Smart Healthcare: International | SmartHealthcare.com

Staff unwilling to abandon paper, finds researcher

Fri, 26 Feb 2010 14:30:40 GMT

Health providers need to design mobile ICT systems well or staff will continue to use paper, according to Norway's medical informatics research centre

Professor Dag Svanæs, of the Norwegian University of Science in Technology in Trondheim, said that simulations run by centre's usability lab show staff being reluctant to abandon paper even when computer devices are easily to hand.

The research centre in Trondheim builds mocked-up health environments such as wards, then films medical professionals using technology, with the footage then reviewed by health staff and technology developers. One simulation saw a doctor searching for paper and pen to copy something off a computer screen.

"It shows the strength of some of these habits," Svanæs told the SmartHealthcare.com Mobile and Wireless Healthcare conference in Birmingham on 24 February 2010. "Paper is very efficient for a lot of purposes."

He said that most computer equipment has been designed for offices, following Xerox's Parc research centre which in the 1970s created many of the concepts used in today's computers. But in health, "very few of the 'use situations' are like the office," Svanæs said. "We have to move from classic usability simulations to clinical practice."

Each health situation may need different equipment, he added, with many more such 'use situations' in hospitals than in primary care. "It's not possible to find one device that fits all 'use situations'. It requires a deep understanding of the users, the tasks and the use situations," he said.

An important aspect involves how data is shared with the patient, Svanæs said. The research centre looked at how X-rays could be presented to patients using personal video screens mounted on arms by every bed in a Trondheim hospital, with the doctor using a personal digital assistant (PDA) to choose which scans to show. Some of the problems related to the graphical user interfaces of the screen and the PDA, but the biggest problem was that patients felt the doctor was hiding the list of X-rays on his PDA.

Svanæs added that such simulation work could help resolve problems between the groups involved in such systems, for example the healthcare provider, an ICT firm, the staff and the patients. Recalling one simulation project, he said: "We became something of a neutral meeting ground" for discussions about how the system would work.

Changing the DNA of healthcare: genomics and informatics

Wed, 20 Jan 2010 09:00:00 GMT

Genomics may lead to tailored medicines and treatments, but will present informatics with some significant technical and ethical questions

At the turn of the last century, photography was still a new technology to many consumers. They would purchase a Brownie camera, take their pictures, and send it off to be developed. Today, we are on the verge of doing the same with ourselves.

Genomics – the science of unravelling human DNA – is promising a variety of healthcare developments, from more efficient drug prescription through to personalised medicine. But do we have the legal and ethical skills to cope with it?

A genome is a complete list of all of the genes that make up a living organism's DNA. By understanding the order in which all of the genes fit together, we can understand what makes a person the way that they are. The first draft sequence of a human gene was produced in 2000, as part of a competing effort between the publicly funded Human Genome Project and Craig Venter's privately funded Celera project, which attempted the same thing. The sequences released by the different projects were refined over the next few years.

Companies are already offering personalised genome mapping services. 23andMe, for example, sends kits through the mail for collecting saliva samples. These are then used to analyse variations in genomes that lead to understood differences in physiology, and other areas such as personality and other characteristics.

But Keith Batchelder doesn't believe that such services hold much relevance at the moment. "They have shown by their limited uptake in the direct-to-consumer market that it is a promise that is yet unrealised," argues the chief executive of Genomic Healthcare Strategies, a consulting firm that helps companies to capitalise on genomic research. "Most of the genomic information that you get from those scans is not currently applicable to anything even as prescriptive as lifestyle changes."

23andMe did not respond to that comment, but it is worth noting that the company does not claim to sequence entire genomes. Rather, it focuses on finding variations in genetic makeup known as SNPs. However, complete personal genome sequencing is coming. Prices are dropping, and before too long, it will be possible to sequence genomes for $1000 (£610) or less.

At that point, it becomes possible not only to understand common variations between an individual and society at large, but rather, to completely understand that individual's biological makeup.

DNA on a smartcard

That would mean that, in the future, it might be possible to create medicines specifically tailored for an individual's own genetic makeup. Barry Schuler, a technology industry veteran and board member at genome research firm Synthetic Genomoics, gave a lecture on genomic research at the TED Talks series of public meetings in June 2008. He describes the future of genomics as a shift from "shit against the wall pharmacology" to more precise medical treatment.

This will mean that instead of bombarding all sufferers of a health problem with a cocktail of drugs designed for everyone, patients will receive drugs designed specifically for their genetic makeup. Eventually, we'll walk around with our genome encoded on a smartcard, he predicts: "You will give your genome to the pharmacist and he will give you a tailored medicine that works just for you."

However, don't expect that to happen tomorrow, says Batchelder. "I think that's years away, but a more intriguing question is when people can be accurately put in groups that will benefit from understanding the response to drugs, or therapies, or the avoidance of adverse events," he says.

In the meantime, there are still some valuable findings to be applied from genomic research in the healthcare context. For one thing, it becomes easier to predict the effects of specific drugs on certain individuals. One such drug, Warfarin, is designed to prevent blood clots, but certain genetic variations make some people more sensitive to it, which can lead to excessive thinning of the blood. Understanding these genetic variations can help physicians to prescribe the appropriate medication.

The worry is that as our level of sophistication increases and we are able to garner more information about individuals more cheaply, it could lead to a crisis of privacy and ethics. One potential problem commonly mentioned is that insurance companies or employers could get hold of genetic information and use it to make decisions about whether they cover someone, or take them on for a job.

However, lawmakers are already tackling the problem. In 2008, the US Congress passed the Genetic Information Nondiscrimination Act, which forbade health insurers and employers from discriminating against individuals based on their genomic makeup.

Christian Burks, president and chief executive of the Ontario Genomics institute (OGI) in Canada, says that there are other issues to consider. "If I looked at myself getting a battery of tests at birth, for the first 20 years of my life, any impact of that information will mostly be determined by my family," he explains. "Who could and should know, and when does a patient's right to protect their information autonomously kick in?"

One of the things preventing the easy exchange of complete genome sequence information is the inadequacy of our health records, he adds. They are simply not sophisticated enough to encompass that kind of information as of yet.

However, with compression technology, it could become possible to hold a full genetic sequence in a record -- assuming that the available standard formats supported the storage. An article in the journal Genome Medicine last July by Mohammad Al-Ubaydli and Rob Navarro indicated that there is not yet a comprehensive standard for incorporating genomic medicine into health records.

Clearly, there is still a long way to go before genomic medicine reaches the point where it totally alters the way that healthcare works. Nevertheless, it is already showing significant promise. In decades to come, people may look back on the way that patients are treated today and consider it barbaric. Putting our genetic makeup under the microscope is set to help our doctors see the bigger picture.

Analysis: How will 2010 handle health IT?

Michael Cross — Wed, 16 Dec 2009 09:00:00 GMT

The new year will see tough decisions for England's National Programme and a surge of activity in the US

Any hopes of 2010 becoming the year in which healthcare IT moves on from the trauma of NHS Connecting for Health and the English National Programme for IT may be in vain. In the first half of the year at least, painful changes in scope, together with cuts in central administration and contract renegotiations will continue to generate heat.

In the second half of the year, however – regardless of the result of the general election – the agenda may move on. For many in the industry, that move could be over the Atlantic.

The first major event in the diary will be the NHS Management Board's decision on whether "significant progress" has been made in acute hospital implementations. The larger of the remaining local service provider contractors, CSC, said last week that it is "in the early stages of discussions with the Department of Health on the reshaping of our contract to meet the future needs of the National Programme for IT. We expect these discussions to conclude in due course to the satisfaction of both the NHS and CSC."

The first half of the year will also be a critical time for the introduction of the Summary Care Record (SCR) in England. Assuming the London deployment goes ahead successfully – a big assumption, given the capital's dismal track record in healthcare IT – implementation across a significant part of England will follow.

A more difficult decision will be over whether to combine the SCR with the Healthspace personal health record. Officially, an announcement on Healthspace's development is expected in January, but this is highly likely to slip. Given the lack of public enthusiasm that has so far emerged for the scheme, Healthspace must be a prime candidate for postponement or outright cancellation in the quest for chancellor Alistair Darling's IT project economies.

The same must go for the delayed and still embryonic national electronic prescriptions service – unless a rock-solid business case is forthcoming.

Known unknowns

A big unknown for 2010 is whether Google and Microsoft will introduce their respective personal health record services in the UK. These have been talked about with enthusiasm by Conservative leader David Cameron, so much will depend on the general election outcome.

And, despite its status as one of the "big three" government websites, the long term future of NHS Choices must also come under scrutiny in 2010. The announcement in the Smarter Government strategy that underlying site data will be available to all raises the possibility of NHS Choices being replaced by initiatives from the private or voluntary sector.

However the current portfolio of centrally funded IT projects is by no means the only game in town. A significant challenge that will emerge in the year will be creating an IT infrastructure to support "total place" initiatives, or whatever a new government chooses to call projects that link up services in a locality. As the Conservative-sponsored independent review of health and social care pointed out, NHS and social care organisations will need to work together more closely to meet the challenges of the future: "Information-sharing will need to become the life blood of this relationship."

Whoever grasps this nettle will face an onslaught from the privacy lobby – especially if the NHS suffers more headline-grabbing IT security breaches.

On the brighter side, 2010 will be the tenth anniversary of the HL7 healthcare data standard in the UK, and a chance to show that, where the local will is there, different arms of the health service can be linked up, especially for the benefit of the chronically sick.

But developments in the UK are likely to be overshadowed in industry circles by the rising profile of President Obama's $19bn (£11.7bn) healthcare IT pledge. All eyes will be on the first real test of the Nationwide Health Information Network (NHIN) by the Department of Veterans Affairs and healthcare provider Kaiser Permanente. The Department of Defense is due to join the next phase of the pilot programme early in the year.

If all goes well, the US programme will create a strong temptation for US-based IT suppliers to wash their hands once again of the troublesome NHS market. But as we have seen in the NHS – which began with the advantage of having an integrated health service to computerise – success is no certainty.

But making predictions is a dangerous business. Back in 1998, this writer contributed to a research-based work of fictional futurology called Healthsmart 2010, produced by Smart Healthcare's publisher Kable. In it, we proposed that, by 2010 the NHS would have been transformed by the "information revolution... in ways that affect everybody." We said that 2010 will be the age of the "informed patient – at least among those social groups that have access to information technology." And we warned that "security is a serious issue".

So we got part of it right.

Michael Cross

How sensors will become home helpers: home monitoring technology

Wed, 04 Nov 2009 09:00:00 GMT

Suppliers are working on fitting patients' homes with monitoring devices, allowing them to stay there for longer

It's like a scene from Big Brother. An elderly woman, who hasn't seen another living soul in days, shuffles across the room and sits in front of the television. An hour or two later, she goes to make a cup of tea, but forgets why she got up. She does this three times in a row before deciding to take a nap.

Sensors littered around the house have been monitoring everything, including her footfalls, the water pipes, the bed, and the TV. A software-based expert system compares today's activity with baseline trends garnered from daily monitoring. It alerts a home care physician to the fact that the patient appears to be walking more slowly than normal, and retracing her steps repeatedly. The pressure sensor in the bed shows that she's sleeping at unusual times. Early signs of dementia are appearing. Clearly, it's time for a human being to give her a call.

Such scenarios may not be as far fetched as one might think. As countries around the world consider major reforms to their healthcare systems, companies are hoping to use technology as a means of cutting down on costs.

An ageing population, combined with the need to reduce costs by introducing efficiencies, is making such systems more attractive, say their advocates, especially as the technology required to implement them matures.

"The national average salary for a skilled nurse is $76,000 (£47,000)," says Brian Bischoff, chief executive of Healthsense, a US-based company already selling sensor networks to help patients transfer back into home care and reduce the strain on primary care facilities. "We're enjoying the macro savings from these technologies. The ability to detect that someone needs assistance and keep that safety net there for them, that's what allows people to transition down a level of care."

At a time when primary health care providers are under strain from an ageing population suffering from more chronic diseases, anything that can help to lighten the load is bound to appeal. Companies like Intel – which formed its own healthcare division as part of a major restructure – have been eyeing this opportunity with interest, lending it more credence.

Healthsense sells a system called eNeighbor, which uses sensors to monitor the behaviour of patients at home. The system can automatically detect a need for assistance without residents activating a call device, the company says, and can monitor for specific individual issues, such as wandering, or forgetting to take medication. The systems communicate using WiFi wireless networks, explains Bischoff.

Sensors and sensibility

Not everyone is convinced of sensors' utility, however. "This is pretty much a waste of time and money," argues Peter Cochrane, former head of research at BT from 1993-99, and founder of Cochrane Associates. "All you need is an iPhone or BlackBerry. The sensors built in tell you exactly what people are doing. They also have all the processing and memory to manage the lives of the old and infirm."

"People don't sleep or shower with their BlackBerries. When you're in your home, it's a different environment, and this is why it's effective. People don't have to take it with them," protests Bischoff.

Could a phone measure your respiration rate, temperature, and carbon dioxide output? James McLaughlin, director of the Nanotechnology and Advanced Materials Institute at the University of Ulster, says that point of care monitoring systems will increasingly provide more intensive day-to-day analysis of patient conditions in the home.

"The last 10 years have seen the development of body-worn vital sign measurement systems," he, says, adding that these will be commercially available within two years. "You would directly monitor ECG, temperature, respiration rate, CO2, all in the chest area, and the smart programs in there would assess your ECG arrhythmia. Only then would we bother the physicians."

The future holds lots of promise for sensor-based monitoring systems, McLaughlin says. Sensors may listen to you sleep in bed, and monitor your heart rate from across the room, he predicts. Accelerometers may be embedded in home devices to see how well they are being handled. Telephones could measure the mistakes made when dialling numbers, while sensors embedded in floors could measure movement across surfaces and detect signs of stumbling on one foot or falling.

However, other more intrusive monitoring must be made more acceptable for the home. Measuring blood and urine, for example, is still a challenge.

Nevertheless, sensors could be the answer to some of the work load challenges facing primary care, and could help drive down the cost of home-based support. But there is one human element that all of these experts seem to have forgotten: won't these remotely monitored people get just a little lonely?

France revives its uphill struggle for EPRs

Michael Cross — Wed, 21 Oct 2009 08:00:00 GMT

France's DMP electronic patient record scheme has gained fresh momentum under new agency ASIP Santé

France's troubled programme to create a lifelong electronic medical record has been revived under a new drive towards implementing e-health, initiated by the Sarkozy government. A new agency, ASIP Santé (agency for shared information systems in healthcare), led by the Ministry of Health and Sports, will bring together all parties involved in e-health in France.

ASIP replaces three former agencies, giving a sharper focus to the national healthcare IT programme, which is also benefiting from a hefty injection of central government funding.

ASIP's main focus will be to relaunch the DMP (Dossier Médical Personnel), a lifelong shared electronic record. It will attempt to assuage critics of the five-year-old scheme by giving patients control over access to their electronic records.

However the DMP will be only part of a programme that points to a greater emphasis on e-health by Roselyne Bachelot-Narquin, secretary of state for health in the Sarkozy government. Under a EUR10bn (£9.1bn) national initiative called 'Hospital 2012', EUR1.5bn is ring-fenced for healthcare IT. Suppliers are expecting a spate of procurements by regional hospital consortia.

ASIP Santé's states its objectives as follows:

- Implementing a general heath information infrastructure, addressing medical, technical and legal requirements, and promoting its use;
- Creating and setting standards for security and interoperability, both technical and semantic, for domestic and international use;
- Designing and deploying shared healthcare IT systems such as the DMP, leading initiatives in telemedicine, and monitoring outbreaks and offering support through both surveillance and alert programmes to national public health organisations;
- Facilitating and increasing the use of IT systems in health and the wider medico-social sectors, both for healthcare professionals and the general public.

The agency's founder members are the Ministry of Health and Sport, the CNAMTS national health insurance agency for employees and a public investment company, Caisse des Dépôts et Consignations.

The initiative is interesting because, despite the high profile of its pioneering SESAM-Vitale health smart card scheme, now in its fourth version, France has not been a major actor on the European healthcare informatics stage.

One reason is the highly charged political and professional controversy created by the introduction of national IT systems. Although the SESAM-Vitale system has successfully automated reimbursement transactions at GP level, through which medical professionals reclaim fees from insurers, many clinicians remain suspicious of a scheme introduced at a time of headlong confrontation between the government and health professionals.

The DMP, likewise, has a troubled history. When it was originally announced in 2004 as a lifelong record accessible by clinicians, an overt aim was to control rising costs by cutting the number of unnecessary or repeated tests and procedures. Opponents claimed that this was an attack on clinical freedom. The EUR1.5bn project also became embroiled in rows over confidentiality and consent. Last year, the National Ethical Committee warned the ministry that the project would fail.

ASIP Santé says that lessons have been learned. An interesting feature of the relaunched DMP is that citizens will be able to retain their existing choice over who holds their main record, with only indexing and demographic information held centrally.

The programme begins with at least two advantages over England's National Programme for IT. First, the political argument has come out into the open before the system's deployment is attempted. Meanwhile the SESAM-Vitale system provides a basic infrastructure for authenticating patients' identities and handling contents. The Vitale 2 version of the card, to be deployed in earnest next year, will enable clinical data to be loaded up to the DMP.

However, like the English national programme, much will depend on the acute sector's ability to implement electronic patient records. Progress appears to be accelerating following health reforms which provide greater regional autonomy. For example, six hospitals in eastern France's Franche-Comté region are implementing Cerner's Millennium on a centrally hosted infrastructure. All six have deployed scheduling and radiology systems, with implementation of a full electronic medical record (EMR) system, including electronic prescribing, at one. Meanwhile in Valenciennes, in the north of the country, a single Cerner EMR is planned to serve 13 facilities.

"We feel quite good about the marketplace, in particular regional procurements will happen," Bruno Slosse, vice president and general manager, Cerner France, said.

Michael Cross

Hospitals reset the video: new uses for video conferencing

Wed, 07 Oct 2009 08:00:00 GMT

Acute trusts are moving beyond telehealth to use video conferencing for baby monitoring and the training of surgeons

As this week's announcement from the Scottish Government about the nationwide introduction of telehealth by NHS 24 confirms, the use of video conferencing for remote diagnosis is well established. But clinical needs are finding further uses for such technology.

The Princess Royal Maternity Hospital in Glasgow is using it to create 'babycams' that are used to link mothers to their newborns through video conferencing in situations where they have been separated by premature birth and other medical complications.

Chris Lilley, a neonatal consultant, was already using video conferencing units as part of a remote diagnostics system for babies with cardiac problems: "Then we thought that this would be a good way of matching up babies and mums that couldn't be together."

"The first case was a lady who was being treated about a quarter a mile away on the same site with a serious skin tumour," he says. "She was going to be there for about 12 weeks and there were problems with her care that meant she was not able to visit the unit and had given birth to a very premature baby who also could not move from the unit."

The video link has been credited with helping mothers bond with their babies and begin breastfeeding, despite not being in physical contact with their babies. "With premature babies we need to get mums to produce a small amount of breast milk for us to start them on accepting milk and that is very important part of premature care," says Lilley.

Steve Woollett, head of public sector for Tandberg, which donated six bedside units for the project, says clinical staff are creating specialist uses such as the babycams. But away from telehealth, surgical training is set to be another big user of video conferencing.

He says that training in endoscopy – internal examinations using cameras on fibre optic cables – is set to be a particular growth area. "The government at the time didn't recognize how big endoscopy was going to be so training places were rather few and far between initially.

"Now when people are at the stage where they need to be supervised in operations, rather than taking the day out and having to visit another site customers now can work in their own hospital and at the allotted time can dial in from a desktop video unit to supervise the procedure." More network capacity, including England and Scotland's N3 health network, and better video coding has increased the quality of video shared between organisations, making surgical training viable.

Watching Eurovision

Elsewhere in Europe, such work is already underway. In June the Temdec project (Telemedicine Development Centre of Asia) at the Medical School of Kyushu University in Japan linked hospitals in Norway, Italy and Spain through the pan-European GÉANT research network. This transmitted at 30Mbps using digital video transport system (DVTS) equipment that can be run from a standard personal computer. Staff at the three hospitals were able to show how endoscopic surgery can be transmitted across borders for training purposes.

Dr Shuji Shimizu, of the Kyushu University Hospital's department of endoscopic diagnostics and therapeutics, says that since the demonstration in June, there has been a move to adopt video conferencing for surgical training more widely in Europe although this is at an early stage in the UK: "As far as the UK is concerned, collaboration is just about to start.

"A key is to organise a collaborating team between doctors and engineers in each hospital. But usually doctors do not know engineers and engineers do not know doctors. And they do not know their interests and expertise. So to make a good team is essential but it is sometimes difficult," he says.

He points to two technological drivers for the wider adoption of video in healthcare: the development of the GÉANT academic network dedicated for research and the DVTS, which can transform digital video signals directly into internet protocol. "As a result, we can transmit surgical video with the preservation of its quality," he says.

Kable senior analyst Victor Almeida describes the take-up of video conferencing outside of diagnostics so far as "very niche and very slow". He adds: "My view is this is a growth area as you move care from the hospital into the community and the patient's home.

"It is not a technical issue at all. The technology has been there for a long time but video conferencing has not happened. The time is right and it is key to the modernisation of the NHS. Trusts are paid by results and once they realise how they can cut costs and improve patient care they will embrace it."

Canada's persuasion problems with electronic records

Wed, 23 Sep 2009 08:00:00 GMT

Health InfoWay may struggle to persuade family doctors to move half all Canadians to electronic records by the end of next year

So far, the Canadian government has piled over C$2bn (￡1.15bn) into the modernisation of its health care system, and is racing to meet a significant deadline for implementation next year. How is it doing?

As well as can be expected, according to some, who feel that its goals are nevertheless unrealistic. Canada Health InfoWay is the not for profit organisation formed in 2001 by the Canadian federal government to distribute funds and create guidelines for electronic medical records (EMRs). It wants to have an electronic medical record for every Canadian by 2015, and has also tasked itself with covering 50% of Canadians with EMRs by the end of next year.

"They are being overoptimistic with these projections," warns Norm Archer, professor emeritus in management science and information systems at McMaster University, who has conducted extensive research into the implementation of EMRs in Canada.

Health Infoway refused to discuss its progress, but the numbers in its latest annual report speak for themselves. At the end of March, eight years after the agency was formed, it revealed that it had only met 17% of its 2010 goal. That means it still has to cover two thirds of the 50% of Canadians that it wants to have an EMR by the end of next year.

"Provincially, the problem is getting EMRs into every family practitioner, and that has been an ongoing struggle," says David Wiljer, the founding chair of the Canadian Committee for Patient Accessible Electronic Health Records, who also directs a web portal project for chronic patients at Princess Margaret Hospital in Toronto.

Family doctors in Canada are largely private, and cannot be told what to do. They have to be convinced to move to EMRs. Michelle Greiver, a family physician in Toronto, has spent the past three years implementing and optimising her EMR system.

"My cost to start the EMR was approximately C$30,000, half for software and half for hardware," she says. However, there were additional costs such as an upgraded VPN router and a backup internet line, which she needed several times after the failure of lines provided by eHealth Ontario, the 700-person organisation with the job of modernising the Ontario health system.

"I think we will continue to see implementation failures, and the focus of support may need to change towards supporting those who have purchased, rather than encouraging purchases," she adds.

Health Infoway is obviously taking the family doctor issue on board. It has dedicated its C$500m allocation from the 2009 federal budget almost entirely to accelerating the implementation of EMR systems with such practitioners.

While the organisation battles to get family doctors on board, it is also hitting a moving target in terms of standards, warn experts. Until recently, the most commonly accepted standard for EMRs to support hospital workflows was Health Level 7 (HL7) version 2.

"Many institutions already use that to communicate with each other, but the problem is that it isn't really a standard," Archer says. "Institutions can use version 2 in quite different ways."

Health Infoway would like to migrate to HL7 version 3, says Archer, which supports any and all healthcare workflows using a more formal methodology, but it is a complex process. And that version was only ratified in 2005, four years after the organisation was formed.

But problems with eHealth Ontario are symptomatic of the fact that Canada Health Infoway isn't fully in charge of these projects. In Canada, healthcare falls under the jurisdiction of the country's 10 provinces. If and when the Canadian provinces are willing to modernise their health records, they form a partnership with Canada Health Infoway, procuring the funds for implementation, and hopefully following the guidelines competently.

"Ontario has done some things centrally, and they made some bad mistakes and wasted a huge amount of money," says Archer. The province recently fired the head of eHealth Ontario, after media attention over almost C$5m in no-bid contracts, and alleged overpayment of consultants. eHealth Ontario was only created in 2008, to replace the Smart Systems for Health Agency, which spent C$647m while failing to implement EMRs.

Faced with an army of sceptical private physicians, a depressed economy, a huge geographical area, and a problematic division of jurisdiction, Canada Health InfoWay certainly has its work cut out. It has just over 15 months to attempt to meet its first deadline, and in the meantime, an auditor general's report evaluating its progress will be published this autumn.

Adverts, access and health records: Google and Microsoft

Wed, 01 Jul 2009 08:00:00 GMT

Google and Microsoft look to advertising to fund their free health record services praised by David Cameron

Web 2.0 seems to be popular in government at present. In the US, the president has taken to delivering his weekly briefings on YouTube. The White House has a blog, and Obama even has a Twitter account. Now, the Conservative party in the UK has latched onto the idea of using Web 2.0 services to complement public services, but opposition leader David Cameron is thinking about taking it one step further - particularly in health care.

"In this age of austerity, a web-based version of the government's bureaucratic scheme [using] services like Google Health or Microsoft Health Vault cost virtually nothing to run, so this is where some really big savings could be made," he said in April at the party's spring forum. "Not just shaving a bit off this budget here; that cost there, but instead replacing whole chunks of the expensive, bureaucratic government machine with more modern methods - for a tiny fraction of the cost."

He was referring to NHS Connecting for Health's National Programme for IT, which has run into serious budget, deadline and privacy concerns. With companies such as Microsoft and Google now providing free health records management services that are controlled by the patient, we could theoretically get this aspect of the programme for free. But is it such a good idea?

Deven McGraw, director of the health privacy project at the Washington DC based Centre for Democracy and Technology, doesn't think so. "If the opposition party is suggesting turning it all over to Google and Microsoft, there will be a price to be paid for that, in the sense that people's health information will be more at risk of being used for marketing purposes," she says.

That's a good point. It comes down to advertising and ownership of data. Google's mission statement clearly spells out its goal of organising the world's information, but it has to make revenue somewhere, and over 99% of that money comes from online advertising.

John Coulthard, director of healthcare and life sciences at Microsoft, makes no bones about the need for advertising revenue, but argues that it can be done ethically. "The NHS spends hundreds of millions of pounds a year on advertising. Smoking, obesity, change for life, diabetes - tonnes of stuff," he says. "What would happen if you said to your Health Vault account 'it looks like I'm pre-diabetic'?"

Advertisements could be tailored to target people according to their potential health problems, Coulthard argues. With an increasingly privatised healthcare system, he says that the opportunities for more commercial advertising around private healthcare may also open up in future.

Private patients

However, farming outpatient healthcare records to private companies preoccupied with advertising raises privacy concerns. Can companies manage patient data and leave those patients in control of their own records, without contravening privacy boundaries? Dr Deborah Peel, a practising physician and founder of US-based non-profit Patient Privacy Rights, is currently in the process of putting together an international set of privacy benchmarks against which to measure private sector patient record management systems.

Peel asked both Google and Microsoft to work with her on defining the parameters to join the consortium and help evaluate adequate patient record privacy, but only Microsoft responded. "The one technology company that said that wanted to stand with consumers on controlling their health information was Microsoft," she says. "They built out Health Vault according to our privacy principles. Google is not in favour of consumer control over data".

However, Google isn't interested in selling ads directly targeting users of its health record system, either. "At this time, we have no plans to host ads in Google Health. Our business goal is to offer a valuable service to our users and drive brand loyalty and more searches on Google.com where we make our money on advertising," the company said.

The principle underlying both Google and Microsoft's healthcare records systems is that the patients should have control of their own data. Today, healthcare providers have that control, and patients have little or no input into the content of their own records. However, putting that control in the patients' hands raises its own issues. If the patients control that data and can update it, how can doctors trust it to be accurate? "A lot of the physician community here basically says we don't trust the information that is in a patient health record, unless they know what the source of that data is," says McGraw.

Coulthard argues that Health Vault can tell who make changes to a patient's record, so that doctors can tell if a patient altered their weight information to avoid embarrassment, for example.

There are doubtless many possible benefits to be gained by farming out patient record management to private sector companies that excel in pushing the technological envelope. For example, Coulthard describes a potential scenario in which a Facebook plug-in could be used to connect people with the same ailment. Could hay fever sufferers automatically find each other using a social network, and talk about ways to mitigate their medical problem?

You can bet that Hippocrates never had to grapple with such thorny issues. On the one hand, the power of social networking could create new opportunities in healthcare - and also, incidentally, costs a lot less than an arcane, centralised system. On the other hand, it raises distinct privacy issues. Is the UK government ready to address those issues, having lost 25m HM Revenue and Customs records on two CDs? Given the billions that we have already spent on the National Programme for IT, perhaps now is an unsettling time to be mulling these questions.

Attacking a new millennium's bug: swine flu and epidemiology IT

Wed, 20 May 2009 08:00:00 GMT

Epidemiologists are using IT to track and tackle the H1N1 swine flu virus with a sophistication unavailable in earlier epidemics

1918 was a hard time for the human race. The influenza epidemic that broke out that year killed up to 40m people, ending more lives than the first world war. Now, people are drawing comparisons with H1N1 - the 'swine flu'. But as this virus continues to spread and mutate, we have one advantage on our side: information technology.

90 years ago, the closest thing anyone got to crowd sourcing was an Amish barn-raising. With the internet now connecting us more than ever before, networks are helping health workers to track the spread of the virus on a local, national and international level.

In the UK, the NHS has used its central NHS.uk website to promote awareness of the disease, and to warn the public what to do about it. The Health Protection Agency has also been working with other European agencies to help analyse the nature of the virus. It provided what it says is the first isolate of the virus for vaccine researchers to work with.

At an international level, the World Health Organisation had to move quickly to try to document the spread of the new bug. Its health technical manager for non-administrative IT systems Patrick Briand and his team rushed to roll out a daily reporting system for H1N1 outbreaks, along with a case summary reporting system. Both of them were cobbled together in little more than a couple of weeks using Microsoft Sharepoint.

"It was more prototyping for some of these applications than by-the-book development," says Briand, who was taken off his daily work routine and put into an emergency working team. Briand and his colleagues had to liaise with epidemiologists who were trying to understand what information they needed to track about this worrying new strain. Rarely has requirements gathering - the part of the software development cycle when the developers document what the users want - been conducted so quickly.

The organisation had already been working on some other applications when the outbreak occurred. A weekly reporting system called FluID, due to be rolled out any time now, will provide longer-term, broader data to help health workers understand infection trends. And an event management system will collate data from multiple sources including news sites, to provide a central point of intelligence about new infections, perhaps before they are even identified locally as H1N1.

From anthrax attacks to flu

In the US, the Center for Disease Control has been hard at work on three systems: BioSense, BioPhusion and the National Electronic Disease Surveillance System (NEDSS).

BioSense was created in 2003 in response to the anthrax attacks in the US. It retrieves data from acute healthcare institutions to help both acute healthcare workers and health administrators understand what was happening on the ground. It complements BioPhusion, which is a system to retrieve less structured information from a variety of sources, says Terry Boyd, director of the division of informatics and shared services within the National Center for Public Health Informatics at the CDC.

"It pulls information from a wide variety of sources to give a complete picture of what's happening," says Boyd. "They pull information from labs, veterinary areas for animal investigations, information about what's showing up on the news, and information about hits to the CDC web site to show how interested the public is in what's happening."

Finally, NEDSS provides a standard method for disease reporting in the US, and enables policy makers to more closely track nationally notifiable diseases, including emergency outbreaks such as H1N1.

The CDC's efforts contrast with more grassroots initiatives such as ProMED Mail, a mailing list organised by the International Society for Infectious Diseases. Originally started as a means of monitoring the potential use and effect of biological weapons, the system has expanded from a membership of 40 to more than 50,000. The site now uses RSS feeds and Twitter to send out quick reports. "Its purpose has become to be an early warning system for outbreaks of newly emerging diseases," says Larry Madoff, the service's editor, adding that ProMED Mail was the first to report publicly on SARS.

Madoff argues that this grass roots effort contrasts with those of more top-down institutions. "ProMED has long been an advocate of transparency. The official public health sector hasn't always been," he warns, pointing out that EPI-X, the CDC's communications network for disseminating epidemic information, is only open to healthcare professionals, rather than to the general public. "Ministries of health of various countries sometimes try to contain information for economic and political reasons."

One of the problems for health workers is getting all of this data into the system. The WHO, which deals with cases across the globe, has to cope with information in many different formats, says Briand. "We take the information how it comes. If it comes in an unstructured way, we have people here who can enter it," he says, adding that information may arrive in emails and spreadsheets. "We don't want the structure to be a barrier for collecting information, especially in poorer countries."

"The secret with informatics is to make it as easy as possible for folks to provide the information you're looking for, and in many cases that means doing it in the way they're already used to," agrees the CDC's Boyd. "But one thing that the Office of the National Co-ordinator for Health Information Technology is looking towards is the day when we can tie this information into electronic health records and not have to re-key any information."

That day will be fraught with privacy difficulties as the authorities work to strip identifiable patient information from the data for privacy reasons. But it would be one more step in the road to efficient epidemiological reporting. In the meantime, the many and varied reporting efforts already in place look set to help researchers mitigate the threat of this bug - even as their data shows that we're well past the point of containment.

Indian outsourcers look to NHS business

Wed, 01 Apr 2009 08:00:00 GMT

Outsourcing firms from India are already providing the NHS with some services, but they are lobbying for bigger contracts

Recent media reports have suggested that Indian outsourcing companies will be making a concerted effort to win business from the UK public sector over the coming months, and in particular, from the NHS.

Several of the large outsourcing companies – such at Tata Consulting Services (TCS), which provides a patient record system in the Indian state of Gujarat – have built up extensive capabilities in their home country.

Collectively, the Indian companies have been lobbying Parliament, through an all-party group promoting trade links with the UK, to bolster their share of British public sector contracts.

"The Indian outsourcing firms, like many other firms in the current
climate, view the UK public sector as an attractive market place," says Michael Larner, a senior analyst at Kable.

"The healthcare market is a particular target given not only the scale, the budgets involved and the adverse relationships with incumbents; but also they often can demonstrate expertise in this market on the back of their work with the Indian government."

The Indian companies have also been bolstering their "nearshore" capabilities which, Larner says, should make them more attractive as suppliers in sensitive areas such as healthcare.

In fact, several of the large and mid-tier Indian outsourcing companies are already heavily involved in NHS projects, but often as subcontractors.

TCS was part of the Fujitsu Services-led local service provider contract for the Southern cluster: the firm provided clinical application implementation and data migration in a contract reported to be worth £120m.

The Southern cluster contract was terminated last May, but TCS remains listed by NHS Connecting for Health as a supplier under the organisation's Enterprise Wide Arrangements, which guarantees that suppliers will offer the NHS the best possible price for future work.

Mastek, another Indian outsourcer, is part of the BT-led Spine project under a 10-year deal valued at £35m, primarily for application development and support.

Such experience is no doubt invaluable to the outsourcing firms themselves, as well as to the NHS. However, the transition from subcontractor to lead contractor in an organisation as complex as the NHS remains a significant hurdle, especially for companies with a more limited UK workforce.

Matching ambitions and capabilities

When it comes to picking an IT contractor, capabilities and experience are likely to matter more than geographical origin, however.

The term "Indian" is used rather loosely when it comes to IT services companies. By no means all Indian firms undertake classical outsourcing, with staff transferring from the client to the supplier. Many are focused on specific IT functions such as remote management, software development and customisation, and testing.

Such contracts need not involve the transfer of patient data, so the supplier's geographical location is less of a consideration. Many such tasks involve working with generic business services or "back office" applications, where specific knowledge of the NHS might matter less than a solid understanding of the application software or the development environment.

At the same time, the larger "Indian" companies, in particular TCS, Wipro and Infosys, have global ambitions and an increasingly international workforce. Gartner predicts that these "India-3" vendors will overtake IBM Global Services, Accenture and EDS (now part of HP) as the leading IT services companies by revenue.

Whilst the India-3 have expanded their capabilities outside the sub-continent, so the US and European services firms have increased their investments there. Several of the large IT service firms now have significantly more staff in India than they do in the UK.

"There is now very little difference between the large Indian companies and any other large IT player," says Alex Blues, a member of the management group at PA Consulting. "They are now global players. There is a difference between using them, and going offshore. If you contract with TCS, to use one example, it doesn't necessarily follow that the work will be offshore."

Deciding whether to give work to a second-tier contracting company, where the work is more likely to go offshore, is more politically charged, according to Blues. However, if political or privacy considerations make offshoring unacceptable, that will apply to contractors whether they are based in India, Japan, the United States or Australia.

But, as Blues points out, finding the appropriate skills at the right costs is likely to be more important than geography. "For some IT tasks it [location] is practically irrelevant, for example in remote infrastructure management. They are accessing the data in this country.

"It is different, for business process outsourcing, where transactions might be carried out in India," he adds. "But it is also a myth that it is much cheaper to go offshore. The difference in costs between Newcastle and Mumbai is less than the difference in costs between London and Newcastle."

Obama and e-health records: can he really?

Danny Bradbury — Wed, 11 Mar 2009 09:00:00 GMT

US president Barack Obama wants to ensure every American has an electronic health record by 2014. It's an ambitious task, but the work is already under way

He has promised to turn the US upside down, making its oil driven economy greener, educating its children and ploughing money into infrastructure. But Barack Obama's biggest challenge lies in healthcare.

"To lower health care cost, cut medical errors, and improve care, we'll computerise the nation's health record in five years, saving billions of dollars in health care costs and countless lives," the US president said in his first weekly address from the White House on 24 January 2009.

Since then, he has managed to get both houses of government to vote through a stimulus package, the American Recovery and Reinvestment Act of 2009, which includes that promise to make every American's health record electronic by 2014. Can he pull it off?

One significant difference between the US and the UK is the former's lack of cohesion. Each of its 50 states has had its own approach to healthcare, and its own level of maturity in IT. As of 2007, according to research from George Washington University, 20%-25% of outpatients were being served by some form of electronic health records (EHR) in the US. However, data on performance is hard to come by.

"I have never seen a scorecard," says John Halamka, chief information officer and dean for technology at Harvard Medical School. However, he hopes that the stimulus package will change that. The act includes provisions for incentives that can be used by states to promote the adoption of IT in healthcare.

This may begin to identify the worst states, as well as the best, although Halamka reckons Massachusetts, New York, Tennessee and Indiana are the strongest performers, based on research conducted about those states' EHR roll outs.

"There are incentives around e-prescribing and physicians' use of EHR instead of paper based systems," says Andrew Hurd, chief executive of Carefx, which provides workflow portal systems to US healthcare providers. "All of those are positive. But being able to provide more standards that vendors can write code to is important as well."

Standardisation has been considered one of the primary problems facing the introduction of EHR in such a fragmented sector, but things are improving. The Healthcare Information Technology Standards Panel (HITSP), of which Halamka is also chair, was created under the American National Standards Institute (ANSI) in 2005, after the Bush administration set a goal of national EHR adoption within 10 years.

"The technical standards are at this point harmonised," says Halamka, describing them as "well described, agreed upon by consensus. The next step of course is getting them implemented". He has already recommended the creation of regional implementation groups that can function as best practice centres to help healthcare providers on the journey to what he calls "meaningful use": the practical deployment of these records for e-prescribing, laboratory exchange and quality measurement. Along with the adoption of the standards, this is something else that the act prescribes explicitly.

Connecting for health, US style

But regional implementation is not enough: there must be a means of communicating this information between regions. The US Department of Health and Human Services has been working on a Nationwide Health Information Network (NHIN), which it envisages as a "network of networks", in keeping with the federated model. These networks are called health information exchanges, and the DHHS has already commissioned 15 contractors to work on trial implementations of prototype architectures.

One key characteristic of the EHR movement in the US is the need to keep information customer-centric. Personal health records are a concept enabling customers to gather their information from different providers (perhaps their primary and secondary care providers, for example) and store them in one place.

Where? The answer may be a little scary. Google launched Google Health last April, with Halamka involved in its creation, while Microsoft has its Health Vault. These sites already have links into large numbers of pharmacies to enable people to extract their health data and store it in one place.

Google and Microsoft have also endorsed Connecting for Health, a consortium that provided one of the original prototype architectures for the NHIE (and unconnected to the NHS IT organisation of the same name). Connecting for Health has an architecture designed to facilitate the exchange of health information between the patient and the third parties that they see fit. The American Medical Association says it is fully behind Connecting for Health.

There's just one snag. "At present, Google and Microsoft have created very strong policies, and they are not covered by HIPAA, so patients have to trust those policies," says Halamka, referring to the Health Insurance Portability and Accountability Act of 1996 which is meant to govern the security and privacy of EHRs.

Halamka says that the policies he helped set out for Google are "stronger than HIPAA." Come to that, the state level health information exchanges are not covered by HIPAA as entities, either, according to a report from the Healthcare Information Management and Systems Society entitled Enabling Healthcare Reform Using Information Technology.

In the brave new world of EHRs, perhaps the standardisation issue is not the problem. Privacy concerns may be the real barrier to adoption – and it may not be the regulators who kick up a fuss. The consumers could well have something to say about it, too.

Danny Bradbury

The Israeli experience: patient records

Wed, 02 Jan 2008 15:12:00 GMT

One of the country's leading healthcare providers has developed the potential for a national patient record

When Dr Orna Blondheim talks about Israel's past record in managing healthcare information the experiences sound very familiar. Until this decade it was plagued by missing clinical information, time wasted in searching for documents and test results, and clinicians making decisions without a full knowledge of the patient's history.

It didn't help that the country has a large immigrant population, so that many had medical records residing as far away as the US, and that it is an insurance based service, with patients going to one of four health maintenance organisations (HMOs) responsible for running hospitals and clinics. There is a large variety of clinical systems and hardware platforms, isolated information repositories and a lack of integration all round.

Blondheim, chief executive officer of the Emek Medical Center, makes it clear that this created a lot of difficulties as soon as a patient had to go to different sources for care.

'Go bring'

"Under the previous circumstances in Israel patients or their families were often sent to 'go bring' results, letters, etc, and physicians often had to take medical decisions based on only partial information," she says. "It wasted time, and affected the quality of those decisions.

"In addition, hospitals, and their various departments, each had different systems and were not communicating with each other. We realised that we had to do something to address this situation."

Clalit Health Services, the parent of Emek Medical Center, took the lead. It is the largest HMO in Israel, accounting for 57% of the market with 5,500 physicians and 9,000 nurses looking after 3.8m patients.

In the late 1990s it began to work on its Ofek network for sharing medical information. The aim was to provide real time integrated medical information, available in less than 10 seconds, at the point of care, with the ability to drill down into the data. It was based on a decentralised structure, with security and privacy safeguards and the ability to scale up for wider use.

The system's key to success is its ability to create a virtual patient record - essentially an integrated electronic health record comprised of information from disparate sources that can be made available anywhere in the network.
The Ofek system began life under a pilot project at Soroka Hospital in the south of the country in 1999. The technology was provided by a company named dbMotion, which was then a start up but has since become larger.

It was then steadily developed over the next few years. Blondheim says the thrust of the work was to provide information to clinicians in a smart manner, so it would be quickly available wherever it was needed.
"For example, if the patient had results from different laboratories they could all be collected in one place; the same for diagnoses."

It works on the principle of a minimum data set being made available on the first screen. This includes the most recently added details in a number of areas, such as medication, hospital procedures, laboratory results and diagnoses. The clinician can then drill down into the earlier details for any section.

Blondheim says that when a user enters the system they enter the patient's name, which is then sent out to all of Clalit's hospitals and clinics, and that it receives a reply from the relevant one within seconds. The information appears on the screen very quickly - a big asset considering the usual impatience of physicians for information.

None of the previous information can be changed, but clinicians can add further details to the patient history in the individual clinical systems, which will appear on the front screen of the integrated Ofek record the next time a request is made.

Arrangements are in place to protect patient confidentiality. Only the patient's primary clinician, the medical director for their district, and those who are registered for access against the patient's name, are allowed to see the record. Any other users, such as consultants, need the patient to provide access through the smart card that Clalit provides to all of its customers. The only information on this card is to confirm that the patient is who they say they are and is covered by Clalit.

A clinician who has to see all the patients in a hospital may have special permission to access all of their records, but there are limitations on the rights of nurses and assistants, who are excluded from pathology and genetics information.

"But the system itself is very flexible," Blondheim says. "Any organisation can choose who it allows for access."

She says another big advantage is that it is very intuitive, especially for anyone who is comfortable using the internet. Its use has spread without any formal training programme, with most users picking it up with a minimum of instruction.

"It's also very important to realise that, in order to integrate the medical information from different medical systems, you do not have to change the computer systems they are working with. This is very hard and it often puts people off.

"The beautiful thing about this solution is that it enables people to integrate with their own systems."

This is an important point, when even the coding, clinical language and data structures differ, and some hospitals work with complete health information systems while others rely on departmental systems.

As the solution has been rolled out around Clalit's treatment centres it has identified a number of benefits. On the clinical front it supports faster, more accurate diagnoses, reduces duplicate testing and procedures, increases patient safety and helps to shorten the care cycle.

Administratively, it eases the management and follow-up of the care process, ensures better communication between care providers, provides more time for the encounter between patient and clinician, with less time spent chasing paper, and provides for a dramatic improvement in the dialogue between the care provider and the patient. It also lays the ground for more proactive and preventative care, enables efficient clinical work flows, reduces costs for the healthcare system and increases patient satisfaction.

The Ofek system for integrated electronic health records has proved successful to the point where it is now covering all of the company's 14 hospitals and thousands of clinics, plus two government run medical centres - Sheba and Ramban, which asked to join the system.

Proven concept

"It proved the concept that it could be extended to other hospitals," Blondheim says. "Once we proved we could connect to the two big government hospitals we covered a lot of the technology and ethical issues. It can all be solved.

"Theoretically it could be the basis of a national healthcare record, but there are issues that have to be overcome. It's a political issue, in that the other HMOs are competitors and this raises obstacles. It's also a financial issue, in that somebody has to put up the money.

"It's in the air all the time, and I hope that people will demand that they shouldn't have to come to the point of care without all their information available there."

She does not dismiss the idea of overseas access to the virtual patient record but qualifies it heavily by saying it's "for the future".

More immediate ambitions include providing patient access to the records from home and building a dialogue on the patients' involvement in their medical records. But more pressing is to make the system more responsive to the needs of physicians.

Surveys have shown that those working in different specialties would like different information in the minimum data set, while keeping all the information in the background, and Clalit is looking to respond to the demand.

"They are always in a hurry and looking at those first two or three screens is very important," Blondheim says.

Problems and potential: HL7

Wed, 02 Jan 2008 14:53:00 GMT

The HL7 conference made clear that some painstaking work is needed to achieve interoperability

It may have something to do with the number of syllables and the potential for tongue tripping, but the very word 'interoperability' suggests that it isn't easy. In real terms it is a complex business that has already taken several years of work, and is likely to demand a long term evolution rather than result in a 'Eureka!' moment.

It has its enthusiasts, however, and a number gathered in London recently to discuss the state of play at the HL7 conference. If one thing became clear it was that the effort is taking place on constantly shifting ground.

There is a long standing option for providing interoperability of a sort in the form of middleware. Tony Mottram, a board member of HL7 UK, said that while there is no single definition for the term, it usually involves breaking and reassembling messages for grouping and rerouting according to the purpose.

He said there is a debate over the advantages, but to him one of the main ones is that it supports end to end communication between disparate systems. In addition, it can provide different interfaces to accommodate different user bases, supports the harmonisation and rationalisation of processes, and allows each discipline to retain control of its own data, something which is not always the case with other methods of communication.

Collaboration tricky

One of the perceived disadvantages is that it needs the collaboration of all the stakeholders to implement, something which gets trickier as the number expands. Also, it may increase the overhead costs attached to a process, and may not be possible to rationalise without jeopardising the outcome.

It is still used, however, because it is tried and trusted, is less disruptive and does not carry the risk of a 'big bang' approach. But the holy grail of end to end messaging is still some way off, intensifying the need for an interoperability framework.

This is where HL7 comes in. Ed Hammond, US chair of the organisation, said it is now placing an increasing focus on interoperability standards, aligned with paying more attention to the clinical community.

He identified a number of recent changes which are shaping the work, among them the addition of geneomic and proteomic data to health records. Numerous standards are needed to make this work and he said there is no time to waste in getting them in place.

Other changes include a movement towards a more preventitive and proactive healthcare model, in which the balance of data going into records would be different, modifications in workflow, and the integration of data from a range of different sources.

"We have to deal with multiple sets of care," he said. "We have to understand what is common about the data and deal with the multiple classes."

This is creating a framework for interoperability that takes in semantics, functions and business in the healthcare process, and privacy and security. The latter area is "still not quite fully embedded" in the relevant work, Hammond said.

He also made the point that HL7 should see itself less as a specialist organisation and more as a larger, clinical based community. This is necessitated partly by its work now relating to electronic health records, which is demanding that standards are influenced by policy as much as technical matters.

Data and care

"We need to combine the political and technical side of things," he said. It is not necessarily true that more data means better care, and it has to be worked out what standards are necessary.

Among the future factors that he said would have an influence are the growth in evidence based medicine, which requires standards for knowledge representation, knowledge extraction for data, knowledge transfer and its use. Others include standards for clinical guidelines, care plans and decision support, and for data to be reused in clinical trials.

An indication of the problems involved was provided by Grant Kelly, the Snomed clinical lead for Connecting for Health, who stated bluntly that "clinicians and standards are not natural bedfellows".

In a description of the importance of standards for an electronic patient record, he said they have to be sold to clinicians on the basis of their benefits, and help to tie together the various clinical activities covered by the National Programme for IT. Good records support good decision making, and they have to be in a form that is easily shared, as decisions are often made by clinicians other than the doctor who is in charge of the patient's treatment, notably out of hours or in an emergency. The fact that notes are not always fully legible intensifies the problem, and to date standards of knowledge transfer among clinicians have not been particularly good.

The central question is what do clinicians want, but Kelly suggested that as things stand they do not really know - with the exception of GPs who want what they have already.

"At least if we get going now we can find some common ground," he said.

Forging guidelines: interoperability and remote care

Wed, 02 Jan 2008 14:49:00 GMT

A US based industry organisation has laid the ground for a market of interoperable remote care products

A step towards interoperability took place on the other side of the Atlantic in September, when the Continua Health Alliance unveiled the key components of the first set of technical standards for personal health products. It describes it as a move towards building a market of connected products and services that support the drive to remote and self-care.

Although the organisation, which was set up in June 2006 and already has over 130 member companies, is focused primarily on promoting healthcare at home, it acknowledges that interoperability of the relevant devices is one of the prerequisites. Earlier in the year its president and chair David Whitlinger said it had a mission to establish a marketplace of interoperable personal telehealth systems.

One of its priorities has been the development of a set of guidelines to increase assurance of interoperability. The idea is that manufacturers that meet the guidelines, ensuring that their products work seamlessly with others, will be permitted to use the Continua certification logo to promote them.

The full set is due to be published early in 2008, but the September announcement provides an indication that Continua has emphasised the importance of the tried and trusted in its decisions.

Technology marriage

It says that Version One, as it has named the standards, represents a marriage of well developed healthcare informatics data standards with proven consumer electronic technologies. This integration provides the necessary specifications for connectivity, and includes the Bluetooth Medical Device Profile Specification (Bluetooth SIG), USB Personal Health Device Specification (USB Forum), Health Level 7 for integration with standards based electronic health records, and ISO/IEEE 11073 Personal Health Device Specifications from the International Standards Organisation and the Institute of Electrical and Electronics Engineers.

The healthcare record standards will use HL7 CCD for documents and HL7 v2.5 for messaging. These will help to provide a bridge between a healthcare provider's electronic record system and a remote patient monitoring server, which in turn can be linked to a remote monitoring system in the patient's home.

Devices covered by the ISO/IEEE standard include pulse oximeters, thermometers, weighing scales, strength fitness equipment and monitors for medication, glucose levels, cardiovascular condition and blood pressure.

Continua explains that this should provide the basis for making patients less dependent on having to go to a doctor's surgery. In managing chronic diseases, a network of readily connected health and medical devices will enable people with conditions such as diabetes to share vital information with their doctors, using devices such as blood pressure monitors and pulse oximeters. They can be combined with the likes of motion sensors, medication reminders and emergency response services to ease the burden on families and professionals who care for old people, while enabling the patients to stay independent.

In addition, data transport hardware and software certified by Continua will further enhance the interoperability of the devices.

Whitlinger says this will support the cause of enabling patients to take an active role in their own care.

"Continua's membership will utilise the Version One guidelines to create connected health devices and services that provide individuals the tools they need to proactively manage their health," he says.

Remote care is still in its pioneer stage in the UK, but it could receive a significant boost from a consumer market of trusted products. The large number of companies already involved in Continua suggests that the move could quickly gain some momentum in the US, in which case it may not be too long before the logo begins to appear in Europe. That could provide the push to make remote care an established feature of the health service.

A standard for Europe

Mark Say — Wed, 02 Jan 2008 14:44:00 GMT

The European Commission is aiming to carve out a route towards EU-wide interoperability of healthcare systems

We've all heard plenty about the number of people coming from other EU countries to work in the UK, less about Brits going to work on the continent, and a lot about the temptations of retiring to Provence or the Algarve. At some time, almost anyone involved in these migrations are going to need healthcare, and the clinicians will be eager to tap into information on the patient's history.

So far it has been a fringe issue, but the interoperability of healthcare systems around the EU is likely to take on a much higher profile over the next few years. It has been on the European Commission's agenda for some time, but now it has begun to gather the momentum that could make it a big challenge for Europe over the next few years.

Many of the problems in achieving interoperability revolve around the nature of the data rather than the ability of systems to exchange information. In healthcare it is critical that data is properly understood, but in the past there has been no guarantee that the person at the receiving end will interpret it in the same way as intended by the sender.

The College of American Pathologists began to address this problem 40 years ago when it began work on the Systemised Nomenclature of Medicine (Snomed) to provide a structure for clinical information. But standards have not been developed to a sufficient extent to make systems truly interoperable within national boundaries, let alone across a continent.

The European Commission implicitly acknowledged this in 2004 when it adopted the eHealth Action Plan. This is a roadmap for the increased use of technologies in areas such as electronic prescriptions and computerised health records, with a series of targets lined up.

It has now trying to move forward. Last year the Commission's ICT for Health Unit produced the Connected Health report, outlining the steps needed to create a framework for interoperability, and it is aiming to publish a set of guidelines early next year.

The steps include standardised services related to identification and authentication, and moves towards semantic interoperability, the latter made more urgent by the development of automatic language processing and intelligent information retrieval. Alongside this is a need for standardisation in areas such as technical interfaces, protocols, messages, documents and even clinical processes, all of which would work better if defined at an international level. This could be supported by a certification process, which could work in a centralised manner or through a network of certifiers.

One of the measures outlined was for an ad hoc expert group on interoperability to compile advice on the necessary requirements. A spokesperson for the ICT for Health Unit says that during the summer it completed a document, Recommendation on eHealth Interoperability, which during consultation received 20 comments from industry and user group representatives, and was discussed at three meetings organised by the Commission.

Some of its main features seem to reiterate the basic aims: starting a dialogue on achieving a European health information space by 2015: indicating where there needs to be agreement and engagement for interoperability; and forming a framework within which all members states could find an appropriate role. But it also calls for a common terminology framework to improve semantic interoperability, and further developing the limited range of applications among which information can already be shared.

The next steps for the ICT for Health Unit involve launching a large scale pilot, under the EU's Competitiveness and Innovation Programme. This will aim to provide a federated solution, which would work across borders, for patient summaries and medication data. It is also working on proposals for conformity testing and accreditation schemes of e-health systems based on international best practice, and on the legal framework for the protection of personal data when information is exchanged.

The spokesperson says its more general aims are "to successfully launch a 'lead market initiative on e-health' in cooperation with DG Enterprise". In effect, it wants to promote plenty of innovation in the field.

One of the recurring features of the EU's plans is an assertion of the need for standardisation. This is encouraging it to work with HL7, the international organisation formed by healthcare professionals and software specialists to develop and implement standards for interoperability.

Martin Whittaker, a director of its national affiliate HL7 UK, welcomes the work the EU is doing in the field.

Standards benefits

"It's good that the EU is encouraging the use of international standards," he says. "It will drive down the cost of software development and the integration of links between systems.

"The risk has been that it would produce unnecessary standards that are not supported by the industry, but because of the current collaboration we think it will choose the right standards."

He says, however, that there are stiff barriers to interoperability on a European scale. There have been efforts within the UK over a number of years with limited success, and there is still a question mark over whether it is technically possible to achieve it across the continent.

He cites the experience of the Veterans Administration in the USA, one of the country's largest healthcare providers.

"It has a huge and complex hospital network, and at least has the same systems in all its hospitals, but it is finding it very hard to transfer information between them. It's even harder to do this just within the UK where there are a variety of systems."

The ICT for Health Unit acknowledges that the barriers are significant. Along with the lack of common standards, its spokesperson says the main obstacles to interoperability are the absence of common certification, market fragmentation and uncertainty - among patients and in a legal sense - around issues such as the protection of personal data and cross-border reimbursement.

There is a starting point, however, in providing a structure for the coding of information. Snomed has laid the basis for this by providing a code structure for clinical terminology. It is the only coding system to be used internationally, and is independent of national languages and their potential for interfering with the exchange of information.

"If we can get to the stage where we can structure and code clinical information the language problem disappears," Whittaker says. "But if there is no code you cannot structure the information."

He says another important element is that HL7 is working with the ISO in the US on a set of relevant standards, some of which have already been published.

The efforts have attracted some attention in the European Parliament. John Bowis, MEP for London, has been one of the leading advocates for action in the EU to support patient mobility. He acknowledges the significance of the interoperability effort in ensuring that patients who have moved from one member state to another, or may even be visiting for medical treatment, get the best possible service by making their information available.

Need for action

"I welcome anything done to improve patient information, particularly on the sharing options and to put security into the exchange of patient records," he says. But there is a need for swift action to maintain the momentum for the guidelines.

"I believe they need to get their skates on because this Commission will run out of time when the European Parliament expires in 2009. They need the proposals to land this year (2007) to have a chance of legislation going through next year."

Bowis says, however, that interoperability of systems has to be supported by other measures to support the aim of responding to patient mobility around the EU. These include providing patients with legal certainty on their opportuntities to go abroad for treatment, an understanding of the relevant procedures if something goes wrong in the treatment - which would have to be dealt with in the country where it took place - and provisions for patient safety.

This takes us to the verge of a separate debate, and it could be argued that the priority is to establish the technical conditions for interoperability. Martin Whittaker suggests that the EU's willingness to work with the specialists who have already laid the ground bodes well for the future.

"The key thing about the European initiative is that we are now working together," he says. "Without that it would be impossible."

Mark Say