My constant, rigorous quest for understanding in the matter of what has become known around here as the Plibersek Uncertainty Principle (PUP), seems at last to be bearing fruit.

Essentially, the Plibersek Uncertainty Principle, which arose from Health Minister Tanya Plibersek’s address outlining “additional support” in the form of MBS consultation items for clinicians creating or adding to a shared health summary, states that no two properties of a ministerial statement, such as meaning and intention, can be known simultaneously.

As I pointed out recently, the meaning of the minister’s statement that “I want to confirm that the use of the longer consultation items will be seen as appropriate by the Medicare Australia Practitioner Review Process and the Professional Services Review in circumstances where there is clear evidence of patient complexity and there is documentation of a substantial patient history” was interpreted by the RACGP for instance, as an undertaking that doctors could claim a payment, prompting its president, Professor Claire Jackson, to “warmly welcome” the news.

Subsequently, however, the minister indicated that her intention, revealed in an interview with the ABC’s AM program, was actually the opposite of what most people – but not the AMA – had believed. “The idea that [doctors] would, during a longer consultation, be paid extra for recording that information in a computer program that many of them are already using,” she told the program, “is probably not the best use of extra health funds.”

At that point, the warm welcome turned bitterly cold, as GPs surmised that they had been, as the colloquial expression puts it, “sold a PUP”.

Having spent the past couple of weeks wallowing around in confusion, you can imagine my relief to have been thrown a lifeline of enlightenment, in the form of another statement by the RACGP, which takes the form of a clarification of the minister’s clarification. You will find the second, or auxiliary clarification here.

In many ways it is a delightful document, which we suggest is probably best delivered in the context of being tucked into bed with a glass of warm milk, and having a caring person – a nanny or Mummy perhaps – reading it to you as a bedtime story.

As you nod gently off to sleep, you will hear a number of “clarification cases”, such as the following:

James is an 18 year old student and lives at home with his caring family, who have registered him for a PCEHR. He has no sexual partners, is on no medication and has no significant past medical history (PMH). He asks you to prepare a shared health summary for him for him.
Q: Can I charge a B?
A: No.
You tell James that Medicare would not regard this as a clinically relevant service and that he would not receive a rebate if you prepared a Shared Health Summary for him.

Just as your anxiety begins to rise, Nanny (or Mummy), will then calm you with the tale of Case 2:

James goes on holiday to Thailand some weeks later. He has unprotected casual sex and develops a purulent discharge. On return home he consults a community-health run STI clinic, which run some tests and tell him he has gonorrhoea and prescribe treatment.
Personally Controlled Electronic Health Records (PCEHRs) and the use of item numbers in general practice
He sees you the following week with swollen painful joints, which have severely interrupted his football training. You diagnose Rieter’s Syndrome and are considering referral to a rheumatologist but you have no details of his results or treatment.
You say you will have to ring around to sort this out and request that he return on the following day. The tests might have to be repeated if state health is not contactable.
James is annoyed and asks if a shared health summary wouldn’t have been of use. He asks if you can now create one when he comes back to assist with effectively sharing his care between community health, local pathology providers, your practice and the rheumatologist. You suggest to James that when he attends consultations with other health care professionals involved in his care, that he let them know he has a PCEHR so they can view the shared health summary and add event summarises if they have also upgraded their software.
Q: Can I charge a B if this takes < 20 minutes or a C if this takes 20 – 40 minutes?
A: Yes – James has asked you to co-ordinate his ongoing care, and the service is both clinically relevant and very important in reducing duplication and minimising fragmentation of care.
If it takes 20-40 minutes it can be billed as a Level C, as the consultation is complex, involving assessment of a number of organ systems, and includes significant counselling and education components.

I think I can safely leave you in the arms of certainty, while I go off to play with the dog.

I couldn’t help but wonder, as I read today’s feature article on the alleged failings of electronic health records which the Financial Review plucked from its New York Times feed, whether we now have a negative consensus in both our national newspapers on the value of ehealth.

The story is a bit of a shocker, really, because it takes the findings of a single contrarian study built from re-purposed data and reaches conclusions that invite a good deal of questions. Perhaps there is some justification for the New York Times to have run it, but it has absolutely no relevance to Australia.

In my opinion, Information Week did a much better job reporting the survey than its more fabled competitor. Essentially, researchers at Cambridge Health Alliance in Cambridge, Mass., and the City University of New York School of Public Health claim a 40% to 70% higher rate of imaging test ordering and higher order rates for blood tests among physicians who had electronic access to results at the point of care.

The Fin didn’t attempt to give the story any local flavour or context. It makes no effort to explain the differences between the use of computerised patient records in the US and in Australia, probably because the Fin’s feature editor doesn’t understand that you can’t do a direct translation between the US situation and the Australian healthcare system.

The sub-editor just stuck up a heading and a stand-first that probably appealed to the likely prejudice of its readers: “Glitch in online health records may lay budget low. Putting patients [sic] records online was meant to save costs but a study has found the opposite is the case.” What “glitch” are we talking about, precisely?

We are left to try to make sense out of it for ourselves. Are we to assume that according to this study, the introduction of GP desktop software and hospital EHRs in Australia over the past two decades has led to doctors ordering significantly more testing and consequent budgetary strains? Or is the Financial Review relating this to the forthcoming introduction of a PCEHR?

Are readers of the Financial Review any more aware than its senior journalists of the fact that the funding structure in the US is completely different to ours, and that, for instance, our GPs pay a few hundred dollars per year for their desktop software and their US equivalents many thousands of dollars a month, and that here essentially they are dealing with Medicare, and not a multitude of health funds?

Would they know that relatively few Australian GPs have, say, an ultrasound machine in their building and therefore as a rule tend to utilise such tests less frequently than in the US, where every primary care physician will do much more testing, because practically every facility available is right on hand?

Is the fact that the measurable savings from ehealth measures stem not so much from the existence of electronic records as their linkage to things like eprescribing systems not germane to any discussion of costs and benefits? Should they not be informed that Kaiser Permanente, for instance, which does have an end-to-end ehealth record system, has documented so many savings as to make the findings of this report a matter for great mirth?

It’s much cheaper for the Financial Review to run something from its New York Times feed than to develop a local angle and assign a journalist to follow it up, but ultimately it damages the brand.

In my opinion, anyone who cares about the future of ehealth in this country – and for that matter the practice of responsible journalism – should grab a keyboard and send off a letter to the editor.

The relaunch of the UK’s patient.co.uk website, with plans to offer a series of apps, including one that will allow patients to make medical appointments on their smartphones – according to eHealth Insider – has got me thinking about the lack of anything that compares even remotely in Australia.

Patient.co.uk describes what it is offering as “Trusted Medical Information and Support”, and I couldn’t help but compare the link it offers to a Guardian story which quotes a report by US scientists on the dangers of sugar to one our Medical Observer ran just a day or so ago, in which some of our scientists condemn their US counterparts’ call for measures to curb sugar consumption.

The expert opinion in Australia, it seems, is that tooth decay is “the only disease proven to be related to excess frequent sugar consumption” and “sugar is just another form of over-consumed calories … no more metabolically deadly than starch or fat calories”.

That’s not the opinion of Dr Robert H. Lustig, one of the authors of the US report, which was also picked up by Time magazine. Lustig’s 2009 lecture, “Sugar: The Bitter Truth” [below], sparked a New York Times piece by health writer Gary Taubes posing the rhetorical question, Is Sugar Toxic?

When you have such diversity of opinion, it seems to me that patients need all the trusted information they can get.

If I were writing on health, I wouldn’t be prepared to just present two sets of opposing opinions. I’d want to know why doctors in Australia seem to be taking a more benign view of the medical implications of sugar, and the potential for its role in commerce to influence research and government policies.

Having read  UK nutrition authority, John Yudkin’s 70s book, Pure, White and Deadly, which linked sugar to type 2 diabetes  and elevated triglycerides, I’m not so sure that Lustig isn’t on to something.

In an environment in which television seems to be constantly switching from food programs to radical weight loss programs, it would seem to me to be a worthy topic for, say, Q&A.

Anyone with the slightest idea of large-scale software development would have been staggered by the surpassing silliness contained in yesterday’s piece in the Medical Observer, in which “ehealth consultant” David More trots out his analysis of the problem which has brought the desktop software side of the PCEHR project to a temporary halt.

According to More, it would have been terribly easy to avoid trouble: “Had they planned properly they would have had a consistent data model for all the sites and they would have noted that there was this issue [at the outset],” he said. “It just reflects incompetence, frankly. If they knew what they were doing they would have addressed these problems before they started.”

The only illumination one could gain from that is that More simply had no idea of the cause of the problem, no inkling of a solution, and insufficient humility to admit that in truth, he’s not much of an ehealth expert. It really is long past time lazy journalists scratched him out of their sadly tattered contact books.

The very idea that you can anticipate every problem before you begin a hugely complex IT project and construct a data model that uncovers every deviation is ludicrous.

The very nature of software development is that it’s a process of getting things right. The recipe is largely the following: Develop, test, identify bugs, fix them. Endlessly repeat.

What happened in this particular case is that the wave site developments were a dynamic operation, with the developers constantly engaging with NEHTA staff to identify problems and challenges. As issues arose, NEHTA made changes to the specifications to address them. In parallel with that, the specifications were being run through further quality assurance testing.

As the work proceeded through 2011, NEHTA kept the sites informed about the changes that were being implemented to resolve their concerns, allowing them to integrate them in the work.

What when wrong, essentially, was that in October, the change log was finalised. The list of issues NEHTA provided at that point of things that would be fixed in November omitted a number of new items that had been included in response to feedback or problems, or new issues that were still to be identified during testing in November.

That meant developers working on the October change log would have had to upgrade their software later to reflect the changed specifications.

NEHTA decided that rather than have that happen, it was better to call a halt, have everyone build to the November specifications, and deploy the software once.

The main impact is that they deploy later than expected. Rather than February it’s more likely to be May. Of course this will be worked out between NEHTA and the sites, but it’s the sort of rational reaction coming from sites, rather than the sort of hysteria coming from some commentators.

Anyone who’s actually involved in doing ehealth, as opposed to just talking about how others should do it, will know that you have feedback loops on early versions of specs to later ones. They will also know that keeping a complete change log is essential. That is how you address this sort of issue before the project starts. Data models have nothing to do with it.

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It’s already been something of an annus horribilis for CSC, but the final days of 2011 have brought even worse news for the company’s shareholders, with the announcement that it might be forced to write off the $1.5 billion value of a disputed contract with the NHS.

Over at eHealth Insider, there’s a summary of the year’s events that details the serial catastrophe for the company, starting in February with its missing yet another deadline for the delivery of its Lorenzo patient records system. That accelerated in May, with a scatching assessment of the CSC contracts by the National Audit Office which essentially delcared that the original vision of an integrated care records service would never be delivered; the £2.7 billion already spent had not delivered value for money and the remaining £4.3 billion looked like being an equally fruitless investment. In August, the public accounts committee suggested that doing a new deal with CSC was, umm, not altogether sensible.

Even that failed to quash occasional outbreaks of optimism, along the lines that a memorandum of understanding in May indicated that revised terms might not be a complete disaster for CSC, and suggestions it might be more expensive to drop CSC than to patch something together, somehow.

Now in a filing to the US Securities and Exchange Commission, the company reveals that itwas recently informed that the memorandum of understanding and the proposed amendment would not be approved by the U.K. government, and that it expected further discussions in January over proposals that would make modifications to the scope and value of the contract,which “differ materially” from those in the memorandum of understanding.

Until those negotiations are completed, CSC said it could not estimate the amount it would have to write down in the third quarter of its 2012 fiscal year, but the total could be equal to its net investment in the project, which was $1.5 billion as of Nov. 30. It is possible  that the company will take on additional costs as well.

Last month, CSC revealed a Securities and Exchange Commission investigation of its accounting in the Nordic region had been recently expanded to Australia. It posted a $2.88 billion loss for its fiscal second quarter on a large write-down that reflected the investigation, declines in its stock price – off 50 per cent this year – and challenges in its business.