Monday, July 06, 2015

Weekly Australian Health IT Links – 6th July, 2015.

Here are a few I have come across the last week or so.
Note: Each link is followed by a title and a few paragraphs. For the full article click on the link above title of the article. Note also that full access to some links may require site registration or subscription payment.

General Comment

What a busy week with Telstra off and rolling, education for the new PCEHR tendered and the new Royal Adelaide Hospital seemingly in more Health IT trouble.
Enjoy the read!
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Govt readies e-health record push to boost adoption



Training drive slated for 2016.

The Department of Health will renew efforts to address under-utilisation of electronic health records by the clinical community, with a training and promotion campaign due to kick off in January 2016.
The federal government’s $1 billion e-health scheme - originally dubbed the personally controlled electronic health record (PCEHR) but since rebadged myHealth Record - has struggled against poor adoption rates since the system went live in 2012.
Ahead of the May 2015 budget, Health Minister Susan Ley said the government would make the electronic health records ‘opt-out’ - giving all Australians an account by default.
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New service provides consultation with your doctor by telephone or video

Telstra Health has launched a new GP telemedicine service – ReadyCare – that facilitates access to a doctor using phone or video to receive advice, treatment, diagnosis and prescriptions.
Registered doctors have been employed by the service which will operate 24-hours a day from a purpose built telemedicine centre in the Sydney suburb of Alexandria. The service can be accessed by calling 1800 READYCARE (1800732392) or through the ReadyCare app.
Shane Solomon, Managing Director of Telstra Health, said patients calling ReadyCare will first speak to a telemedicine assistant to determine if the call is suitable for a telemedicine consultation and a GP will then call them back at a time that suits the patient.
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Telstra's GP telemedicine service, ReadyCare, is up and running

Simon Thomsen Jul 2, 2015, 11:10 AM
House calls by a doctor have a whole new meaning with Telstra launching ReadyCare, its telemedicine service, today.
The telco’s health division has built the digital project, including a purpose-built centre in Sydney’s Alexandria. It lets people speak to a doctor via phone or video for advice, treatment, diagnosis and prescriptions. Patients are screened, first up, to see if they’re suitable for an e-health consultation.
Telstra Health managing director Shane Solomon said the 24/7 service was the next logical step in Australian health care in the digital era. There’s even a smartphone app, as well as a toll-free number to call.
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Telstra launches its telemedicine service

ReadyCare opens for consultations
Telstra Health, the telco's healthcare focussed business, has officially launched its ReadyCare service.
ReadyCare offers 24/7 remote consultations with GPs through a hotline (1800 READYCARE) or an app.
An Android app will be in the Play store from tomorrow and an iOS app is expected to be available within the next two to three weeks.
ReadyCare is a product of Telstra Health's partnership with Swiss telemedicine company Medgate.
"ReadyCare is based on technology and processes used by Medgate, the leading telemedicine provider in Europe, who currently conduct more than 4300 telemedicine consultations daily," Telstra Health managing director Shane Solomon said.
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Medical privacy 'at risk'

29th Jun 2015
A NATIONAL privacy rights group has criticised plans to transition the PCEHR to an opt-out system, warning the “minimal value and benefits” of a PCEHR do not match the privacy risk of establishing a repository of every Australian’s identity and health data.
The Australian Privacy Foundation warns the data repository won’t just be of high value to hackers. 
“The identity data will be seen as very useful to the government, especially when cross-matched against internet and tele­communications metadata and other government databases,” it says.
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The other data retention: Concerns over opt-out eHealth model

Australian Privacy Foundation says opt-out model for eHealth record not justified
The government's move to change the current national eHealth record rollout to an opt-out model has raised concerns among privacy advocates.
A 2013 review into the Personally Controlled Electronic Health Record (PCEHR) recommended changing from opt-in to opt-out in order to boost uptake to help the system to reach critical mass.
The government's response to the review included moving to rename the PCEHR to 'My Health Record' and trialling an opt-out approach.
"Doctors have indicated they’re much more likely to use the system if all their patients have a record," health minister Sussan Ley said earlier this year.
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Indigenous Eye Health On Track and Online

on July 1, 2015 at 12:10 pm
In a report published by the Medical Journal of Australia, support for Indigenous eye care is improving according to 42 recommendations made in a roadmap aiming to close the gap in health services. University of Melbourne researchers Dr Marian Abouzeid, Mitchell Anjou and Professor Hugh Taylor said that progress has been made to increase services, improve efficiencies and support better Indigenous patient engagement with the eye care system.
Key objectives of the roadmap include:
  • The increase of accessibility and uptake of eye care services by Indigenous Australians
  • Improvement of coordination between eye care providers, primary care and hospital services
  • Improvement of awareness of eye health among patients and clinicians; and
  • Ensuring culturally appropriate health services.
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New Royal Adelaide Hospital faces a dud IT system, surgeons say

  • July 02, 2015 9:29PM
  • MEDICAL REPORTER BRAD CROUCH
THE troubled $422 million IT system that is meant to run the new Royal Adelaide Hospital is “disastrous”, according to surgeons who have rejected State Government assurances that all is well.
The usually conservative Royal Australasian College of Surgeons has warned it could not guarantee patient safety under the planned system because of problems that include doctors being prevented from prescribing essential medicines.
SA Health’s planned Enterprise Patient Administration System (EPAS) was supposed to be introduced to hospitals across the state but is now in just three, including the Repatriation General Hospital – where medical staff have officially complained to Health Minister Jack Snelling because it is compromising patient safety.
The new RAH has been designed to operate solely with EPAS and there is no space for a paper-based records system.
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eHealth delays threaten new Royal Adelaide Hospital

Friday, July 3, 2015 - 11:02
Promised as a flagbearer for the brave new world of eHealth when it opens in April 2016, the $1.85 billion new Royal Adelaide Hospital (nRAH) will instead have to cope with a “hybrid” environment including paper records and workflow due to delays in a decade long program to implement a state-wide electronic health record.
Promoted as Australia's most advanced hospital, the nRAH is also facing supply chain issues due to SA Health’s a failure to complete a long running rollout of Oracle, initially commenced in 2010.
A report from the South Australian Auditor General handed to the Parliament this week says a 10 year, S214 million program commenced in 2007 to deliver a state-wide Enterprise Patient Administration System (EPAS) had “ambitious timeframes and an under estimation and lack of detailed understanding of the effort required. In particular, the underestimation of effort required to implement EPAS at a major hospital site.
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Health | Fri Jun 26, 2015 11:48am EDT

Online tools can help manage pain

By Lisa Rapaport
 (Reuters Health) - People with chronic pain may be able to use online tools to manage their symptoms, lessening the need for frequent doctor visits, an Australian study suggests.
Researchers tested a series of web-based pain management tutorials on a group of adults who had been suffering symptoms for more than six months. Regardless of how much contact the patients had with clinicians, they all experienced significant reductions in disability, anxiety and average pain levels at the end of the eight week experiment as well as three months down the line.
“While face-to-face pain management programs are important, many adults with chronic pain can benefit from programs delivered via the internet, and many of them do not need a lot of contact with a clinician in order to benefit,” lead study author Blake Dear, a psychology researcher at Macquarie University in New South Wales, said by email.
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Melbourne doctors get behind a new health website

Date June 29, 2015 - 12:45PM
A new health website backed by Melbourne doctors was launched at the weekend.
Doctors are usually very wary when patients turn to "Dr Google" to look up symptoms or self-diagnose an illness.  
But a group of Melbourne health professionals are behind a new regulated website designed to give accurate medical information.
Launched on the weekend, HealthAnd.com touts itself as an e-health site to store health information and answer frequently asked medical questions. 
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Vaccine records need GP attention: audit

Michael Woodhead | June 29, 2015 |
An audit of the national immunisation register has exposed a number of holes in the system including tardy notification by GPs, poor communication and practice software incompatibilities
The audit of the Australian Childhood Immunisation Register (ACIR) that covers more than two million children up to the age of seven was carried out by the Australian National Audit Office.
Overall the audit concluded that childhood immunisation data was generally well managed by the department, with accuracy rates in excess of 98%.
However it revealed a number of concerning areas that the authors said needed improvement.  
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Tech Talk: 'Smart skin’ UV detector

Serkan Ozturk | July 1, 2015 |
In this week’s Tech Talk, we take a look at 'smart skin' technology, new travel medicine software for GPs and plans for the expansion of eHealth in rural NSW.
'Smart skin’ UV detector
Dubbed 'smart skin’ technology, Australian researchers are confident that a new material containing fine layers of zinc oxide will soon alert wearers to harmful levels of pollution and UV radiation.
Developed by a team at RMIT, the technology involves users wearing stretchy electronic sensors that have the ability to sense gases such as hydrogen and nitrogen dioxide, as well as UV exposure.
Researcher Dr Madhu Bhaskaran (pictured, with the material) says the technology — to be integrated with smart watches and other digital devices — is expected to be available to the public in the next five years. “The UV sensors can play a vital role in preventing skin cancer by warning people when the UV index is high and UV exposure has exceeded a safe level,” Dr Bhaskaran says.
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Scanning the brain's magnetic fields offers hope for epilepsy patients

Date June 29, 2015 - 6:30PM

Bridie Smith

Science Editor, The Age

Stewart Duguid used to have an epileptic seizure every fortnight. He never knew when they  would strike,  and they proved impossible to control with medication.
"I had the tonic clonic seizures, the ones where you fall to the ground and shake," the 26-year-old said. "I'd wake up exhausted and need to get my breath back."
However, for the past year he has been living seizure-free after being among the first Australians to have a MEG machine scan his brain's magnetic fields.
Using the machine, doctors were able to pinpoint where the abnormal activity was coming from before surgeons operated last May and removed a section of brain from his frontal cortex.
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SA's new regional primary health network starts work

July 1, 2015
The new body managing primary health services across regional South Australia begins operations today.
Last year, the Federal Government announced it was slashing funds to the nation's 61 Medicare Locals introduced by Labor, replacing them with 'Health Networks'.
The networks will focus on national priorities of chronic disease management, mental health, aged care, e-health and ensuring a sustainable workforce.
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CEOs reveal their biggest mistakes

  • June 28, 2015 12:58PM
EVERYONE makes mistakes.
Chances are, your boss has made more than you. Here, six Aussie chief executives reveal some of their early blunders, and importantly, what they learned in the process.
Phil Offer, CEO, Medical Director
“Before moving into e-health I worked in telecommunications for more than 16 years. The great thing about the industry’s pace is you need to make calls on issues all the time — which is code for, things don’t always go to plan.
In the early noughties, I reviewed pricing for the lead handsets that the acquisition teams were recommending. Back then, ‘big data’ and ‘algorithms’ weren’t even buzzwords, so demand planning was more art than science.
The team decided to capitalise on a new Nokia handset and drop it to a lower price to stimulate sales. We thought it would go well and modelled the sales upside and short-term impact from the handset subsidy.
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NBN satellite to give bush a cleaner bill of health

The NBN satellite service promises to deliver a boon for rural Australia with results of one telehealth pilot program highlighting its enormous potential to provide diagnostic health services to those in remote locations.
A trial by a team of CSIRO researchers has used the interim NBN satellite services to successfully deliver a solution that ­connects specialists to patients in remote areas, who generally have little or no access to eye screenings.
The trial was carried via the ­installation of satellite dishes in eight community health centres — four in the Torres Strait Islands and another four in southern Western Australia. The retinal images and health data was uploaded over satellite broadband on to the electronic health records of the patients and sent to specialists for consultation.
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Warning: digital challenges ahead

There were a few interesting tech news facts this week. I thought this one was pretty crazy: a Dutch campaign group used a drone to deliver abortion pills to Polish women, in an attempt to highlight Poland’s restrictive laws against pregnancy terminations.
There was scary news too: a private health insurer encouraged its members to use a Facebook-owned exercise app to qualify for free cinema tickets. Not surprisingly, Facebook was entitled to disclose all information shared via the app, including personal identity information, to its affiliates.
But there was also this: Telstra has launched its ReadyCare telehealth service. For those willing to pay $76, a doctor on the other end of the phone or video link is ready to care for you. No need to visit a GP or emergency department.
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NEHTA reduces time and effort for vendors connecting to the PCEHR

Created on Wednesday, 01 July 2015
The National E-Health Transition Authority (NEHTA) has today published revised guidelines for software vendors that will reduce the time and effort of integrating their products with the Personally Controlled E-Health Records (PCEHR).
The Conformance, Compliance and Accreditation (CCA) Governance Group and NEHTA have listened to and acted on feedback from the health software industry and state and territory governments about the need to make this process quicker and more accessible.
However, vendors have previously undergone a ‘Conformance, Compliance and Accreditation (CCA) process’ to obtain approval to connect to the PCEHR which involved NEHTA observing vendor self-assessments. Under the new guidelines, from 1 July 2015, NEHTA will no longer observe vendor self-assessments. Instead, vendors will ‘self-declare’ conformance to PCEHR specifications directly to the Department of Health as PCEHR System Operator under a new ‘Conformance, Compliance and Declaration (CCD) process’.
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Kiwi tech receives clean bill of health as Orion wins big in UK

“This award is welcome recognition of the vital health benefits Orion Health is helping provide across the United Kingdom."
New Zealand-based technology firm Orion Health has won the 2015 HealthInvestor award for Technology Provider of the Year for establishing partnerships that deliver better healthcare services.
Presenting the award at a gala evening with over 1300 health sector leaders in London earlier this month, judges claimed Orion Health stood out for having a “big impact in providing technology to health services where it most mattered across numerous major UK health projects.”
The judges cited Orion Health for its role in “innovative and ground-breaking partnerships” helping a “highly vulnerable, formerly ill-served group of patients, generating great results,” and an “excellent example of clinical business partnership in patients’ interest.”
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Turnbull says Libs vindicated as 5 pay for high-speed broadband

Annabel Hepworth

Only five consumers have been willing to pay for internet speeds exceeding 100 megabits per second on the National Broadband Network, undermining Labor’s rhetoric about the demands for super-fast broadband.
The Australian can reveal that while the NBN has been rolled out to more than one million homes and businesses, just five consumers are on the package offering 250Mbps downloads and none has taken up a 500Mbps package.
The Australian has also been told that while 34 accounts are on the “gigabit nation” 1000Mbps downloads option, these are not genuine services provided to an end user as a one-gigabit service because they were either ordered in error or are being used for testing by service providers.
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  • Jul 3 2015 at 2:49 PM

Coalition policy shift creates NBN Co mess

by David Havyatt
In opposition, Malcolm Turnbull framed the NBN rollout as "in crisis," despite all NBN Co had achieved up to September 2013. As Communications Minister he has framed the NBN as a "mess" that needs to be "fixed," a frame that has been accepted by most commentators.
Eighteen months after NBN Co provided the Minister with its Strategic Review, he is persevering with that message while in reality the "mess" is a direct result of policy shift by the Coalition Government.
Mr Turnbull's pre-election framing reached a high point with the assertion that the "real cost" of Labor's NBN plan would be $94 billion, a figure splashed across the front page of the Daily Telegraph with no alternative analysis. The Coalition policy committed to all Australians having a 25Mbps service by 2016.
The Coalition's confidence in their ability to change the NBN was repeated by the Prime Minister in his Letter to Australians on election night, saying: "I want our NBN rolled out within three years and Malcolm Turnbull is the right person to make this happen."
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Mark Zuckerberg thinks telepathy is the future, here's how it could actually work

Date July 2, 2015 - 10:48AM

Caitlin Dewey

Internet satellites, virtual reality, even real working AI: It all pales in comparison to the future that Facebook chief executive Mark Zuckerberg has in mind. In a Q&A session with site users on Tuesday, the 31-year-old said he envisions a world where people — presumably Facebook users — don't need these types of communication intermediaries. Instead, they'll communicate brain-to-brain, using telepathy.
"One day, I believe we'll be able to send full rich thoughts to each other directly using technology," Zuckerberg wrote in response to a question about what's next for Facebook. "You'll just be able to think of something and your friends will immediately be able to experience it too."
But hold up: Is that even possible? And is that something anyone actually wants? TL;DR: Theoretically, yes; and, er — maybe not.
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Enjoy!
David.

Sunday, July 05, 2015

Some Intelligent And Hardly Complimentary Commentary On The Government Plans For The PCEHR. There Are Some Serious Issues Raised Here.

DoH asked for submissions on their plans for the Legislation around a modified PCEHR
Here is the link:
They closed on June 24, 2015.
In response, first we had some useful commentary from the RACGP.
You can find their submission here:

RACGP Submission to the Department of Health on the Electronic Health Records and Healthcare Identifiers Legislation Discussion Paper

24 June 2015
The RACGP welcomes the commitment made by the Government in its 2015-16 budget to strengthen the national e-health system and support the continued development of the PCEHR. There are well identified issues with the current PCEHR model that require meaningful engagement between the Federal Government and the healthcare sector in order for these issues to be addressed effectively and for the PCEHR to be adopted. It is our view that the ongoing work program should focus on:
  • the core clinical documents relevant to general practice (Shared Health Summary and Event Summary)
  • medicines reconciliation, and
  • point-to-point communication (interoperable Secure Message Delivery).
These are the core clinical value propositions for GPs and other clinicians and provide the platform for continuing engagement with the clinical community.

Downloads

RACGP Submission To The Department Of Health On The Electronic Health Records And Healthcare Identifiers Legislation Discussion Paper (pdf 423KB)

Here is the direct link:
I was quite surprised to read the submission and see just how many issues the RACGP identified. The make it very clear there is a massive mountain of work to do to get their support.
There is some coverage of this submission and one from the APF found here:

The other data retention: Concerns over opt-out eHealth model

Australian Privacy Foundation says opt-out model for eHealth record not justified
The government's move to change the current national eHealth record rollout to an opt-out model has raised concerns among privacy advocates.
A 2013 review into the Personally Controlled Electronic Health Record (PCEHR) recommended changing from opt-in to opt-out in order to boost uptake to help the system to reach critical mass.
The government's response to the review included moving to rename the PCEHR to 'My Health Record' and trialling an opt-out approach.
"Doctors have indicated they’re much more likely to use the system if all their patients have a record," health minister Sussan Ley said earlier this year.
"We also need full coverage if we’re to cut down on inefficiencies created by not having one seamless records system, such as double ups with testing, prescriptions and other procedures."
However in a submission (PDF) to a Department of Health consultation, which closed late last month, the Australian Privacy Foundation (APF) argued that moving to an opt-out model is not justified.
The shift will only increase the risks to privacy that already exist from having "a high value repository of every Australian’s identity and health data".
"With respect to the proposed move to opt-out, we believe that there is a strong possibility that there will be a realisation amongst the population at large that the PCEHR is actually a thinly disguised national identity number attached to some health information, none of which can be relied upon because there is no way to medico-legally trust the information contained," the APF argued in its submission.
"[T]he identity data will be seen as very useful to the government, especially when cross-matched against internet and telecommunications metadata and other government databases," the organisation argued.
The government should either decommission the system or completely re-architect it "such that it is able to support major changes to existing health care work practices and is much better and more closely integrated with existing health record systems".
The shift to an opt-out model will have consequences for the risk profile of the eHealth program, the APF said.
Lots more here:
There is also coverage here:
http://www.medicalobserver.com.au/news/medical-privacy-at-risk

The Australian Privacy Foundation (APF) Submission is found here:
Here is the Exec Summary.

Summary and Conclusions

The Australian Privacy Foundation has  a number of very serious concerns with the PCEHR, the  proposed changes to the system and its enabling legislation.
These can be summarised as follows:
1. The value of the PCEHR, as only one eHealth system in Australia, has not been  demonstrated. The PCEHR has been implemented such that it replicates current health care  practices and therefore offers limited functionality. The opportunity to enable better and  more effective and efficient work processes has been missed;
2. The documentation available on the websites of NEHTA and the Health Department is old, inconsistent, incomplete and does not adequately describe the fundamental drivers and requirements of eHealth care or the way in which these have been architected and designed
into the system; and
3. The risks to privacy of a high value repository of every Australian’s identity and health data are not matched by the minimal value and benefits inherent in the PCEHR. Moving to an opt-out model is not justified and will only increase that risk.
A major factor is the poor legislative protection afforded to health information in Australia which, in our opinion, has led to a lack of trust that the risks are, or will be, adequately managed. With respect to the proposed move to opt-out, we believe that there is a strong possibility that  there will be a realisation amongst the population at large that the PCEHR is actually a thinly disguised national identity number attached to some health information, none of which can be relied upon because there is no way to medico-legally trust the information contained. However the identity data will be seen as very useful to the government, especially when cross -matched against internet and telecommunications metadata and other government databases.
Based upon our many concerns, we do not believe that the proposed changes to the system or the legislation will achieve any significant improvement in use by the health community
We contend that the government has only two alternatives: either decommission the system as soon as possible, or completely re-architect the system such that it is able to support major changes to existing health care work practices and is much better and more closely integrated with existing health record systems.
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Disclosure - I am a member of the Health Committee of the APF.
I have also found submissions here:
Here is the summary from the Office of The Australian Information Commissioner:

General comments

The OAIC welcomes the opportunity to provide the Department of Health with comments on the Electronic health records and healthcare identifiers: legislation discussion paper155 KB (the discussion paper).
The discussion paper outlines a range of proposed changes to the Personally Controlled Electronic Health Records Act 2012 and the Healthcare Identifiers Act 2010. The proposed changes relate to areas including governance, participation models, the obligations of eHealth system participants, and privacy. While section 3.5 of the discussion paper is named ‘privacy’, the OAIC considers that privacy considerations arise in relation to all sections of the paper. We have therefore commented on a range of proposals throughout the paper.
In making the comments below, we recognise the benefits that are expected to accompany an effective eHealth record system in Australia. These benefits include better health outcomes arising from the improved availability and quality of health information, fewer adverse medical events, and efficiency through reduced duplication of treatment.
However, changes to the eHealth record system do pose potential privacy risks. The system is expected to increasingly handle significant volumes of sensitive health information. In addition, the Government has announced trials of an opt-out model of participation, with the possibility of that model being expanded nationally in the future. Under opt-out arrangements, the health information of an individual who does not opt-out will be handled in the eHealth record system without that individual’s express consent.
In the context of an opt-out system, it is important to provide individuals with control over if and how their health information is handled, and to ensure strong privacy protections are in place for those who do not exercise their choice to opt-out. We consider that an eHealth system operated on an opt-out basis should be designed with privacy as a critical consideration. Ensuring that privacy is adequately addressed is fundamental to establishing and maintaining public confidence in the system.
We acknowledge that the discussion paper raises for consideration a range of privacy issues, and explains the Department’s approach to managing these. We welcome this focus on privacy as a central consideration. The specific comments below outline the OAIC’s views on the key privacy issues that in our view are raised by the proposals. 
The Consumers Health Forum responds here:
The College of Psychiatrists highlight some very serious issues here:
These two paragraphs raise an issue I have no idea how the PCEHR could ever properly manage
“The RANZCP also wishes to emphasise an important issue in relation to mental health diagnoses under the PCEHR system. Mental health diagnoses are often less clear cut than their physical health equivalents. Diagnoses can change as more information becomes available, research in the field develops or courses of treatment are found to be more or less effective. Therefore, a change in a patient’s mental health diagnosis is a common occurrence and -if previous diagnoses are not critically reviewed -it can and does result in many years of unnecessary treatment and stigmatisation of the patients concerned.
Consequently, the RANZCP considers that more information is required as to how the issue of a changing diagnosis will be reflected in a PCEHR. If a diagnosis is made by one practitioner and then reviewed, changed or removed by another, for example, how will this show up? Are there measures in place to avoid stigmatisation of an individual due to an incorrect diagnosis? Any PEHCR system would need to be flexible enough to allow easy correction of mislabelling and adjustments made as the result of new information coming to light or a change in presentation.”
This Google Search may soon find others:
(submission "Electronic Health Records and Healthcare Identifiers: Legislation Discussion Paper")
All in all there is some serious thought provided here. Will be interesting to see what responses we see. I bet all this is just ignored - but would be happy (no thrilled) to be proved wrong!
David.

AusHealthIT Poll Number 277 – Results – 5th July, 2015.

Here are the results of the poll.

Is Conducting Trials Of Opt-Out Of The PCEHR In Defined Geographical Areas A Practical and Implementable Idea?


Yes 5% (5)

Probably 13% (14)

Neutral 8% (9)

Probably Not 23% (25)

No Way 51% (56)

I Have No Idea 0% (0)

Total votes: 109

Seems a pretty good majority do not think the planned opt-out trials are a practical idea.

Good to see such a great number of responses!

Again, many, many thanks to all those that voted!

David.

Saturday, July 04, 2015

Weekly Overseas Health IT Links -4th July, 2015.

Note: Each link is followed by a title and few paragraphs. For the full article click on the link above title of the article. Note also that full access to some links may require site registration or subscription payment.
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Nurse Smartphone Ownership, App Use Eclipses that of Docs

JUN 26, 2015 7:32am ET
According to a new survey, 95 percent of nurses own a smartphone and 88 percent of them use smartphone apps in their daily work to improve patient care—a higher percentage than physicians.
The survey of 241 nurses, conducted by market research firm InCrowd, found that bedside access to drug interactions and clinical data were the most popular uses of smartphones by nurses.
“Nurses reported using their smartphones for fast access to patient care information across a wide range of daily nursing tactics, from receiving patient photos of a rash to setting a timer for meds administration,” stated InCrowd. 
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How can hospitals protect their medical equipment from malware?

Posted on Jun 26, 2015
By Adam Winn, OPSWAT
The challenges in protecting hospitals from cyber attacks are very similar to those faced in ICS and SCADA environments; the equipment used in hospitals is not user-serviceable and therefore often running out-of-date software or firmware. This creates a dangerous situation where:
The devices have known vulnerabilities that can be easily exploited by bad actors
Administrators are not likely to notice malware running on the device as long as nominal operation is maintained
The end goal of bad actors infecting a medical device is to use it as an entry and pivot point in the network. Valuable patient records are not likely to be present on the medical devices, but those devices often have some level of network connection to the systems that do contain patient records.
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Report: Telehealth Video Visits to Reach 158M by 2020

Telhealth video visits will increase from 19.7 million in 2014 to 158.4 million per year by 2020, according to a new report from Tractica. The report, “Telehealth Video Consultations“, examines the telehealth market and technology issues surrounding telehealth video visits for both clinical and non-clinical applications. The firm also predicts that, while clinical consultations currently constitute more than three-quarters of the market, growth over the next several years will be especially strong in non-clinical settings. Tractica forecasts that non-clinical video consultations will outnumber clinical consultations by 2019.
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Why nursing homes should embrace HIEs

June 26, 2015 | By Susan D. Hall
Inefficient and unclear communication between hospitals and nursing homes can complicate care, so researchers are looking to health information exchanges to change that, according to research published at Applied Clinical Informatics.
Researchers from the University of Missouri undertook a project--using a $14.8 million grant from the Centers for Medicare & Medicaid Services--aimed at reducing avoidable re-hospitalizations among nursing home residents, according to an announcement.
In assessing the HIE readiness of 16 nursing homes, they found that while many used electronic record-keeping internally to support patient care tasks most of the technology was not used to communicate externally, such as with hospitals or off-site pharmacies. In additon, tracking patients' medications or scheduling appointments often was done using separate systems.
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Internet of Things just the beginning of disruptive healthcare innovation

June 26, 2015 | By Alok Saboo
By John DeGaspari
The proliferation of Internet-connected devices is changing healthcare delivery, said panelists at last week's 2015 BIO International Convention in Philadelphia. And there's much more disruptive tech in the industry's future. 
Brandon Staglin, director of marketing communications at the One Mind Institute, discussed the role of digital therapeutics in the treatment of neurological disorders, according to an article in Bioscience Technology.
Staglin, who was diagnosed with schizophrenia in 1990, spoke of the healing potential of wearable sensors, saying they could help monitor his thoughts, set schedules and help with medication adherence.
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American Patients Want To Chat With Their Doctors Over Facebook or Email

By Andrea Alfano, Tech Times | June 25, 3:25 PM
House calls are mostly a thing of the past, at this point. Today's patients are looking for Facebook calls.
A national survey of over 2,000 American customers of a retail pharmacy found that many patients want more online resources. More than a third of the patients surveyed had contacted their doctor via email in the past six months, and 18 percent sought medical help via Facebook, according to the study, which was published in the Journal of General Internal Medicine.
As many as 57 percent of the patients who participated in the survey expressed that they wanted to be able to use their physicians' websites to access their medical information. That seems completely reasonable in this day and age. Why wouldn't it be possible to access your own health information on the Internet? 
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Epidemic of Healthcare Cyberattacks Requires Action, Says WEDI

JUN 25, 2015 7:54am ET
The Workgroup for Electronic Data Interchange has released a “primer” addressing some of the challenges that healthcare organizations face in defending themselves against the epidemic of cyberattacks and how to counter them.
According to WEDI, the frequency, scope and sophistication of cyberattacks on healthcare organizations are growing at an alarming rate. It estimates that between 2010 and 2014 about 37 million healthcare records were compromised in data breaches. However, in the first four months of 2015 alone, more than 99 million healthcare records have already been exposed through 93 separate attacks.
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HIEs evolving as demand increases

June 19, 2015 | By Marla Durben Hirsch
Both health information exchanges (HIEs) and providers' needs regarding them have evolved since HIEs were first launched, according to a new report from NORC at the University of Chicago researchers for the Office of the National Coordinator for Health IT.
The report, released June 19, examined HIEs from March through May 2014 in six states: Iowa, Mississippi, New Hampshire, Utah, Vermont and Wyoming. The researchers found that providers' HIE needs have moved beyond simply connecting disparate electronic health record systems and the need to meet Meaningful Use requirements into more of a desire for information at the point of care to improve healthcare delivery. For instance, some of the priority items providers are pursuing or would like to see include admission, discharge and transfer alerts, care coordination and interstate data sharing.
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Not all vendors take EHR usability seriously

June 9, 2015 | By Marla Durben Hirsch
Electronic health record vendor commitment and understanding of the need for usable EHRs varies significantly, according to a new study published in the Journal of the American Medical Informatics Association (JAMIA).
The researchers, from District of Columbia-based MedStar Health and elsewhere, noted that poor EHR usability increases provider frustration, can hinder adoption of the systems and leads to errors that can jeopardize patient safety. The problem is so acute that the Office of the National Coordinator for Health IT's 2014 certification criteria includes a requirement that vendors attest that they use user centered design (UCD) processes and report the results of usability testing.
However, most usability studies focus on providers, not on EHR developers. To learn more about vendor views regarding usability, the researchers visited 11 unidentified EHR vendors to analyze their UCD processes and determine what challenges vendors face in integrating usability with EHR development.
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NATO takes a look at Avera's telemedicine program

June 23, 2015Eric Wicklund - Editor, mHealthNews
Avera Health's telemedicine platform may be going global.
The South Dakota-based health system, long praised for delivering healthcare to remote locations across the Midwest and West, is hosting NATO officials who are looking at different methods for responding to global disasters, ranging from armed conflicts to tsunamis and earthquakes.
"This project is aiming at the creation of the multinational capacity in responding to major situations, disasters (and) civil emergencies, in countries where we would send our teams and they may need to consult experienced physicians at a distance from where they are," Romanian interior ministry official Raed Arafat, the NATO director for the project, told the Associated Press.
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Pharmacists given access to SCR

23 June 2015   Lyn Whitfield
Community pharmacists are to be given access to the NHS Summary Care Record, the Health and Social Care Information Centre has announced.
The move, which follows a long campaign for access by pharmacists, and a pilot at 140 sites, will be backed by £7.5 million of investment in training, and will start this autumn.
In a statement, the new minister of state for community and social care, Alistair Burt, said: “Pharmacists are an untapped resource in our health service – as experts in medicines, they can help people to manage their conditions and take some of the pressure off our GPs.
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How long do physicians spend charting on EHRs each day?

Written by Akanksha Jayanthi (Twitter | Google+)  | June 24, 2015
A common clinician complaint regarding EHRs is the interruption in workflow and productivity. A recent survey conducted by the Physicians' Alliance of America sought to determine how much additional time using EHRs adds to clinicians' work days.
The survey gathered responses from more than 250 clinicians nationwide.
The majority of respondents (34 percent) said they spend less than 30 minutes per day charting, followed by 23 percent who spend between 30 and 60 minutes and 17 percent who spend between 60 and 90 minutes. Nine percent of respondents indicated spending more than 120 minutes per day on charting.
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NASA's 1st humanoid robot in space will aid with medical tasks

Written by Akanksha Jayanthi (Twitter | Google+)  | June 24, 2015
Astronauts sometimes need medical care, too, and NASA has developed a robot to administer such care.
The Robonaut 2, a second generation humanoid robot developed by the space agency, lives on the International Space Station. It is the first humanoid robot in space.
In addition to assisting astronauts on missions and, for example, providing an extra pair of ambidextrous hands, R2 is undergoing testing for its telemedicine capabilities.
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Google develops mHealth wristband

June 24, 2015 | By Judy Mottl
Google is developing a mHealth wristband for pharma clinical trials and drug tests to provide research teams with real-time data on patient vital signs, from pulse and heart rates to light exposure and noise level monitoring.
While the device will be used by patients and lab research participants, it will not be sold directly to consumers, according to Bloomberg. 
"Our hope is that this technology could unlock a new class of continuous, medical-grade information that makes it easier to understand these patterns and manage serious health conditions," Andy Conrad, head of the life sciences team at Google, told CNN.
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Machine training future of health IT

June 25, 2015 | By Susan D. Hall
In the next three years, the healthcare industry will have to focus as much on training machines as on training people, according to a new report from Accenture.
Eighty-four percent of healthcare executives agree or strongly agree that their industry will need to focus on using algorithms, intelligent software and machine learning as well as human workforce training. Eighty-three percent foresee provider organizations needing to manage intelligent machines to keep up with the surge in clinical data, according to an announcement.
Intelligent machines will also manage data from various disparate sources, such as diagnostic tests, Internet-connected devices, genomics and medical records. Forty-one percent of those polled said their data volume has grown more than 50 percent in the past year.
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University of Oregon Sexual Assault Case Sheds Light on Medical Privacy Limitations

by Kate Ackerman, iHealthBeat Editor in Chief Thursday, June 25, 2015
A recent University of Oregon sexual assault case highlights a potential legal loophole when it comes to students' medical privacy.
A UO student -- known only as Jane Doe in court documents -- last year said she was raped multiple times by three members of the men's basketball team. Although the Lane County district attorney declined to prosecute the men, the university found the players responsible and dismissed them from the team and school.
It later was discovered that one of the players was suspended from a previous college team over sexual assault allegations. In January, Doe filed a lawsuit against the university and its head basketball coach for "deliberate indifference" in recruiting a player with an alleged sexual assault history.
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Online health info balances power between patients, docs

June 24, 2015 | By Susan D. Hall
Online health information can empower patients and even shift the balance of power between patients and their doctors, according to an article at the Journal of Medical Internet Research.
The study is based on focus groups with 32 participants recruited from an arthritis research center in British Columbia, Canada. Participants were asked to talk about the types of online health sites they visited as well as how the information they gleaned affected their relationships with their doctors.
The participants looked to sites that include university and medical webpages, as well as social media sites (Twitter and Facebook), chat rooms and other sites for information on research and treatment options, medication self-management strategies and resources.
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How hospital IT teams maintain continuity amid chaos

June 24, 2015 | By Dan Bowman
The following is an excerpt from an article published in FierceHealthcare's eBook "Hospital Disaster Recovery." Download the eBook here to read more.
In the midst of disaster, hospitals often serve as a refuge, a place of comfort for those in need of care or shelter. But even hospitals aren't immune to chaos, as electronic health record systems, network connections and even whole power grids can be rendered useless in the blink of an eye.
Response to and recovery from IT outages are critical, as UC Irvine Health's Charles Podesta knows all too well. Prior to accepting a role as chief information officer for the Orange, California, health system in September 2014, he served for five years in the same capacity for University of (Burlington) Vermont Medical Center (then known as Fletcher Allen Health Care). A little more than one year into his tenure—and roughly one month after completing implementation of a brand new electronic health record system—the 562-bed hospital suffered a freak power outage that left its EHR system out of commission for nearly half a day.
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Slow progress

The mental health systems market isn’t changing quickly as National Programme for IT contracts come to an end, but it is changing. Kim Thomas reports.
Mental health trusts in London and the South are now coming to the end of the contracts negotiated under the National Programme for IT, under which local service provider BT supplied them with the RiO electronic patient record. Next year, it will be the turn of trusts in the North East, East and Midlands.
It should be a time of frenetic activity in the market – but that hasn’t been the case. In London, many trusts have opted to stay with RiO, entering into direct contracts with the supplier Servelec. A few have gone elsewhere – Advanced Health and Care, for example, has won five of the former BT contracts.
The NME trusts seem to be biding their time, says Jim Chase, managing director of Advanced Heath and Care. “It is strangely quiet in many respects because, given that people have to look at their requirements, look at what the market has to offer, go through a procurement process and then do a system implementation, there is not a lot of time left.”
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Survey: HIOs Split in Cost-Benefit Analysis of Direct

June 23, 2015
Health Information Organizations (HIOs) using Direct Messaging technologies are split down the middle as to whether the benefits of the technology outweigh the costs.
This was one of the findings of a survey from the Healthcare Information and Management Systems Society (HIMSS) Interoperability and HIE Committee’s on Direct Messaging. The HIMSS Interoperability and HIE Committee surveyed 75 HIOs across 27 states on how they are using Direct. Fifty-one percent agreed the cost of using Direct was worth the benefit of information exchange. A larger percentage of HIOs, 67 percent, openly supported Direct as a method in exchanging data.
HIMSS posted the results on a blog. Most of the respondents were from Health Internet Service Providers (HISPs).
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Direct Messaging Has Value, But Not Without Challenges

JUN 23, 2015 7:38am ET
A survey of 75 health information organizations in 27 states finds that two-thirds support Direct messaging protocols as the method of choice for exchanging data via secured messaging software.
In the 2015 Direct Messaging Survey, 51 percent agreed that the cost of using Direct was worth the benefit of health information exchange. The survey, conducted by the HIMSS Interoperability and HIE Committees, was designed to provide visibility on the use and value of Direct messaging for increasing interoperability and facilitating information exchange.
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House FY16 Funding for ONC Flat, Proposes AHRQ Termination

JUN 23, 2015 7:26am ET
Congress increasingly is talking a good game about the need to significantly enhance interoperability of health information technology systems, but the funding purse remains closed for now.
For two years, the Obama administration has shot for the moon with its budget request for the Office of the National Coordinator for Health Information Technology—including a whopping $91.8 million for FY 2016. And for the third year, the initial budget proposal for ONC from the House is flat, about $63.387 million.
The House, where budgets originate although the Senate surely will have its say as well, also proposes termination of the Agency for Healthcare Research and Quality, effective October 1, 2015, when the federal FY16 budget year starts. However, agencies may after Oct. 1, with conditions, carry out activities of AHRQ that already are in progress, including activities in ONC and patient safety activities in the HHS Office of the Assistant Secretary for Health.
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5 health IT trends set to shake up industry

Posted on Jun 23, 2015
By Erin McCann, Managing Editor
For those healthcare providers still resistant to technology, you've got a problem on your hands: You're going to be left behind. This is where healthcare it going – with or without you.
That's according to a new Accenture report, Healthcare Technology Vision 2015, which lays out five key trends in the industry that show adaptation might be the best business model.
First, Accenture analytics are calling it the "platform revolution" – that is the ever-increasing ubiquity of mobile and cloud platforms that far surpass merely the ability to track in real-time a patient’s health. Rather, this is a platform that addresses interoperability, "that captures the data from disparate sources such as wearables, phones and glucometers, and pulls it all together to give a patient and caregiver a holistic and real-time view of the patient's health," they write.
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Infographic: Direct messaging trends

Posted on Jun 23, 2015
By Mike Miliard, Editor
The 2015 HIMSS HIE and Direct Messaging Survey published this week, conducted jointly by HIMSS' Health Information Exchange and Interoperability & Standards Committees, polled accountable care organizations, health information exchanges, hospitals, policymakers, vendors and other stakeholders in 27 states about how the state of Direct messaging, and how its doing when it comes to facilitating HIE.
Five years since its launch, how much impact has the secure messaging tool, developed via a unique partnership – "a classic, fantastic, soon-to-be-legendary example of how the public and private sectors can come together in a collaborative, entrepreneurial explosion of mojo to improve and advance healthcare in America," in the immortal words of former HHS CTO Todd Park – had on the improving ease and efficacy of healthcare data exchange?
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Study: Tablet, app use does not improve patient knowledge of care

June 22, 2015 | By Judy Mottl
Supplying patients with tools such as tablets and patient portal apps does not have a great impact on their understanding of their care and treatment, according to a study published in the Journal of the American Medical Informatics Association.
Originally, the authors thought that the tablet and app "would result in greater knowledge of team members' names and roles, planned tests and procedures, medications and higher patient activation."
They handed out the tools to 100 patients at Chicago's Northwestern Memorial Hospital to be used for the duration of the patients' stay. The researchers then looked at patient use and satisfaction with the portal through questions specifically created for the study. The goal was to evaluate how such tools can help patients become more involved in and aware of care activity, from knowing physicians' names to procedures being ordered.
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NASA refines robot for medical tasks

June 22, 2015 | By Susan D. Hall
NASA has a humanoid robot aboard the International Space Station that might one day help the agency by performing medical tasks in space, guided by human hands on Earth, reports Quark.
It's the second iteration of the Robonaut 2, known as R2. It's made up of multiple component technologies and systems--vision systems, image recognition systems, sensor integrations, tendon hands, control algorithms and more, NASA says on its website.
Working with private-sector partners, NASA has been exploring how the robot could help reduce fatigue and prevent stress injuries, provide assisted walking in rehab scenarios and use telemedicine to perform an ultrasound scan of a medical mannequin and to use a syringe as part of a procedure, according to a NASA announcement.
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Docs Seen as Key Driver for Patient mHealth Adoption

JUN 22, 2015 7:38am ET
Despite the explosion of mobile healthcare technology available to consumers, just 15 percent of physicians are discussing wearables or health apps with their patients as tools for achieving wellness, according to market research firm MedPanel.
At the same time, the firm found that physicians at accountable care organizations are more than twice as likely to discuss wearables or apps compared to physicians not part of an ACO.
In a separate survey of 500 medical professionals by Research Now, 86 percent of providers said they have a better understanding of a patient’s medical condition with the help of mHealth apps, while 76 percent reported that they believed apps helped patients manage chronic conditions. And, 46 percent of those surveyed thought that apps can make patient transitions from hospitals to home-based care easier.
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Telemedicine may support flexible work-life balance, survey finds

Written by Akanksha Jayanthi (Twitter | Google+)  | June 22, 2015
More than half of physicians would be willing to conduct video consultations with patients, largely to help improve work-life balance, according to a survey conducted by telemedicine platform provider American Well.
In collaboration with QuantiaMD, American Well surveyed more than 2,000 primary care physician on their perceptions of video consultations.
Fifty-seven percent of primary care physicians said they would be up for telemedicine consultations, 12 percent said they were unwilling to have a video visit and 31 percent said they were uncertain.
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Data Independence is Up to Patients Now

Scott Mace, for HealthLeaders Media , June 23, 2015

For patients to get the medical data they deserve in a way the HIPAA Omnibus law says they deserve it, they need to demand that providers cut the red tape. Whether they will do so remains to be seen.

When former national coordinator of healthcare IT, Farzad Mostashari MD, stood on stage at the annual HIMSS conference in April and called for a national day of action on July 4 for patients to request their medical records, headlines followed.
But now that the headlines have died down, and the date is approaching, I wonder just how big a day it will turn out to be.
Russ Branzell, president and CEO of CHIME, expressed sympathy about patients' difficulty in obtaining their records. But CHIME still supports the gutting of Meaningful Use requirements that providers prove actual patient viewing/downloading/transmitting of their data, a decision now in ONC's hands.
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Google Reveals Health-Tracking Wristband

June 23, 2015 — 11:30 PM AEST
Google Inc.’s life sciences group has created a health-tracking wristband that could be used in clinical trials and drug tests, giving researchers or physicians minute-by-minute data on how patients are faring.
The experimental device, developed within the company’s Google X research division, can measure pulse, heart rhythm and skin temperature, and also environmental information like light exposure and noise levels. It won’t be marketed as a consumer device, said Andy Conrad, head of the life sciences team at Google.
“Our intended use is for this to become a medical device that’s prescribed to patients or used for clinical trials,” Conrad said in a telephone interview.
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‘No-Brainer’ System Improves Infusion Safety at Vermont Hospital

JUN 22, 2015 7:23am ET
It is a simple safety technology that most hospitals should be able to implement without much difficulty. That’s the message Charles Still, senior systems analyst at 99-bed Southwestern Vermont Medical Center in Bennington, Vt., wants to send colleagues about a cheap and easy way to increase the safety of infusions.
At SVMC, there are up to 19 unique data elements on a patient infusion label and different departments in the hospital have different needs for their labels. Pharmacy technicians, Still notes, are concerned with IV component drug and concentrations while nurses focus on the correct patient name and drug.
Like many other hospitals, SVMC has used plain black and white labels for infusion orders. However, during the past 14 months the hospital has phased in a new type of label, with oncology/chemotherapy on board for the past four months. These labels are the same size as previous labels but are far easier to pick out the most critical information.
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Hospital employee indicted for fraud after swiping data of 12K

Posted on Jun 22, 2015
By Erin McCann, Managing Editor
A former employee at a major New York health system has been indicted, along with seven others, for stealing personal data of 12,000 patients, enabling more than $50,000 in fraud.
Manhattan's district attorney last week announced the indictment of Monique Walker, 32, a former assistant clerk at the eight hospital Montefiore Health System, for swiping patient data and supplying it to an identity theft ring. Walker, who had access to patient names, Social Security numbers, dates of birth, among others, reportedly printed the records of as many as 12,000 patients and supplied them to seven other individuals who used the data to make multiple purchases from department stores and retailers.
Walker, according to the New York County’s District Attorney’s office, sold the patient records for as little as $3 per record. Co-conspirators were able to open credit cards and make several unauthorized big ticket purchases at Barneys New York, Lord & Taylor and Bergdorf Goodman, among others. Defendants have been charged with grand larceny, unlawful possession of personal identification information, identity theft and criminal possession.
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EXTREME essentials for interoperability

Posted on Jun 22, 2015
By Mike Miliard, Editor
Writing in the Journal of the American Medical Informatics Association this past week, two health IT researchers put forth five use cases that help define what an "open" electronic health record should really look like.
Dean F. Sittig, professor of biomedical informatics at the University of Texas Health Science Center at Houston, and Adam Wright, medical informatics researcher in the Department of General Internal Medicine, Brigham & Women’s Hospital, use the term EXTREME – it stands for EXtract, TRansmit, Exchange, Move, Embed – to shape a definition of useful interoperability.
  • An organization should be able to securely extract patient records while maintaining granularity of structured data.
  • An authorized user can transmit all or a portion of a patient record to another clinician who uses a different EHR or to a personal health record of the patient’s choosing without losing the existing structured data.
  • An organization in a distributed/decentralized health information exchange can accept programmatic requests for copies of a patient record from an external EHR and return records in a standard format.
  • An organization can move all its patient records to a new EHR.
  • An organization can embed encapsulated functionality within their EHR using an application programming interface. Goals: access specific data items, manipulate them, and then store a new value.
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Healthcare cybersecurity primer outlines defensive strategies

June 22, 2015 | By Alok Saboo
By John DeGaspari
A new primer on cybersecurity outlines the challenges that healthcare organizations face and steps they can take to defend themselves against cyberattacks.
The Workgroup for Electronic Data Interchange's (WEDI) "Perspectives on Cybersecurity in Healthcare" covers three prime areas of cybersecurity: the lifecycle of cyberattacks and defense; the anatomy of an attack; and building a culture of prevention.
To build that culture of prevention, the report recommends a strong cyberdefense strategy that addresses how to prepare for and monitor attacks and recover from breaches.
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How Much Should Cancer Drugs Cost?

Memorial Sloan Kettering doctors create pricing calculator that weighs factors such as side effects, extra years of life

By  Peter Loftus
June 18, 2015 11:21 a.m. ET
One of the nation’s top cancer hospitals is challenging the pharmaceutical industry to adopt a more rational approach to drug pricing.
Memorial Sloan Kettering Cancer Center in New York has created an interactive calculator that compares the cost of more than 50 cancer drugs with what the prices would be if they were tied to factors such as the side effects the drugs produce, and the amount of extra life they give patients. In many cases, the website calculates a price that is lower than the drug’s market price.
The project, led by Peter Bach, a physician and director of the hospital’s Center for Health Policy and Outcomes, is the latest salvo from doctors and others against the escalating costs of cancer drugs, which increasingly carry price tags of $100,000 or more per patient for a year or a course of treatment. A colleague of Dr. Bach’s at Memorial Sloan Kettering recently blasted cancer drug prices as excessive in a speech before thousands of cancer doctors at a meeting in Chicago.
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A Digital Divide Between Homo Informaticus and the U.S. Health Care System

by Jane Sarasohn-Kahn Monday, June 22, 2015
The American patient is a consumer looking for uber-satisfying customer experiences from the U.S. health care system. Legacy stakeholders -- doctors, hospitals and pharma -- best listen to the voice of this customer. If not heeded, health care consumers will increasingly patronize health services through pharmacies, retail stores and digital offerings untethered from traditional health care. This could result in continued fragmentation of a consumer's health and wellness data, quite separate from the patient's clinical data in electronic health records and insurance claims systems.
Two forces are underneath the phenomenon of consumers' adoption of retail health services and products: The emergence of homo informaticus and people's search for trust and transparency in health care as out-of-pocket payments grow.
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Enjoy!
David.