Does Australia need another EHealth Strategy? The need for ehealth education for all doctors.

Last week I presented at the Menzies Centre for Health Policy conference at the University of Sydney.

My topic was “Does Australia need another EHealth Strategy?”

The focus was on the need for clinicians to be educated in ehealth, as it influences almost every aspect of healthcare delivery today. Without a well educated and supported group of people with a real healthcare background, we will not be able to deliver a real solution that utilises technology to deliver better healthcare.

Below are my notes for the presentation. I look forward to your comments.

Australia’s healthcare system is recognised as world class by any international comparison, and it use of information technology has been also been commended by many international think tanks. So at first glance it would appear that Australia is doing OK in the world of ehealth. Like most things there are two sides to this argument, and whilst I do not want to take away from Australia’s success to date, I propose that in fact we need a radical rethink of the national ehealth strategy to enable us to improve our healthcare system and take advantage of the improvements of technology that are taking place whilst ensuring the quality and safety of our healthcare system.

First, let’s define what we mean by ehealth. If we use the definition used by the WHO. The define ehealth as the transfer of health resources and health care be electronic means. Simple enough, take a doctor, or other health professional, add a computer, and the result is ehealth. Today that basically means that almost every healthcare interaction from primary care through secondary care, acute care in a hospital, public health interaction, all the way through to healthcare funding at the highest level is to some degree affected by ehealth. Very few if any healthcare transaction today does not have the involvement of a computer somewhere in the process. In reality ehealth is probably involved in several steps, which is why it is very important that we have a cohesive strategy about its use.

What do we mean by strategy. It is both a policy and an actionable plan to deliver on a goal using the resources we have available. A strategy needs a goal, and to be relevant to healthcare that goal needs to match the goals of the broader healthcare system. I put it to you that an enviable goal for ehealth, and the healthcare system in general is the Triple Aim of the Institute of Healthcare Improvement. To improve the patient experience of care, including quality and satisfaction, improve the health of populations, and reduce the per capita cost of health care. I believe that at any health interaction all healthcare providers will have at least one, most likely two, and possibly all three of these goals in mind. In the chain from patient to provider to payer all three of these aims should, at some stage, be top of mind for someone in the system. I believe ehealth should share these aims.

Australia has made attempts at developing a national ehealth strategy before. In 2008 the federal government embarked on an ambitious program to develop an ehealth strategy and integrate it within the broader healthcare and information technology strategy of the nation as a whole.  It was an idea worthy of congratulations, and also some early celebrations.

Prior to that ehealth strategy was left pretty much in the hands of the people implementing the technology. As it was deemed they had been successful in implementing ICT in other domains, it was assumed that they would be able to deliver it in healthcare as well. To many people healthcare was put up as just another industry that would benefit from the transformative powers of technology to make it more efficient, more accountable, and more effective. To this day we hear the comparisons, usually in derogatory terms, between banking and healthcare. We can do our banking on line, or through a hole in the wall, why hasn’t healthcare delivered the same value from ICT?

For some aspects of healthcare that analogy makes sense. If we look at the payers then to a large degree that transformation has occurred. However when it comes to actual delivery of healthcare we are looking at a much more complex interaction than any banking or retail transaction that involved not just the transfer of data, but also some very advanced decision making involving anatomy, physiology, pathology, psychology, sociology and even a bit of economics. Balancing the various sciences and arts involved in healthcare delivery has been recognised as far back as Hippocrates who said, “there is art to medicine as well as science”.

The main problem with our ehealth strategy to date is that we have failed to recognise this art aspect of healthcare, and have feverishly worked on the data side of things in isolation. Data is important, and it is critical that we recognise its value, but in relation to the healthcare interaction, not in isolation. This is an appreciation healthcare providers develop over their professional careers, which unfortunately we have not captured in our current ehealth strategy.

Let me use the Personally Controlled Electronic Health Record as an example of this. It was one of the main aspects of the recommended ehealth strategy that was taken up and used to spearhead ehealth in Australia. From a data perspective it makes a lot of sense. One point of reference for all information relating to a patient’s health history should enable all providers to collaborate more effectively. From a data base expert’s perspective, that makes sense. However from a clinician’s perspective it offers a different potential, and from a patient’s yet another. The challenge is to develop a system that meets the requirements of the key players, the patient and the provider. To do that they need to be actively involved in the development, and they weren’t to the degree they should have been.

I don’t blame the government, or even the developers of the system for this. I think we need to recognise as healthcare professionals that we should have been much more vocal and collaborative early on and taken charge of this project, and ehealth in general, and not let it be delivered to us by unrelated ehealth agencies.

We saw similar issues in the development of telehealth recently as well. We let the bureaucracy responsible for payments take control of the strategy and implementation, and as a result saw a system designed to meet one of the triple aim’s goals, reduce per capita cost, but without paying more than lip service to the other two.

I put it to you that the greatest failing of our ehealth strategy has been our failure as healthcare providers to take control of it. In hindsight we complain about what we have received, but in reality we should have been leading the initial thinking about the strategy, the development of the strategy, and the implementation of the strategy to ensure it delivered on its promise.

But it is not as simple as that, very few problems ever are. The greatest impediment to clinical leadership in ehealth is lack of skills. We are not taught the basics of ehealth or technology at medical school. It is assumed that because we have an email address we understand the intricacies of health informatics. We have no career path for those clinicians who do have an interest in the area, no recognised post graduate training, certification, job prospects. Whilst we have progressed well in many other aspects of healthcare science and policy, we have not in ehealth because we do not recognise the need for proper education and career progression for healthcare providers in this area.

Other countries have. In the USA you can receive board certification in clinical informatics, and there exists the equivalent of a learned college for such professionals. Hospitals have positions for Chief Medical Informatics Officers, and Chief Nursing Informatics Officers, and department dedicated to the delivery of better health outcomes through ehealth. In Hong Kong when they developed their ehealth strategy they developed large clinical coordinating committees led by clinicians provided with support to develop a strategy and implement it.

In Australia we need to foster the education of our healthcare professionals on the role of technology, how it can be used, and how they can be more involved. This requires that they all have at least an introduction to the science of health informatics and the opportunity to integrate it into their clinical careers. I am not suggesting that we need an army of health informatics academics, but we do need many more health informaticians from the ranks of the various healthcare providers to enable us to develop and implement a strategy that will deliver on the triple aim for patients, providers and payers in the healthcare system.

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One Response to “Does Australia need another EHealth Strategy? The need for ehealth education for all doctors.”

  1. Malcolm Crompton Says:

    George – thank you for this, a very balanced and clear eyed discussion. Would that there be more. I particularly like your definition of ‘strategy’ as ‘both a policy and an actionable plan to deliver on a goal using the resources we have available’. Many strategies fail that test. Also your quote from Hippocrates who said, “there is art to medicine as well as science” and your linkage of that insight into the vital need to develop a system that meets the requirements of the key players, the patient and the provider.

    Two observations:

    1. Nehta went to extraordinary lengths to engage consumers and health practitioners and many of us gave huge amounts of time to the process, the Cinical Leads especially. It wasn’t the outreach that was missing, it was the response. And the fact that all parties wanted an uncompromising win rather than a workable compromise for all interests.

    2. My second comment flows from the first: Yes, healthcare providers need to be involved and to lead as you suggest (and have been given the chance to do so over many years). BUT they cannot insist on being the only point of view at the table (see point 1 above)! The weak involvement of health consumers and the potential dominance of healthcare providers in the latest review of the PCeHR is potentially a major weakness. The willingness to listen to all parties AND to take their perspectives and interests into account will be vital. The recent editorial comment in The Sydney Morning Herald was very poor in that regard as pointed out by a Letter to the Editor shortly after (See “Electronic health records will make it easier to save a life”; 11 Nov 2013 http://www.smh.com.au/comment/smh-editorial/electronic-health-records-will-make-it-easier-to-save-a-life-20131110-2x9zh.html).

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