Big Data and Personalised Medicine

November 4, 2015

My recent presentation on Big Data and Personalised (for my US friends Personalized) Medicine.

I believe this is the most valuable input the information technology industry can provide to healthcare.

The challenge is to ensure we do it in collaboration with the healthcare industry and not in a siloed way as we have in so many other aspects of healthcare.

We also need to take some responsibility for educating the healthcare workforce on this important area. Having gone through med school and watching my son go through now they are struggling to come to grips with the value of data. It is an area the ICT industry understands, so we should play a more active role in helping them learn its value and how to use it. There may even be an opportunity to develop a whole new healthcare sector specialising in data rather than body parts 🙂

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

October 21, 2013

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.

The Art and Science of Digital Medicine from TedMed Sydney 2013

April 30, 2013

I recently had the privilege to present at the inaugural TedMed Sydney event held on April 20 2013 at the University of Sydney. This was a satellite event for the larger TedMed event being run in Washington DC. It was a particularly exciting as I was speaking back at my old Alma Mater, I studied medicine at the University of Sydney. To make it even more special I was speaking in the same session as Professor Martin Tattersall. Professor Tattersall is a legendary physician at the Royal Prince Alfred Hospital where I trained. He is recognized for his clinical skills and his humanity. He was the oncologist who looked after my mother during her 2-year battle with lung cancer, and I will never forget the kindness he showed her and us during that time.

The problem with TED talks is that the go very quickly. I had prepared a speech, but on the day the adrenaline kicks in and the clock ticks down, and I suspect I may have missed a few of the salient points I wanted to say. So below I have my prepared notes, which I hope emphasise the point I wanted to make. When the video becomes available I will post it too, so you can compare the two.

The Art and Science of Digital Medicine

Dr George Margelis

I love gadgets, I am unashamedly a geek. My first Personal Computer was back in 1981, a Sinclair ZX81, since then I have gone through multiple iterations, and today I have 3 computers and 2 tablets on my desk with 3 redundant internet connections. So as you can see I am not a Luddite.

Today, to paraphrase Marc Antony in Shakespeare’s Julius Caesar, I have come not to praise technology, but to bury it.

Over the last decades many entrenched myths have developed about technology and healthcare. They are based on good intentions, and a common desire to do the right thing. However the net effect has been wasted money, wasted energy, and wasted opportunity.  But that is not the worst of it. The real problem is that people who we could have helped, if we had done it right, were not being helped. We were breaching the very basis of the Hippocratic oath, First do no harm. We thought we were doing the right thing, but in practice we weren’t.

The first myth is that technology will save the healthcare system. We have heard that it will save the healthcare system billions of dollars, prevent thousands of medical errors, solve the challenge of chronic disease, and even stop childhood obesity. Because, as my technology colleagues have told me, these are just the fault of a flawed healthcare system run by greedy doctors and poorly managed patients, all of which can be solved by the right app on their phone.

They are Wrong. Healthcare is a complex endeavor, balancing human physiology, psychology, sociology and economics. Technology is a powerful tool we can use to effect many aspects of healthcare, but ultimately healthcare is a very personal endeavor. No app or device alone will change that. In fact, technology has the potential to amplify our problems in a way humans just cannot. For the technologists their desire to simplify everything to data flows is their greatest weakness.

The second myth is that the development of new technology, that is new gadgets that we see being released on a regular basis will drive innovation in healthcare. New tablets, phones, sensors, imaging devices will lead to innovation. Again wrong. Innovation in healthcare is very different to invention. Each new gadget, is a new invention. It is only an innovation when someone does something better with it. A faster chip, a better screen, a new program are all great inventions, but until someone takes that capability and delivers a healthcare outcome using it, it is just another shiny bauble by the bedside.

The gadgets are not our enemy, they are our tools. As with any tools, in the hands of the right person they can make beautiful art, and in the wrong hands they can create havoc. It is our responsibility as the healing profession to ensure they are used well. The challenge we face is that the technology for gathering information has overtaken our capability to utilize it. It is up to us to speed that up, and at the same time simplify it. We hear about big data, it is up to us to turn it into good data.

That is where you come in. The doctors, nurses, allied health workers, medical administrators. You need to identify the problems, and use the gadgets to make the improvements. You need to take charge, and stop believing that the latest device will solve your problems, because the people who make that gadget have no idea what your problems are

However, it is not all about the doctor. The greatest change in healthcare is the rise of the E-Patient. The E has many meanings. Empowerment is the key to better healthcare, so the Empowered Patient is one of those meanings. The key to power in the past has been access to knowledge. For centuries locked away in medical libraries and arcane journals that knowledge has now been freed by the power of electronics. So the Electronic Patient is another meaning, because thanks to the internet and the computers that have made the world’s knowledge available via the press of the button the doctor can no longer hide behind their shield of knowledge. Again, the electronics is but a tool. The real innovation is in people making that knowledge available and accessing that knowledge, and using it to improve their health. A journal article in itself will not make anyone healthier, but accessing it and changing your actions based on that evidence will. Technology can make the knowledge more accessible, but like the proverbial horse to water, it can’t make you drink from the fountain of knowledge. Education can, so the third E is for the Educated patient. Not in the classic K-12 sense, but in health literacy. No doubt the two are related, but unless we ensure the health literacy of our population is improved all our efforts in healthcare reform will be wasted.

The E-Patient along with the E-Doctor and the E-Health system can change healthcare. By combining the art and science of medicine with the art and science of technology we can develop solutions to our healthcare problems. Separately medicine and technology cannot. Each can make a difference, but when combined, with a deep understanding of what we want to achieve, the potential is limitless.

To do this we need to develop a clinically focused innovation model that combines the two. Doctors need to understand technology, and technologists need to understand healthcare. We need to make sure we are working towards a common goal, healthier and happier patients. To do this we need to collaborate. This sounds simple enough, but we come from very different worlds. For us to collaborate, we must first cohabitate.  We need to bring technologists into our domain, the hospital, the clinic, the labs. We need to introduce them to who we work with, our patients and their families.

They need to understand how we work, how we think, and how we accept that sometimes, despite our best intentions, we can’t solve all the problems. The art of medicine is as much to know when to stop, as it is to keep going.

In technology there is only one direction, forward.  We can learn from that, and develop the burning desire to continuously improve what we do. We can learn to measure more, analyse more, think more before and after we act.

At the intersection of doctor, patient and computers lies the brave new world of digital medicine. It is our responsibility to take charge of it and mold it into a tool that can deliver on the triple aim: Improve the patient experience of care, improve the health of populations, and reduce the per capita cost of healthcare. We can’t do it alone, but we can lead it, and it is our responsibility to do so.

April 4, 2013

David Lee Scher has a great blog I recommend to everyone. His insight as both a doctor as well as a technologist is awesome.

The Digital Health Corner

In previous posts I discuss how patient-centric care differs from patent-centered care and how patient empowerment must precede patient engagement.  I would like now to delve into what I consider critical elements of patient-centric care. They all involve technology to various extents.

1.    There must be buy-in from providers. I am including payers, healthcare systems as well as clinical providers in this category.  While I realize that much of healthcare is devoted to satisfying legal and regulatory mandates, there is great opportunity to improve the care experience (and dare I say outcome) of patients by changing the focus from provider to patient.  Physicians do care about their patients.  However, they are finding less and less time to devote to direct patient care. This same situation will repeat itself with non-physician providers as they assume more responsibility for patient care. Unless physicians support efforts to provide patients with tools to

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What Broadband Giveth Health Taketh Away

November 12, 2012

I was a big fan of the government’s National Broadband Network when it was first announced as part of then Prime Minister Kevin Rudd’s election promise in 2007. I am not an engineer, so to be honest I wasn’t sure that the suggested architecture was the best option. I left that to the technical guys who understand those things. They seemed to agree that technically the model was a good one, even though it probably was the most expensive way to do it.

I was a simple doctor, who recognised the value of technology in improving the quality and efficiency of our healthcare system. I attended the big launch event in 2009 at the University of NSW that discussed the value of the new system to the various aspects of society. I even took part in the NBN launch in 2010, I was the doctor on the other end of the home telehealth service talking to the Prime Minister and selected dignitaries to demonstrate how the NBN could be used to deliver healthcare services straight into the home of older Australians.

My excitement was not because data could spew done the line at megabits per second, or that we could have crystal clear video at any location My excitement was because I believed that the government was producing a logical coherent strategy for collaboration across the various government sectors to combine and provide an integrated solution for healthcare that took advantage of the enhanced communications possibilities provided by the optic fibre in the ground to 93% of the Australian population, and the wireless and satellite services to the rest.

Today, much of that excitement has gone.

In 2010 the new Prime Minister, Julia Gillard announced that her government would make access to doctors easier by subsidising telehealth consultations. This was not a new idea. We had been talking about telehealth consultations for many years, and to be honest telehealth had actually moved on quite a bit from when we first started talking about the use of video conferencing as a way of extending the already strained healthcare workforce. However, it was a positive move, a small step forwards towards an integrated technology enabled healthcare system.

The Medicare items for telehealth consultations came into effect in July 2011. They were a bit disappointing, as they only subsidised specialist consultations, not the much more common, and often more important primary care or GP visits, and totally ignored allied health and nurses. My eternal optimism kept me positive. It’s a first step, and over the next couple of years, as they realise the benefit of linking people up with the technology they will continue to develop the reimbursement. The Department of Broadband Communications and Digital Economy (DBCDE) produced a great vision video which showed allied health workers and doctors speaking to their patients in their homes. This wasn’t what the new Medicare items paid for, but I assumed that the various departments must have spoken to each other, and this was a vision of where we were heading.

My excitement peaked on January 22 2012 when the minister for health and the minister for broadband were on stage together talking about how the NBN and modern medicine would work together to provide great new services to patients in their homes, and they would foster this with a $20 million grant to support such projects. It was nirvana to geek doctors like me, DBCDE and Department of Health and Ageing with the folk at NBN Co. working together to give Australia world class telehealth services which would make things better for us all.

Then reality set in. Within months of the launch of the well intentioned, but not perfectly designed telehealth consultation items, the folk at Medicare were working out how to make it a bit more difficult to bill them for such items. To be fair, their original incentives were a bit over the top. $6000 up front and a 50% bonus for using telehealth were pretty generous, and smart doctors decided that they were eligible for those benefits. Maybe some were a bit over zealous, but they met the requirements set out by the government, and they delivered a service to patients. Was it clinically useful. For most patients, it probably was. For some maybe not so useful, and for some it probably was not useful at all. However that is part of learning what works and what doesn’t in medicine. We learn that way during our early years as junior doctors, and hopefully there is a system in place to catch the things that slip through. The same occurs for early attempts at telehealth. They were not all going to be the most efficient and effective way to deliver care, because everyone involved was on a learning curve.

However, the folk at Medicare decided that it was to easy to use this new fangled video conferencing stuff, which in the consumer world many companies were offering for free, so they added some new clauses. The doctor and the patient had to be more than 15 kms away from each other, and the payments became staggered. Essentially it added a couple of new steps for the doctor to go through to use telehealth with their patients. We all know that doctors have lots of spare time, and the one thing they love is extra paper work, so it really shouldn’t be a problem. It seems some doctors were deemed to have abused the system, they provided the service to patients who should have been able to go and visit the specialist in person. Sitting in a waiting room full of sick people, and getting your children to take the day off work to take you to the specialist visit is definitely better than making the telehealth service available to all Australians.

Then it got worse. Come the Mid Year Economic and Fiscal Outlook on 21 October 2012 there were a slew of new restrictions added to the telehealth reimbursement from Medicare. First only Australians deemed to be remote, that is not live in major cities and outer metropolitan areas were now eligible. The problem is that is not where most Australians live, so the bulk of the Australian population cannot access these services. Even worse, those areas that were eligible were actually the least likely to be able to use the service at present, because the connectivity required to deliver the service doesn’t exist in those areas.  Just in case that wasn’t enough disincentive to stop the greedy doctors from billing the code, since their potential “customers” had now been decreased by a very significant percentage, they had to justify the new equipment, the required training, the required support services, and the associated disturbance to their workflow for the relatively rare rural patient who needs their service.

The net effect according to the budget papers is a saving of $134 million over 4 years. There was not a lot of detail on how that saving is calculated, but the only way you can save money in Medicare is to not have doctors bill for the service. Well of course they won’t bill the telehealth consultation, it is too much work for too little return for them. So if the patient still wants to see a doctor, and remember in this case it is for a specialist consultation deemed to be necessary by their GP, they will just have to find a way to get to their practice. That the doctor can be reimbursed for, so Medicare still pays the doctor to deliver the service, just with a different billing code. The patient has to get there, spend a big chunk of their day, and probably that of a family member, because visiting a specialist is not something you want to do alone, to get there. Hopefully by then they are not too stressed out by the travel and associated anguish to spend some quality time with the doctor, and get back home. Assuming they get to do this in a reasonable time, there may not be any detrimental effect on their health. It may be a bit too hard, so they will postpone it, in the knowledge that if things get bad enough they can call an ambulance and go to the local hospital, who will arrange for a specialist to see them in the emergency department. That is probably a much better use of the budget money, and everyone enjoys a ride in an ambulance and a couple of days in a hospital bed.

In the mean time the roll out of the National Broadband Network continues unabated. The promise of broadband delivered video consultations with your healthcare workers remains a major benefit for the NBN. As long as you can pay for that service out of your pocket, and you can find a doctor who provides it then that probably still makes sense. Spending government money to lay the fibre to allow this to happen, and then saving the money you would spend to actually deliver a service over the fibre seems to make sense to some.

So my initial excitement that the government had a coordinated plan for the integration of technology into healthcare and other sectors of society has been significantly dampened. We seem to have two government departments at odds with each other about the value of telehealth. We have some innovation happening around the edges, but most of them have moved on to new things, because health and broadband, despite its promise doesn’t make business sense to anyone. The folk at NBN Co. tell us that new applications running on the network will revolutionise healthcare, and education, and many other things. However as many of these things are social benefits funded through our tax dollars through the government, it seems there has been a significant effort by the relevant departments to slow down its uptake, just in case people decide they like it and want to use it.

I still believe telehealth is a tool with great potential to improve the efficiency and effectiveness of our healthcare system. It has been shown to work when it is allowed to. However if it is not allowed to grow, if clinicians are not allowed to experiment to work out how to best use it, and if extra paper work is thrown in front of clinicians who want to use it, then it will fail. It will be another expensive failure, not because the technology doesn’t work, but because we have turned it into yet another silo in our already highly fragmented healthcare system. The NBN, the great communications tool which has the potential to integrate so much cannot defeat active disincentives which entrench policy that supports the fragmentation.

Yet another silo is not what healthcare needs, but if telehealth is only reimbursed for a small fraction of the community, only in certain circumstances, and only with certain providers, it becomes a very small not sustainable silo. At the same time we will invest billions to connect the whole nation to a network that has the potential to unite us, but not health, and probably not education, and the list goes on. We will have the world’s best network of non-connected silos in the world.

That is why I am no longer very excited by the National Broadband Network.

Is telehealth dead in Australia?

October 23, 2012

The recent MYEFO Budget Update released on October 22 2013 has added further restrictions to the telehealth consultations announced by the prime minister in the lead up to the last election, and eventually made available on July 1 2011. From January 1 2013 new geographic restrictions have been added to those introduced in the May budget basically making telehealth consultations available only to those who live in remote areas. Those in outer metropolitan areas and major cities of Australia as defined by the Australian Standard Geographical Classification Remoteness Areas (ASGC-RA) will miss out.

In my opinion this is the beginning of the end of telehealth consultations in Australia. By marginalising them to only a delivery method suitable for remote populations, essentially a technology enabled version of the Royal Flying Doctor Service, they are significantly blunting the value proposition for telehealth consultations. Actually they are restricting it more than the RFDS, as it can deliver services to places not limited to those classified as remote, but to those areas that need its help. Essentially these changes have taken away from clinicians the right to make that type of decision. Rather than expand on what seems to have been a successful program, it has chosen to “strangle it on the vine” to prevent its growth.

Telehealth consultations have the possibility of radically improving the efficiency and effectiveness of healthcare delivery for all Australians by allowing clinicians to provide a more cost effective, and better targeted service to those who need it. It is not just about extending specialist care to those in remote areas. Whilst that is part of it, the problem is that by marginalising it to such a small part of the population they effectively strangle its growth. As a result less clinicians will try it and make it part of their normal repertoire. It will not become a tool that many clinicians will use, and those that do will be stifled by the extra paper work associated with delivering it, and the fear of an audit which shows that a patient lived 1 km outside the boundaries of remote Australia, and therefore was not eligible.

The bright hope of the telehealth announcements and subsequent actions by the government was that technology would be seen as an enabler of health reform. The concept of delivering care is the most efficient and effective way that is suitable for an individual patient seemed to be becoming a reality. Telehealth had the possibility of not just delivering care to remote Australia, but to many areas of need, with short supply of healthcare providers of many different types. More exciting was the prospect that clinicians could develop new and innovative models of care for people with chronic disease, which now includes diseases like cancer and auto immune diseases as well as the well known ones of diabetes, heart and lung disorders and others. These are the major burden on the Australian health system, and the inefficiency in their management has led to them becoming a major cost burden on the healthcare system. By innovating in new models of care that could leverage technology such as video conferencing to make that care not just cheaper, but as evidenced in many trials also better, there was an opportunity for Australia to become a world leader.

However, in an attempt to save $130 million over 4 years the government has lost an opportunity to potentially save billions from the annual healthcare expenditure, which is at $130 billion now, and predicted to continue rising. I remain slightly confused how that money will be saved. The individual still has the right to receive the same level of care,   they just have to work out how to get to the specialist’a rooms in the city. The hidden costs associated with that still need to be paid for.

At a time when we are investing, in my belief wisely, some $40 billion to deliver a National Broadband Network, we have essentially cut off one of its best business cases, telehealth consultations, to save a relatively small amount. To a rational investor this would seem bizarre. To a nation that prides itself on being a world leader in healthcare and innovation it is essentially the kiss of death to an opportunity which had not only great local value, but also potentially an opportunity for Australia to become the telehealth hub of the Asia-Pacific region, and possible even beyond.

What healthcare can learn from the Cheesecake Factory

August 18, 2012

If you have visited the USA chances are you have visited the Cheesecake Factory. I have and I have to say it was a great experience. However I never thought it would be used as an example for healthcare. The food was tasty and voluminous., and for those of you who knows me, that is a compliment. So when a recent edition of The New Yorker published an article by one of my favourite healthcare writers Atul Gawande titled “Big Med” looking at what healthcare can learn from the various chain restaurants in the USA, and I was very interested to read it.
Dr Gawande uses the experience of a Cheesecake Factory employee with the health care system to ask the question, why can’t we learn from world’s best practice in healthcare?
Why can the Cheesecake Factory provide consistently high quality outcomes in the way of food cost effectively whilst hospitals struggle to provide consistent quality services?
The answer lies in balancing standardisation and flexibility, and providing people with the right tools to enable them to access standardised protocols whilst making sure they have the requisite knowledge to make optimal decisions.

Measuring Care to make it Accountable: Lessons from Meaningful Use for Australia

May 30, 2012

Today I read the Commonwealth Fund’s report on the “Recommended Core Measures for Evaluating the Patient Centered Medical Home“. I have been a fan of the Commonwealth Fund for many years. Its research in comparing healthcare systems has been the center piece of many presentation I have seen over the years, and Australia ranks highly, but not quite at the top.

There has been much discussion about moving from an activity based system to a outcomes based system, which sounds great. However without a good idea of what the outcomes are, and ensuring they are reasonable, we cannot proceed towards an outcomes based system. In this document they make a great first attempt at defining what sort of outcomes a well coordinated primary care system can reasonably deliver in the short to medium term. It looks at the three criteria of cost, utilization and clinical quality, so there is something in there for all stakeholders.

It is a great example of taking reform and turning it into something quantifiable which can be measured, and makes a quantifiable difference to the health of the patients and the population. I believe that if we used these sort of criteria in Australia for our health reform projects and helped translate them to the politicians and general population in a way that is relevant to them, we would be far more progressed in our health reform journey.

The other key thing is that they demonstrate the value of good use of technology in healthcare to capture relevant information and make it readily available in near real time so we can use it to drive clinical actions. It has a lot in common with “meaningful use” used by the ONCHIT in the USA for driving adoption of technology in the healthcare system. From one of my previous posts you would know I am a big an of clinically relevant meaningful use, and this I hope we can keep an eye on these initiatives, and see how we can leverage them for bettr healthcare. we can

What is Innovation in Healthcare and whose job is it?

April 28, 2012

I was recently asked to present at a forum run by the Australian College of Health Service Management on Controversy, Collaboration at Innovation. To try and fit into the theme I focussed on innovation, but tried to be controversial about how the collaboration between the technology sector and the health provider sector has failed to date. You can see the presentation at this link.

To me the main issue is the difference between invention and innovation. From the technology industry’s perspective there has been a lot of inventions which have been passed off as healthcare innovations. However they have not been successful for a couple of reasons. Firstly they are not actual healthcare innovations, and just calling them that doesn’t make them so. They are new tools that need to be built into a process, and to date that has been the main barrier. Secondly, healthcare providers, who really are the folk who would deliver innovation in healthcare, have never been trained to seek innovation. This is mainly because they are taught to practice in a  risk averse way, so trying new things is not something they do as part of their normal business. In some ways this is a good thing, you don’t want your doctor running random experiments on you, but there are ways  to provide safe sand pits where those sort of experiments can be done. Linking this to a quality and safety agenda is key to this. Thirdly, the current way we evaluate new healthcare interventions is designed for evaluating drugs and specific interventions, and not process improvements. Assigning a process innovation to a double blind placebo controlled randomised study is both difficult, and often counterproductive. If the clinicians have a robust quality and safety framework they should be able to integrate process innovations into their normal workflow, and be able to build up at least anecdotal evidence of how these process innovations would affect the care they provide.

Clinical care is a very individual thing, both from the provider and the patient perspective. Whilst it is important to have a best practice mind set, individuality is important in at least style of care delivery. After all people pick their providers not just based on their knowledge, but on their personality. By enabling them to also be innovative, and test those innovations in the real world, we should see a Darwinian evolution of new clinical processes. Those that are most effective, or most efficient should become more prevalent, whilst those that are not will go the way of the DoDo. This requires a level playing field to be developed from the outset. Today the processes that have become more prevalent are more a result of perverse incentives in reimbursement models rather than effectiveness. If we can remove these perverse incentives and enable clinicians to be able to choose how they do things in a reimbursement independent way, we should see a new growth in healthcare innovation, driven by healthcare providers. I believe it will not only spur new innovation, but also improve the morale of our healthcare sector and make being a healthcare provider something our younger generation will aspire to, like they did in the past. Who know’s they may even get naming rights to these new innovations, something we used to do a lot of in the early 20th century with diseases. Personally I would like my name to be associated with a cure than a disease.

Relighting the Ehealth Fires

March 28, 2012

It’s been a while since my last post for a number of reasons. To be honest the Australian ehealth scene had started to become a little too toxic for my liking. There was a lot of hostility from various factions about the ehealth activity by the government, and the attacks had started to become personal and unprofessional. As a result I decided to lay low, so as not to get dragged into a dispute that had become more about personalities than philosophies. I did continue to tweet and use LinkedIn to get some of my opinions out there, but it is not as fulfilling as typing into your own blog.

Today I attended the Health-e-Nation conference on the Gold Coast run by my good friend Sally Glass from CHIK Services. I have attended it for the last few years, and whilst it has always been one of the better conferences in Australia, I suspect I was starting to get jaded by the huge promise of ehealth in Australia and the lack of obvious delivery. I was actually more disturbed by the negative press it was getting, the attacks on people who from my perspective were doing the best they could under the circumstances. However today I walked out of the event with a new level of enthusiasm and belief that we really are doing the right thing, and optimism that Australia may well take the world leading position in ehealth and healthcare it so rightly deserved.

What inspired me was a couple of talks, one by the new minister for health in the federal government Tanya Plibersek, which recognised the need to share in the potential financial bounty of a more efficient system for those hard working primary care providers who are the back bone of it, and by Jane Halton, the secretary of the department of health who demonstrated an amazing amount of energy, belief and optimism in how the Personally Controlled Electronic Health Record (PCEHR) will enable a new paradigm in healthcare delivery in Australia.

Their talks were supported by great talks by Dr Jonathan Shaffer from Cleveland Clinic who showed us what a properly enabled healthcare system is capable of when you implement effectively and bring your clinicians along for the ride, and Prof Ricky Richardson from the UK who painted  a great picture of what a patient centric system can do for patients, clinicians and payers.

So while sitting at the Gold Coast airport waiting for my flight home, I pulled out the laptop and started typing, and this is the result.

I unequivocally state that I believe the Australian PCEHR project has the potential to transform, for the better the healthcare system in Australia. It won’t be a straight line improvement graph, it’s more likely to be a hockey stick with a bunch of bumps on the way, but if we the clinicians, the technologists, and the consumers join in a spirit of positive collaboration, it really has the potential to change things.

As Dr Nick Buckmaster from Gold Coast Hospital said, it is a small first step, but it is a mightily important one towards a better coordinated collaborative learning health care system. The next step is to develop a Personally Controlled Care Coordination System which will leverage off the PCEHR. That is what will really transform healthcare, but you can’t get there without taking the initial steps, and the PCEHR is one of those. The others like national licensure, ubiquitous connectivity, and ultimately reimbursement reform are also important, but we have to learn to savour each small step forward.

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