue this point of view until the cows come home. And in a world where health is a separate planet, where time and money have no restrictions, they might have a case.

But after working for ten years these folk have not yet delivered the fundamentals of internet security, for health transactions. While other industry sectors have long ago made ‘it’ work. Says heaps about the mindset. A mindset of re-creating what already works in an attempt to deliver utopia. This yellow brick road is long, and to date, without a destination any side of a visible horizon.

Enough.  Enough already. The teasing stops here.

Let’s wrap this up just in terms of pharmacy. And we will leave the rest of the swamp to be drained by others better informed and capable than me.

That said I often wonder who on high has asked the question as to:

“what is it we want to do with ICT e-health tools?’

Followed by:

“what is stopping us from achieving that goal?”

The answer to the first question seems to me to “too much”. Rather than start small and grow tall we are working backwards and down from the theoretical stratosphere. That we may never reach back up to the lofty destination, as occurred in the UK, does not yet appear to be on the collective radar.

However in the community pharmacy context the answer to the second question is “not much”. Whatever the goal is of a PCEHR in pharmacy it can be pretty much done today. Given an IHI and a few tweaks.

* A GP can print and send a prescription over the web.

* Australia has two ETP vendors that will do that for them

These two vendors have world class software and benchmarked performance pedigrees – that is, it works!

Their transaction hubs are secure

Your dispensary systems can receive and process these transactions

You already transmit and claim the PBS component of the data

In Dick and Jane terms Australian pharmacy is already capable of contributing data into a PCEHR. With as I said, some tweaks. And when we consider that more Australians receive more prescriptions than any other clinical event it seems passing strange that this hasn’t been the bedrock strategy from the get-go.

That said the thing to fix still is that the product ID/NPC/TGA matter has to be resolved so that individual pharmacy medication records can be uploaded into a seamless and national PCEHR platform. A mandatory component

Secondly all your dispensary patients will have to know, and be able to use, their IHI. Is this mandatory? One would think so. Can it be done today? Aside from the Wave sites – the answer seem to be - nope

The governors then have to be responsible for the security and privacy of all data transacted. Certainly this is mandatory and not especially hard given what already exists in ICT-land.

And now we get to the sticky bits. Your client/patient has to opt-in and give permission for you to reticulate their records; and to instruct you as to who can see what detail in those records. If they want to hide their prescriptions relating to their HIV status they can do so.

Secondly is the issue of PCEHR database (s). We all have a rudimentary idea of how banks and other institutions can identify us, verify and protect data and then store and remove the data as and when authorized, and as appropriately required.

Well, honestly, I am not alone in struggling with understanding how this is going to work in terms of linking PCEHR sites. Where will this blancmange of numerous data mountains be stored? How will data be cross referenced and obtained. And, and, and, and……!.

Hence the title above. If a man does bite a dog and requires distemper shots (it can happen), how will that end up in a PCEHR?

Herein lies the dog poop in the crown.

So the best we can do is wait and see what happens closer to July 2012. Will the dog poop become a jewel? Will a PC focused (regardless of whether it is controlled or correct) EHR dazzle us all?

Time will tell.

And there isn’t much time or money left to play with.

Return to home

Clinical Newsfeed

Click here to read more...

Research Reports

Practice Development

Information Technology

Preventive Medicine

i2P Alliance Partners