Is Brown Qld Health's white knight?

By: Suzanne Tindal

CIO profile Ray Brown stepped in two weeks ago as the latest chief information officer for Queensland Health, hoping to bring some stability to a division that has seen a number of faces move through the head technology spot in quick succession.

Ray Brown
(Credit: Queensland Health)

The health department's technology leadership game of musical chairs started in July last year when Paul Summergreene, who had moved over to health in the closing months of 2007 from his CIO position at the state's Department of Transport, left after less than a year in the chief information officer job.

His contract had been terminated, Queensland's Health informed the press at the time. There had been reports that his expenses were being examined, but the department wouldn't comment on the issue.

His position was filled briefly in an acting capacity by the clinically adept Dr Richard Ashby. Ashby had served in several hospitals in emergency medicine and medical administration roles. The Australian Medical Association was pleased of the appointment because of Ashby's clinical experience.

"We have seen millions of dollars in health IT funding wasted over the years in Queensland, so the appointment of a highly regarded senior hospital clinician who is acutely aware of exactly what is required to provide optimal patient outcomes is very welcome," it said at the time.

Yet Ashby didn't remain long, leaving in January to become the executive director and director of medical services at Princess Alexandra Hospital.

A bit of stability in the leadership of the division for the next little while would be a good outcome for the division, so that's what I hope occurs.

Ray Brown

Queensland Health again had to fill the void with an interim appointment, reaching into the ranks of its information division. Brown had been acting as the executive director ICT service delivery since June 2008, before which he had been pursuing an IT career in the Queensland public service, holding senior roles in the Police, Corrective Services and the former Department of Families.

Queensland Health may have hit the jackpot this time. Brown hasn't followed the pattern of leaving after only a brief stint on the job. Instead, he was appointed formally to the chief information officer position last week.

And despite much attention being directed at the leadership turmoil, the CIO doesn't believe that it has damaged the long-term technology strategy of Queensland Health.

Since 2006, the IT gurus of Queensland Health have had a mission: to bring the state's hospitals into the modern world of state of the art clinical information systems. Summergreene's predecessor Sabrina Walsh had primed the way by obtaining funding of upwards of $650 million over four years for e-health initiatives.

Whichever leader was in the hot spot, the e-health holy grail was never out of sight, according to Brown. "The e-Health strategy has stood the test of time and remained sound. Each incumbent of the Queensland Health CIO role has built on the direction and progress of the e-Health Strategy without the need to re-visit significant elements of the strategy or the project artefacts delivered," he tells ZDNet.com.au in an interview last week.

When the CIO started in the role in the acting capacity, it had been his focus and it would continue to be so for the next few years, he says.

Around 20 per cent ($243 million) of the funding first made available in the 2007/2008 financial year had been spent, Brown says. The remaining 80 per cent would be spent by 2011/2012.

So far one of the standout successes has been getting an enterprise discharge summary system up and running, a national first, Brown says. The system sees hospital reports go out to GPs who can use them to service outpatients. Brown says, 55,000 summaries have already gone out from 56 hospitals, with June next year seeing 120 facilities being capable of issuing the summaries.

The e-Health strategy has stood the test of time and remained sound.

Ray Brown

Another win has been getting a new imaging system coming online so that diagnostic images taken in rural locations could be examined and used to diagnose remotely.

Brown is also proud of a statewide mental health system which can now be accessed by all mental health workers. Queensland is the first state to set up such a system, according to Brown.

Looking ahead, of course, the "big ticket item" will be setting up an electronic medical record for Queenslanders. Brown says that Queensland was on track to meet the timeline recommendations made by the National Health and Hospitals Reform Commission, which suggested every Australian should have an electronic medical record by 2012.

"Generally speaking we're pretty comfortable that where we're at today will allow us to actually achieve most of those time frames that are in that report," Brown says.

Yet Queensland Health's outlook doesn't look as rosy as some, having had a later start than some states on creating the records. "At some level I think we're behind some of the other states," Brown admits. He points out that NSW and Victoria had done more work in that area. He stresses, however, that Queensland Health was ahead in other areas, and could catch up on the systems in which it was lagging.

"The forward work program and the way this organisation is structured is probably going to allow us to certainly catch up if not pass some of those other jurisdictions in terms of their e-health agenda," he says.

However, he can't forget that e-health is only good as long as the systems are reliable. Earlier this year one of Queensland Health's datacentres had a train of small problems which lead to some applications going off line.

Brown acknowledges that datacentres are on the agenda at the moment. "We will be migrating all of our production environments over the next four to five years to the new government datacentres that are being established," he said. Those new datacentres, like the Polaris datacentre in Springfield, have at least a tier three rating.

At some level I think we're behind some of the other states.

Ray Brown

There isn't really a planned time for migration, according to Brown. As the department refreshes equipment, the new equipment will be set up in new datacentres instead of in the current ones. The electronic medical record will be established straightaway in a new datacentre.

Along with updating datacentre facilities, Brown will also be looking to make hospitals wireless as the electronic health agenda comes online. The department has recently been doing trials with Cisco to gauge how mobile devices can benefit the health environment.

The results have been positive. Yet in order for mobile devices to have the required affect, older hospitals need to be networked. With only $60 million budgeted this year for all IT infrastructure, this could require an additional line of funding. "That won't cover wireless for the state, that's for sure," Brown says.

This is unlikely to be the only roadblock to Brown's goals in what will be a challenging period of e-health implementation. Yet, most importantly for Queensland Health, Brown at least looks set to remain for a time yet. This will likely bring a little more stability to the department which has seen CIOs pass through too quickly.

"A bit of stability in the leadership of the division for the next little while would be a good outcome for the division, so that's what I hope occurs," he says. And, as mentioned before, he believes in the e-health chalice he has been handed, which could be half the battle.

Make e-health funding priority: AMA

By Karen Dearne

THE Australian Medical Association has called for priority funding for e-health adoption, saying the roll-out should start with e-prescribing and electronic sharing of essential patient information.

E-health is one of seven key areas identified for urgent action, with AMA president Andrew Pesce handing the doctors' Priority Investment Plan to Prime Minister Kevin Rudd and Health Minister Nicola Roxon at a meeting in Canberra.

The AMA wants the Federal Government to assume full responsibility for funding the nation's public hospitals, with the states retaining control over operations and local governance arrangements.

Dr Pesce said the time for talk was over.

"We are offering real solutions to real problems," he said.

"The AMA fully supports the roll-out of e-health initiatives in order to integrate systems, reduce fragmentation and duplication, streamline service delivery and improve quality and safety.

"Priority needs now to go to funding the infrastructure for e-health - especially electronic health records - given that the investment to date has focused on development of standards and technical specifications."

But the AMA rejects the recent National Health and Hospitals Reform Commission recommendation that patients should control their own e-health records, saying medical practitioners should control the electronic sharing of patient information between healthcare providers.

Dr Pesce flagged doctors' concerns over person-controlled health records at an e-health forum last month.

The AMA's action plan for investment includes closing the health gap for Indigenous Australians; boosting patient access to GPs and allied health services; medical training and a restoration of facilities for people with mental illness and sub-acute care.

The AMA also wants to see remote communities wired-up for e-health services such as telehealth and web-based consultations.

And it suggests a new monitoring system, Bed Watch, should be implemented to allow continuous reporting on the number of beds available in public hospitals, and to identify occupancy issues such as access block in emergency departments.

NEHTA releases strategic plan

By: Karen Dearne

THE National E-Health Transition Authority has released a strategic plan repositioning itself as an implementation agency with a role well beyond its present funding to 2012.

"Since its establishment, there has been a misalignment between NEHTA's current direction and the expectations of the various stakeholder groups," the plan says. "As the organisation evolves it is important to ensure a foundation exists for 'what' it has been put in place to deliver."

NEHTA will "co-ordinate and manage the uptake of e-health systems which are of a high priority, interoperable and scalable" nationwide.

Chief executive Peter Fleming said the 2009-2012 plan outlined how NEHTA would fulfil its mission in relation to delivering the National E-Health Strategy adopted by the Council of Australian Governments last December.

"We have considered our future work program based on the (Deloitte) strategy and other important work completed this year, including the National Health and Hospital Reform Commission recommendations," he said.

"As a result we have produced our plan to clearly show our stakeholders the directions we are taking to drive the adoption of e-health."

The four priorities echo program outlines produced by the organisation since its creation as a not-for-profit company owned jointly by all state and federal governments. These are to urgently develop the essential foundations required to enable e-health; coordinate the progression of the priority e-health solutions and processes; accelerate the adoption of e-health, and lead the progression of e-health in Australia.

However, the 46-page document contains little new information, and lacks clear action plans or timelines, with most of the real work scheduled post-2012.

While the Deloitte strategy recommended establishing a fresh, independent, national e-health body to handle investment, implementation and regulatory functions - potentially leveraging NEHTA's assets - NEHTA says it is "in a unique position to drive the e-health agenda" within Australia.

"NEHTA has an overarching sense of the landscape of e-health, both nationally and internationally," it says. "This places us in a strong position to orchestrate key activities and inform key decisions."

In January, Mr Fleming told The Australian a number of large-scale production pilots would start this year but so far there has been no major announcements.

Fleming heads medical e-data project

By Karen Dearne

AUSTRALIA's new e-health boss, Peter Fleming, has a solid technology background and a long-held vision for electronic reform of the health sector.

Mr Fleming, appointed chief executive of the National E-Health Transition Authority yesterday, said he intended to deliver a system that would have "major benefits for the entire nation".

Most recently National Australia Bank's technology and business integration general manager, Mr Fleming previously spent five years as chief information officer of health group Mayne, with oversight of its pharmaceutical business.

"In my time in Mayne we saw the real benefits of being able to move transactions electronically," he said.

"It was a vision that we always thought - once it could be done at a national level - would provide tremendous benefits in removing duplication and also in enhanced patient care."

Mr Fleming replaces Andrew Howard, who has been acting chief executive since the sudden departure of former chief Ian Reinecke in April. Dr Reinecke's resignation followed criticism of NEHTA's structure and lack of consultation with outside stakeholders, contained in a review by Boston Consulting late last year.

The shakeup led to new blood on the board, including the appointment of Australian Securities and Exchange chairman David Gonski as chairman.

Mr Gonski yesterday announced Mr Fleming's appointment, saying the board would work with him to "meet the challenges of the national health agenda".

Although Mr Fleming is not well known in e-health circles, it is understood he was chosen for his experience in large commercial projects.

He started his career at Coles-Myer, where he spent 17 years in the IT department before moving to Colonial Group for seven years and rising to chief information officer.

At Colonial, Mr Fleming was involved in installing a new banking system for the State Bank of NSW. Aushealthit blogger David More said Mr Fleming's biggest challenge would be "coming seriously to grips with a health sector that is severely frustrated by the lack of progress" in e-health.

"He should be stepping back and thinking reflectively about how the authority should interact with the rest of the sector, after its deep disconnect," Dr More said.

"It will be incredibly difficult to attract the levels of investment NEHTA seems to be contemplating without a demonstrable cultural change and improved relations with other stakeholders."

Dr More also warned that the corporate command culture may not sit well with the "professional democracy" of healthcare.

"A difficult implementation in a commercial organisation where the CEO can just tell people to do stuff is very different from this situation," he said.

Meanwhile, NEHTA's board and the Council of Australian Governments are awaiting a comprehensive national e-health strategy being developed by Deloitte. The report is due in a matter of weeks.

Mr Fleming said it would be premature to talk about the strategy, as he had yet to read the draft documents and meet the consultants.

"I need to spend some time understanding the plans and the work done to date, but I really want to work with the team to build a solid action plan for delivery," he said.

"That will obviously mean a huge amount of work with all of the key stakeholders to ensure a common approach." Mr Fleming said he would "certainly be very keen" to speak to the health IT industry and clinicians.

"I'll be looking at the long-term strategy and the best way to do that," he said. "It's an exciting challenge, and the potential benefits for the nation are part of the attraction."

Mr Fleming does not take up his new post until September 29, but he hopes to attend some of the e-health sessions taking place in Melbourne this week.

Michael Legg, president of the Health Informatics Society of Australia - which is holding its annual conference this week - congratulated Mr Fleming.

"We look forward to working closely with him to put in place the infrastructure Australia needs to address the critical shortage in health services that we're going to have," Mr Legg said.

iSoft trims workforce

By Karen Dearne

GLOBAL restructuring by iSoft will lead to job cuts in service delivery in some regions, including Australia and New Zealand, despite the company posting a 137 per cent rise in net profit to $34.7 million last week.

iSoft executive chairman Gary Cohen says a possible 70-100 IT positions may be lost in Britain - or around 10 per cent of the British workforce - but the overall impact would be offset by plans to add up to 50 new sales and marketing people to drive business growth.

According to Britain's E-Health-Insider, iSoft plans to reduce its frontline staff headcount from 193 to 131 through redundancies, and merge the support and technical teams into a single unit.

But Mr Cohen told The Australian that the restructure was "not about cost-cutting".

"This is about tailoring our operations to changed market dynamics, particularly in the UK where the old business was very focused on servicing the National Health Service's IT reform program," he said.

"While we're still working alongside CSC on those contracts, we're moving into a growth mode at the same time and for that the organisation requires a different set of skills.

"So this is about growing our businesses. We're currently a company with revenues of $600 million, and we want to more than double our size in the next three to four years."

Mr Cohen said a process of "bottom-up consultation" on corporate culture change and upskilling has just begun in the Australian and New Zealand operations, as well as in its Malaysian, Middle Eastern and Indian offices.

"While we're not looking at the same sort of restructuring as in the UK, the Australian operation equally needs to align its workforce to the dynamics of the market, and obviously with what's happening at both the state and federal level we're upskilling our competencies and looking to bring on higher-calibre personnel," he said.

"In that process, there may be people whose skill sets don't fit the new model, but we're still evaluating the situation and working through how best to achieve those outcomes."

Mr Cohen said no decision had been taken on likely job losses, but agreed there would be "people who are left behind".

"Let's be very clear, we are driving a cultural change in our company," he said. "Every industry and company needs from time to time to reshape and reposition itself.

"The overwhelming majority of our employees are totally motivated and focused on the future.

"Inevitably there will people who feel they don't fit in any more, and people who we think no longer fit, and that's a conversation we are having within parts of our organisation around the world."

In a statement to the Australian Securities Exchange this week, Mr Cohen said expected to "see more efficiencies come through from further restructuring of the UK business in the current year".

"We'll also continue to focus on building up our sales and marketing: under its previous ownership the company had become too reliant on the NHS connecting for IT program rather than building its own sales teams."

iSoft is also banking on changes mooted by Britain's opposition Tory party, that would allow local health services to deal directly with IT vendors such as iSoft, which holds 60 per cent of the English market.

Leaked details show modest costs for e-health

By Karen Dearne

NATIONWIDE electronic health infrastructure will cost a modest $1.5 billion over five years, or $2.6 billion over a 10-year rollout, according to leaked funding details.

Federal and state ministers have kept tight wraps on costings and timetables since agreeing last December to adopt the National E-Health Strategy, prepared by Deloitte.

The $1 billion to $2 billion range "represents a relatively modest investment" when compared with the total annual health spend of $90 billion, with $60 billion coming from all levels of government.

Deloitte found that "tangible benefits" from implementing the e-health strategy "are in the order of $5.7 billion in net present value terms over 10 years".

Annual savings from a fully integrated system "are estimated to be about $2.6 billion in 2008-09 dollar terms".

The leaking of financial information and costed work programs on David More's AushealthIT blogger website appears to reflect growing frustration with the lack of progress on e-health.

Last month, medical and consumer groups told the National Health and Hospitals Reform Commission they were astonished it had failed to put information technologies at the heart of reform plans.

Dr More, a clinician and health IT expert, said he hoped today's federal budget would deliver a "substantial boost" for the health sector. "But I fear we may be disappointed," he said. "Really, $300 million per annum is small beer in terms of the whole health budget."

Dr More said the costs and benefits contained in the full Deloitte report had been available to all state and federal health bodies for more than six months, "and it is quite wrong in my view that the public does not get a chance to debate the merits" of the proposals.

The strategy identifies four key areas for investment, including foundational activities ($370 million over five years), e-health solutions ($630 million), change and adoption ($470 million), and governance ($30 million).

Big-ticket items include a national e-health solutions investment fund ($500 million over five years) and care provider incentives ($400 million).

In particular, Deloitte called for the present National E-Health Transition Authority to be disbanded, and a fresh e-health entity with a governing board and regulatory powers established.

To date, only a brief executive summary of the Deloitte report has been released, even though the strategy was endorsed by the Australian Health Ministers' Conference as "a practical framework".

Patients may have to foot e-health bill

By: Karen Dearne

PATIENTS may have to pay for their own electronic health records, with the key healthcare reform body urging the federal Government to mandate "person-controlled" systems commercially available from providers like Microsoft and Google.
"We believe that the rapid development of new IT applications required across the health sector to give people the opportunity to have an electronic health record is best undertaken by commercial IT developers in an open competitive market," the National Health and Hospitals Reform Commission (NHHRC) said in a supplementary paper released today. While tech-savvy patients are increasingly keen to manage their own medical records, public agencies worldwide have opted to maintain control over health information-sharing systems to ensure confidentiality, technical security and data quality. But in an unexpected turnaround, the NHHRC said "every Australian should be able to choose where and how their personal e-health record will be stored, backed-up and retrieved", and that the record should be "at all times owned and controlled by that person". Instead of providing a national health IT infrastructure, the Government's role should be "to regulate privacy and technical standards", and allow the market to come up with products that suit both consumers and healthcare providers "By 2012, every Australian should be able to have a personal e-health record," said NHHRC chair Christine Bennett. "The Government must legislate to ensure the privacy of a person's e-health data, while enabling secure access to the data by the person's authorised health providers." To thwart likely objections from doctors over sharing information contained in their patients' records, the NHHRC wants the payment of public and private benefits to health and aged care services "to be dependent upon the provision of data to patients, their authorised carers and other health providers, in a format that can be integrated into a personal e-health record". Microsoft has previously told the NHHRC it was feasible to establish an affordable, consumer-controlled e-health record nationwide within one year. Its HealthVault web-based platform has been designed to allow people to collect, store and share their own medical information with doctors and family members. The commission's interim blueprint, released late last year, has been criticised for its failure to put information technologies at the heart of planned health sector reform. While today's paper said the nationwide adoption of individual e-health records would return between $7-$9 billion in economic benefits from increased productivity and reduced adverse events over 10 years, the federal and state governments have baulked at providing the necessary funding. But the NHHRC believes there is no need to finance patients for the creation and maintenance of their own e-health records. Instead, it calls for public funding for "an appropriate social marketing strategy" to inform consumers and health professionals about the significant benefits and safeguards of the proposed new approach to e-health. It also calls for significant funding and resources to help doctors move to the new arrangements. "Engaging private and public healthcare providers to invest in IT systems and infrastructure, change work practices and participate in personal e-health records will be critical to success," the NHHRC said. "Vendors must ensure their systems are compliant with national standards and can receive and send data with patient consent and appropriate authentication." AushealthIT blogger David More warned that the NHHRC approach was "unbalanced" as it over-emphasised the role of the personally held record "and fails to recognise the importance of the provider's records". "In my view, the person's own record needs to be adjunctive to the records, and systems, used by each health professional to optimise the care they deliver," Dr More said. "The care provider needs information of known provenance and trustworthiness from external sources such as referring doctors and labs. "As well, the benefits case for health IT rests on clinical decision support provided at the point of care, and that is not recognised clearly enough in this approach."

Leaked details show modest costs for e-health

By: Karen Dearne

NATIONWIDE electronic health infrastructure will cost a modest $1.5 billion over five years, or $2.6 billion over a 10-year rollout, according to leaked funding details.
Federal and state ministers have kept tight wraps on costings and timetables since agreeing last December to adopt the National E-Health Strategy, prepared by Deloitte.
The $1 billion to $2 billion range "represents a relatively modest investment" when compared with the total annual health spend of $90 billion, with $60 billion coming from all levels of government.
Deloitte found that "tangible benefits" from implementing the e-health strategy "are in the order of $5.7 billion in net present value terms over 10 years".
Annual savings from a fully integrated system "are estimated to be about $2.6 billion in 2008-09 dollar terms".
The leaking of financial information and costed work programs on David More's AushealthIT blogger website appears to reflect growing frustration with the lack of progress on e-health.
Last month, medical and consumer groups told the National Health and Hospitals Reform Commission they were astonished it had failed to put information technologies at the heart of reform plans.
Dr More, a clinician and health IT expert, said he hoped today's federal budget would deliver a "substantial boost" for the health sector. "But I fear we may be disappointed," he said. "Really, $300 million per annum is small beer in terms of the whole health budget."
Dr More said the costs and benefits contained in the full Deloitte report had been available to all state and federal health bodies for more than six months, "and it is quite wrong in my view that the public does not get a chance to debate the merits" of the proposals.
The strategy identifies four key areas for investment, including foundational activities ($370 million over five years), e-health solutions ($630 million), change and adoption ($470 million), and governance ($30 million).
Big-ticket items include a national e-health solutions investment fund ($500 million over five years) and care provider incentives ($400 million).
In particular, Deloitte called for the present National E-Health Transition Authority to be disbanded, and a fresh e-health entity with a governing board and regulatory powers established.
To date, only a brief executive summary of the Deloitte report has been released, even though the strategy was endorsed by the Australian Health Ministers' Conference as "a practical framework".

Power failure lasting 36 hours cripples hospital care

By: Kate Benson

DOCTORS at more than 100 hospitals in the state could not access patient records or vital test results for up to 36 hours last weekend after a power failure crippled NSW Health's computerised database.
Some records were lost, X-ray and pathology results could not be accessed and staff were forced to use whiteboards to keep track of emergency patients after the main server shut down at 9am on Saturday because of a faulty circuit-breaker.
Back-up power from the Cumberland Data Centre, which provides computer access to the Greater Western, Greater Southern and Sydney West area health services also failed, plunging some of the busiest hospitals in the state into chaos.
Thousands of patients were affected, with doctors and nurses forced to take notes on paper and go to other parts of the hospital to collect hard copies of results, extending treatment times and adding to the confusion.
Some staff, who did not want to be named, said the weekend was chaotic and a shambles. One surgeon said it was fortunate no lives were lost.
The chief executive of Sydney West Area Health Service, Steven Boyages, said hospital blackouts that lasted more than 30 to 60 minutes were unacceptable, but the Health Minister, John Della Bosca, insisted patients were not put at risk. "At no time was there any threat to patient care or safety," he said yesterday.
The Opposition spokeswoman on health, Jillian Skinner, said the blackout was "a serious failure" with great potential for disaster.
"Hospitals affected not only lost access to patient records, some lost some patient records altogether … and couldn't access X-rays unless they physically went to the X-ray department for a film copy," she said. "John Della Bosca should explain why the patient records system lost power, why back-up systems also failed, and whether patient safety was compromised."
A spokesman for Mr Della Bosca said workers doing routine maintenance at the data centre had triggered the outage. No patients had reported problems connected to the blackout but a full investigation would be launched. "If necessary changes will be implemented to prevent a recurrence," he said.
with Louise Hall
BLACKED OUT
Hospitals at Westmead, Auburn, Blacktown, Nepean, Lithgow, Mount Druitt, Cumberland, Blue Mountains, Dubbo, Bathurst, Orange, Mudgee, Parkes, Bourke, Albury, Queanbeyan and Goulburn were affected.

Paper patients' notes out, digital records in

By: Louise Hall

BY THE end of next year, every public hospital in NSW will move from paper patient notes to electronic medical records that can be accessed by any health worker, the Government has announced.
The Minister for Health, John Della Bosca, said the $100 million project to digitise 250 hospitals will save money by eliminating duplicate diagnostic tests and imaging. It will also improve patient safety by alerting staff to a deteriorating patient and reduce the likelihood of errors.
Mr Della Bosca said doctors, nurses, allied health and social workers will be able to access a centralised repository of a patient's medical chart, laboratory results, prescriptions and referrals, no matter where the patient enters the health system.
Peter Garling, SC, recommended an urgent roll-out of electronic medical records (eMR) in his special commission of inquiry into acute care services, which found NSW's record-keeping system is "a relic of the pre-computer age" that puts patient safety at risk.
He said various hospitals and community health centres have established ad hoc databases but they were "spasmodic and patchy". The inability of distinct IT systems to synchronise with each other and lack of IT support staff meant clinicians had to rely on incomplete data to make important medical decisions and spent time chasing information.
Mr Della Bosca said the Government would make implementing information and communication technology within its capital works program a priority, which will make NSW Health the biggest IT user in Australia.
A basic eMR system that allowed clinicians to order diagnostic tests and view results online was successfully trialled at St George, Calvary, Sutherland and Lismore hospitals last year and by last month 20 hospitals were using it.
"Prior to the introduction of eMR, some requests for medical imaging and pathology could require referral back to the requesting clinician due to incomplete or illegible hand-written records," Mr Della Bosca said.
"This technology will improve the efficiency of hospital care and free up doctors and nurses to focus on patients and not paperwork, which will further improve patient safety."
The next step will link hospital-based records to primary care providers, such as GPs, by way of an electronic discharge summary.
But the Health Action Plan For NSW, released in March, revealed the Government would not meet Mr Garling's 18-month deadline for a digital radiological imaging system. This is to be set up in every public hospital to electronically transmit medical images to remote locations.
And an electronic health record, which would extend patients' information beyond hospital walls to all GPs, specialists and health systems in other states, was not possible without a national e-health strategy, it said.
A report commissioned by the Federal Government last December found state and federal governments have spent $5 billion on electronic health initiatives over the past 10 years but have made little progress towards creating a national system for sharing information.
NSW Health has admitted that two previous attempts to implement electronic medical records in 1991 and 1999 had failed, at a cost of $12 million and $30 million respectively.
The National Health and Hospitals Reform Commission has recommended an individual patient-controlled electronic health record owned by the patient who decides which health care providers can access it.

$96m medical IT system useless: whistleblowers

By: Nick Miller

A NEW $96 million computer system for Victorian hospitals that promised to cut down on dangerous medication errors will be almost useless when it goes "live" this year, insiders say.
Other new computer systems that handle finance and manage patient records are plagued with serious problems that take days, even weeks, to fix.
And in a further embarrassment for the years-overdue $360 million HealthSMART program, a hospital chosen by the Government to be a flagship "lead agency" — Ballarat Health System — has quit the project because it could not justify the expense.
An anonymous letter from "health-sector employees" sent to The Age says the Cerner clinical systems, intended to cut down on mistakes in doses or combinations of medicines, is being rushed into hospitals — with none of the medication functions working — so the Government will not be embarrassed before next year's election.
"The whole reason for this system was to introduce electronic medication," the letter says. "But next year is an election year and we must hit the agreed dates. This means the system will be almost useless when first live."
Documents released to The Age by the Department of Human Services under freedom of information, and the department's own website, confirm that when clinical systems go live at the first two hospitals late this year, they will not include its most significant functions.
These include ordering pathology tests or medical scans, medication management for emergency patients or inpatients, and "decision support" functions that cross-check drugs and doses.
Leaked reports show other new HealthSmart systems are highly unreliable.
In the last quarter of 2008, the reports showed serious problems with the "PCMS" system, which tracks patient records, books operating theatres and warns doctors of a patient's particular allergies or chronic health problems.
As of December, the system was used at five health services, including Northern, Frankston and Royal Women's hospitals.
Hospitals also reported major problems with the FMIS financial software that runs budgets, purchases, accounts and assets at seven hospitals, including Box Hill, Northern, Frankston, Monash and Peter Mac.
Ten hospitals were targeted for the Cerner clinical system, with Eastern Health, the Royal Victorian Eye and Ear Hospital and Ballarat Health Service as "lead agencies". The Age's FoI documents say Ballarat is "unlikely to proceed given costs included in business-case".
One hospital CEO told The Age he "will be very surprised if it stacks up", as the system cost hundreds of thousands of dollars to run each year.
Another senior Victorian health IT expert said most hospitals would never take up the software. "No one likes using it because it's s---," he said. "It's totally inflexible."
A Health Department spokesman denied all the allegations, without giving any detail.
A spokesman for acting Health Minister Lisa Neville denied that hospitals were being pressured over HealthSMART to avoid embarrassment before the election.
Opposition health spokeswoman Helen Shardey said it was vital that Victoria's hospitals got a modern IT system, but the Government was failing to deliver one. "It's a massive cost to health services, and it seems the timing is being driven by the next election rather than the best clinical care," she said.

Rudd Govt to abolish patient privacy

By: Suzanne Tindal

The Australian Medical Association (AMA) has slammed draft legislation brought forward by the Federal Government, which will allow it the right to access individual patients' records.
This is 'Big Brother' at its worst.
The draft, which the AMA said had been released last Thursday night before the Easter long weekend, would mean the government had the power to "require a document, extract or copy containing health information (within the definition of the Privacy ACT 1988) about an individual".
The legislation had its grounds in making it possible for the government to conduct administrative checks"This is an act of bureaucratic voyeurism that strips patients of all rights to privacy. It presses the face of government at the keyhole of every surgery in the country. Doctors will be compelled to hand over highly sensitive medical information to justify Medicare claims potentially including a patient's intimate concerns and examination findings, their test results, weight, sexual health, infections ... nothing is protected.
"Worse still, under this legislation patients don't even have the right to know that their records are being accessed. There is no compulsion to even advise patients, let alone seek their permission," Capolingua said.
"Government has no business accessing these records. This information is between the doctor and the patient, and must remain so," she concluded.
There has been a lot of attention on health record privacy in recent times with the attempts to introduce national electronic health records, as they would make private information more readily available. The government is facing the need to pass new legislation to make the introduction of an individual health identifier possible, which the National e-health Transition Authority believed would take until next year.
The office of Federal Minister for Health and Aging Nicola Roxon was unable to provide comment in time for this article.

Qld Health buries TrakHealth suit

By: Renai LeMay

in brief Queensland Health has settled its long-running lawsuit with e-health vendor TrakHealth and its parent InterSystems.
TrakHealth dragged Queensland Health into the state's Supreme Court in December 2005 after the department terminated a contract with the vendor for the implementation of the department's Clinical Information System project and related software. The e-health vendor claimed it was owed damages.
However, Queensland filed a counter-claim against the e-health vendor as well as InterSystems and its CEO Terry Ragon.
"The parties have now agreed [to] a settlement which resolves all matters in issue between them, including all claims and counter-claims in the proceedings, to their mutual satisfaction," a statement issued by TrakHealth this morning said without providing further details.

Roxon lost on e-health, opposition claims

By: Suzanne Tindal

The Federal Government's lack of a true electronic health agenda had left an opposition offer of bipartisanship on the issue dangling useless by the wayside, Shadow Health Minister Peter Dutton said yesterday.
"[Health and Aging Minister] Nicola Roxon and I don't always have a perfect made in heaven relationship, but nonetheless, when I first sat down with Nicola coming into this portfolio only six months ago I gave her an undertaking that we would — on the issue of e-health — provide bipartisan support," Dutton said speaking yesterday at the Annual Health Congress in Sydney.
We've seen no evidence of an agenda which we can support as we go forward.
The upfront expense and long lead times of e-health solutions meant that the benefits wouldn't be delivered for what was politically, a long time, according to Dutton.
Yet the offer was not being used, the shadow minister said: "I offered that bipartisanship from day one. The offer stands today, and we've seen no evidence of an agenda which we can support as we go forward."
His comments echoed those made by Booz and Company principal Klaus Boehncke at the conference. "It's fair to say that political leadership has not been exhibited here as it has elsewhere," he said, pointing to US President Barack Obama, who put e-health onto the agenda in his first address at the White House, the German Federal Health Minister Ulla Schmidt's spruiking of her country's e-health card and the tremendous drive in Singapore to get electronic health records up and running by 2010.
"What you see then in Australia because of this lack of leadership is that many of the states are pursuing their own separate visions of e-health programs," Boehncke said.
The lack of drive and vision has seen talent go overseas to where the fruits of its labour might be implemented, he said. "[There are] disillusioned Australians from the National E-health Transition Authority and from Queensland Health and from a lot of healthcare areas, working hard to make sure that Singaporeans get an electronic health record next year."
What you see then in Australia because of this lack of leadership is that many of the states are pursuing their own separate visions.
In order to move from this point, Boehncke highlighted three areas he thought needed urgent attention, the first being a national e-health investment strategy which was "much more than a business case" since it defined what would be built, for whom and why. NEHTA currently has a business case for a national e-health strategy, which needs to go before the Council of Australian Governments before funding can be allocated to it.
The second was a national infrastructure and definitions around how data would be shared, where it would reside and who owned the data. Where the data resided would go into consultation after the business plan was approved, according to NEHTA CEO Peter Fleming, speaking at an IIR conference last week.
"At this stage the current thinking is that we will not have one central electronic health record that everyone's part of. The expectation is that there will be multiple electronic health records around the country and that those health records will be provided by various players. In some cases it may be health insurers, in some cases it may be Google or Microsoft, it may be professional bodies," he said.
"Where I think we will end up is that we will have a large indexing service not dissimilar to the type of web technologies we know today that knows where an individual's records are stored and can pull that data back as required. Given the current physical restraints, I think that index will also contain some summary data, things that might be required in an emergency.
The last issue Boehncke outlined was the national health identifier, which he spoke on in expanded fashion since it touched upon prior work of his with the past government's controversial Access Card. "[NEHTA is] developing a number for every Australian. But having a number isn't the same as developing an identifier," he said. Boehncke said it was necessary to have that number linked to the physical person, for example, by using a card, but when he asked people in Australia how they thought the person would be linked to their number, he received a lot of different answers.
This type of stuff really makes the things that were stored on the Access Card seem insignificant.
"I get high-ranking state health ministry officials that tell me people in Australia don't need to be identified securely because they trust their GP... The GP will identify the patient," he said. "Other people tell you oh no, no, no, there'll be a new Medicare card. It'll be a smart Medicare card."
Those people thought it would be easy to upgrade the Medicare card to take on new duties, but it wouldn't be, according to Boehncke.
"Let me tell you, from my Access Card experience I know that's not going to be easy because you're moving from a payment card to what becomes an identity card. And you'll have all these questions like we had with the Access Card. Like can you put a photo on it."
When someone asked if the government was dithering because it was frightened of opening up an Access Card type can of worms, Boehncke said that an e-health card would be much more frightening than the previous government's controversial card because of the type of data it would have stored on it.
"This type of stuff really makes the things that were stored on the Access Card seem insignificant because your health data holds a lot more information about you," he said. "To be afraid of an Australia Card when you are trying to identify people in the health setting might be natural when you look at the Australian history in a lot of these debates," he said.
Yet he believed people would voluntarily take up an e-health card because unlike the Australia Card of the Access Card, an e-health card has a true value proposition — the opportunity to save lives.

Medical histories on internet

By:Anna Caldwell and David Earley

AN alarming privacy breach by one of Queensland's biggest pathology labs has splashed patient medical histories over the internet.

The names, contact numbers and private details of at least 100 patients, and potentially hundreds more, were plastered on the website of Brisbane-based Sullivan Nicolaides.

The breach has cast serious doubt on the safety of electronic patient record systems, and angry patients were last night demanding answers.

The Courier-Mail yesterday viewed 102 patients' details before it alerted the lab to the security breach, which has been blamed on a processing error.

Kay Faulkner from Brisbane was devastated to hear the details of her recently deceased husband were so easily accessible.

"This is disgusting," she said.

"Dishonest people can easily misuse the details of someone who has died so for me this is a serious breach."

Rick and Cindy Gore from north Queensland said the security lapse was "completely unacceptable".

"We were never given a password or website to access so there is no reason for this information to be online - it is not like we could log on and check it ourselves."

The use of electronic records in medicine has jumped as software systems become more sophisticated. But the failure at Sullivan Nicolaides has shown the potential for online records to fall into the wrong hands.

All patients affected by the breach were referred to Sullivan Nicolaides by their GPs for the management of warfarin doses, a blood-thinning drug.

Most were from Queensland and northern NSW, with the files dating back to 2007 and 2006.

The records detail relevant medical history, current medications, as well as patient's next of kin.

Sullivan Nicolaides CEO Michael Harrison initially refused to reveal how many patients records were violated and accused The Courier-Mail of "acting like terrorists".

He later apologised and said 103 files were breached, although The Courier-Mail believes it could be many more.

Mr Harrison said the company had taken the security problem "very seriously", and within an hour of being alerted, the records were removed.

He said patients' details were only meant to have been accessed by authorised doctors and staff.

"Honestly, we are flummoxed (by the breach)," he said.

Despite the violation, Mr Harrison said e-health was the future of medicine. "I don't want this to be adverse publicity for e-heath because electronic health records are crucial to ensuring patients get the right care."

Chair of the Privacy and Security Forum and board director of the Health Informatics Society of Australia Peter Croll said that although private medical records should never be publicly available, there was nothing in the law requiring a breach to be reported.

"Obviously it's totally inappropriate," Mr Croll said.

IBA Health raising $124m to pare debt

HEALTH information technology firm IBA Health Group will seek to raise up to $124 million by issuing new shares to reduce debt.

IBA said yesterday it was offering two shares for every seven held by shareholders, at 55c per share -- a 29 per cent per cent discount to the closing price on Wednesday.

The institutional component of the offer, representing about $77 million, was committed.

IBA said its largest shareholder, AEP Financial Services Holdings, had committed to taking up its full entitlement, equivalent to about $32 million.

The balance of the institutional offer, about $45 million, is underwritten by ABN AMRO and UBS.

The retail offer, on the same terms as the institutional offer, is not underwritten.

IBA said it intended to use the proceeds of the offer to retire subordinated secured borrowings of $60 million from AEP, and other senior borrowings.

"The equity raising places IBA in a strong capital position to continue to benefit from investment in health IT by governments worldwide, and the computerisation of healthcare records," IBA chief executive Gary Cohen said.

"The outlook for the company is robust," he said.

IBA reconfirmed its 2009 full-year guidance for revenue of $540 million to $560 million and earnings before interest, tax, depreciation and amortisation of $120 million to $130 million.

"The company is well positioned to generate growth in the current economic downturn, with approximately 90 per cent of forecast revenues for full-year 2009 funded by governments either directly or indirectly," IBA said.

"Additionally, as at the end of January 2009, approximately 94 per cent of IBA's forecast full-year 2009 revenues were recurring, contracted and expected."

IBA shares, which were in a trading halt on Thursday, last traded at 77.5c.

BI key to e-health, says SWAHS staffer

By: Suzanne Tindal

Using integrated business intelligence software can help harness the benefits of introducing electronic health records, according to a senior IT staffer at Sydney West Area Health Service (SWAHS).
The forklift's running around there in a fairly empty warehouse.
SWAHS staffer Trevor McKinnon
"The biggest issue you have with the electronic health records is that nursing staff are providing the bulk of the entry," SWAHS business intelligence and web development director Trevor McKinnon said in a recent interview with ZDNet.com.au. The nurses felt that they were not getting any of the benefit and doing all the work, he said.
Indeed, most of the advantages of having electronic health records were seen downstream, he said, when, for example, doctors were able to see the information nurses had entered.
He hoped that in years to come, business intelligence could alter this perception by running text analytics on the data from the electronic records to make nurses' workload less and not more. Business intelligence would use text analytics to "get into what's written" and pre-write a report which the nurse simply had to review, instead of creating.
"Business Objects certainly has the potential to do that," he said, although he didn't believe it would happen until 2011. NSW Health has a whole-of-state contract with Business Objects and uses the company's Xcelsius platform. McKinnon is one of the leading drivers of its use, taking on not just business intelligence for SWAHS, but for other area health services within the state as well.
Just as business intelligence would help electronic health record acceptance, the progression of electronic health records would help business intelligence. Although the groundwork for electronic records in NSW had been done, McKinnon said, only the emergency departments and intensive care were recording patient information electronically. In other departments nurses were still writing reports by hand.
This limited the breadth of data which McKinnon had at his disposal to run statistics using the business intelligence, with only information such as admissions and outpatient services available for use. "The forklift's running around there in a fairly empty warehouse," McKinnon said, although he admitted that the information being gathered already was prolific enough to keep him very occupied.
This data is currently used to measure performance for the hospitals, and Sydney West Area Health Service uses dashboards built on the information to benchmark how staff are performing. It also is used on the patient side. If a "frequent flyer" patient comes into the emergency department, the business intelligence application can inform the employees which professional the patient saw previously — this often allows cases which don't need hospitalisation to be given other treatment and sent home, freeing up beds.
McKinnon looked forward to when most patient records were being entered electronically so that business intelligence could carry out functions such as finding keywords in records which could alert a doctor to the fact that a patient may need attention, increasing the level of care. "We can't wait," he said.

NSW a silent success in e-health

NSW is leading the country in e-health with both doctors and patients benefiting from new technology, but why wont Health Minister John Della Bosca tell us about it, writes Bryn Evans.

When will some really good health news get some coverage? While the media has recently been fixated by the world financial crisis, political backstabbing, or the misdeeds of the latest rogue doctor, real progress has occurred in NSW e-health that will bring far-reaching benefits to everyone in the state.

On 1 October last year, St George Hospital implemented an electronic medical record system (eMR) for some 2300 clinicians across its emergency department, all wards including pathology and radiology, nine operating theatres and more than 300 outpatients clinics, and allows electronic discharge forms to be sent to general practitioners. The project has been hugely successful, and is the start of a state-wide program by NSW Health to introduce the eMR to every hospital in the state.

The eMR system was first deployed at the St George Hospital in the South Eastern Sydney & Illawarra Area Health Service (SESIAHS), followed by Calvary and Sutherland hospitals, and will be rolled-out to each hospital in the Area Health Service for some 1.3 million people.

All hospitals in the Illawarra region will go live in the next two months, followed by the Northern Coast Area Health Service which is in the middle of its eMR roll out.

In time eMR will spread state-wide.

Some Area Health Services with earlier, less comprehensive eMRs, are planning upgrades.

So why does NSW Health Minister John Della Bosca not tell us about it?

The eMR rollouts mean that patients treated in SESIAHS will have their patient details, medical history, test results and treatment notes updated and instantly available to any clinician attending to them.

No more tedious and inefficient questions such as “Which hospital and doctor did you last see?”, “What did your last test results state?”, “What medication are you on?”, or “Do you have your ultrasound scan with you?” that drive every patient to distraction.

There will be an immense improvement to patient safety as the eMR becomes available everywhere in NSW.

Adoption of an eMR on this scale is the most ground breaking IT project undertaken in Australian healthcare, and NSW Health is leading the way. It is the first step in a journey to provide electronic information that better supports clinicians and brings improved care to patients. Work procedures and practices will be fundamentally transformed as knowledge is shared to provide better patient care.

The eMR finally brings the benefits of ubiquitous online access, akin to electronic banking, within the reach of clinicians and health consumers. It also provides the foundation of information for the personal electronic health record, which health consumers could access over the Internet within the foreseeable future.

But why cannot NSW Health tell the public about this success?

Maybe they are scared of success, and the resulting demands by the Garling Inquiry for more funds to speed up deployment.

For once NSW Health have some really good news. It is following best practice, and has got it right, so they should tell us about it!

Health ignored in stimulus package

By ignoring the health sector in today's stimulus package the Federal Government has missed the opportunity to support one of the most important areas of the Australian economy, according to the Australian Healthcare and Hospitals Association (AHHA). The AHHA is the peak national body representing public hospitals, area health services, community health centres and public aged care providers."Health and community services contribute to the overall strength of our economy in a number of ways and should have been a key focus of this stimulus package," said Ms Prue Power, Executive Director, AHHA. "Firstly, health is one of the biggest components of the services sector, the largest section of the Australian economy. Health care is a growth industry which has the potential to further expand with support from the Federal Government. "Secondly, the health sector is one of our nation's largest employers with over 10 per cent of workers being employed in the area of health and community services. With widespread workforce shortages, there is considerable scope to train and employ health care workers throughout the sector thus creating new jobs and meeting existing needs for health care. "Thirdly, the productivity of our workforce depends upon high quality and accessible health care services. When people lack adequate access to health care it can reduce their capacity to work, affecting both them and their families and compromising the overall efficiency of our economy. "There is clear evidence that our health system currently does not perform well in areas such as the diagnosis and management of chronic disease and the provision of preventive dental care. This leads to the development of more serious conditions which can prevent people from seeking or continuing in employment. "AHHA urges the Federal Government to expand the suite of initiatives contained in today's stimulus package to include an injection of funds into the health sector, in particular focussing on the critical areas of infrastructure and workforce. "This would enable health services to upgrade their infrastructure, train more health care workers and increase the provision of essential health care to the Australian population, providing flow-on benefits to the economy and resulting in a healthier and more productive workforce," Ms Power said.

HealthSmart gets new head

By: Suzanne Tindal

The Victorian Department of Human Services has appointed a new CIO of health services who will also lead up the state's HealthSmart electronic health initiative.
Dr Andrew Howard, not the same Andrew Howard who holds the CIO position for the whole department and had previously been acting National E-Health Transition Authority CEO, will start next week.
A spokesperson for the Department of Human Services was sure there would be ample confusion caused by the two like-named CIOs.
The incoming CIO's role will include taking responsibility of HealthSmart, filling the shoes of Fiona Wilson who left last September.
HealthSmart began as a four-year, $320 million project to update IT systems in hospitals and other medical facilities right across Victoria, but has encountered deadline and budget problems.
Howard has had a medical career within the Victorian public health system, the spokesperson said, but has also held positions in the private sector at corporations such as NEC.

Uniform health system in the mill

By: Karen Dearne

LARGE-SCALE production pilots of a nationwide e-health system will start this year, with the National E-Health Transition Authority set the task of making this happen as quickly as possible.

Peter Fleming says he hopes to run pilot projects this year

NEHTA chief executive Peter Fleming has been given a mandate to create a uniform IT infrastructure, starting with an incremental build-out of existing clinical and communication platforms.

Federal and state government agreement on the urgent need for healthcare safety and efficiency gains - detailed in several recent reports - signals an end to years of under-investment and fragmentation as parties pursued their own technology agendas.

"Legislative changes are needed, but from a technical perspective we aim to be in a position this year to run some pilots," Mr Fleming said.

"We're in very close dialogue with a number of groups about trials of electronic medication management and hospital discharge summaries."

Late last year, the Council of Australian Governments approved $218 million in funds to extend NEHTA's operations.

Mr Fleming said the organisation was working with software vendors to assess their capabilities and move towards the goal.

Medical Software Industry Association president Vincent McCauley said members were "hopeful this is the year things happen".

"That, of course, remains to be seen, but we're keeping our fingers crossed," Dr McCauley said.

The association is advertising for a part-time general manager in response to increased industry involvement in consultations over national projects.

IBA Health Group chief executive Gary Cohen said there had been a fundamental shift in attitudes, and "not many in healthcare are interested in trying to preserve their own patch" any more. "People have realised that we have to do things differently, and we need a more national approach to healthcare delivery," he said.

Mr Cohen said the Rudd Government should be "emboldened" and develop a vision of investing in healthcare IT infrastructure. "There should be a central funding body that's responsible for allocating funds for infrastructure," he said.

"People within state health departments are locked into a particular environment - really, only the federal government has the capacity to make those big changes," Mr Cohen said.

Helen Hopkins, outgoing executive director of the Consumers Health Forum, said there was more recognition among health professionals and bureaucrats that people were important stakeholders.

"Consumers want access to their health information when and where they need it, so we're continuing to push for a full e-health record," she said.

"If that's going to take some time, they want some easier things first, such as their hospital discharge information to be sent to their GPs," she said.

Uniform health system in the mill

By: Karen Dearne

LARGE-SCALE production pilots of a nationwide e-health system will start this year, with the National E-Health Transition Authority set the task of making this happen as quickly as possible.

Peter Fleming says he hopes to run pilot projects this year

NEHTA chief executive Peter Fleming has been given a mandate to create a uniform IT infrastructure, starting with an incremental build-out of existing clinical and communication platforms.

Federal and state government agreement on the urgent need for healthcare safety and efficiency gains - detailed in several recent reports - signals an end to years of under-investment and fragmentation as parties pursued their own technology agendas.

"Legislative changes are needed, but from a technical perspective we aim to be in a position this year to run some pilots," Mr Fleming said.

"We're in very close dialogue with a number of groups about trials of electronic medication management and hospital discharge summaries."

Late last year, the Council of Australian Governments approved $218 million in funds to extend NEHTA's operations.

Mr Fleming said the organisation was working with software vendors to assess their capabilities and move towards the goal.

Medical Software Industry Association president Vincent McCauley said members were "hopeful this is the year things happen".

"That, of course, remains to be seen, but we're keeping our fingers crossed," Dr McCauley said.

The association is advertising for a part-time general manager in response to increased industry involvement in consultations over national projects.

IBA Health Group chief executive Gary Cohen said there had been a fundamental shift in attitudes, and "not many in healthcare are interested in trying to preserve their own patch" any more. "People have realised that we have to do things differently, and we need a more national approach to healthcare delivery," he said.

Mr Cohen said the Rudd Government should be "emboldened" and develop a vision of investing in healthcare IT infrastructure. "There should be a central funding body that's responsible for allocating funds for infrastructure," he said.

"People within state health departments are locked into a particular environment - really, only the federal government has the capacity to make those big changes," Mr Cohen said.

Helen Hopkins, outgoing executive director of the Consumers Health Forum, said there was more recognition among health professionals and bureaucrats that people were important stakeholders.

"Consumers want access to their health information when and where they need it, so we're continuing to push for a full e-health record," she said.

"If that's going to take some time, they want some easier things first, such as their hospital discharge information to be sent to their GPs," she said.