Australia, Convicts, US Public Health and the PCEHR

In what seems to be a rather bizarre twist I was recently trawling through the Physician Executive Journal, a publication of the American College of Physician Executives when I came across an article that really caught my attention. I am used to reading about health policy in various US publications, and I have commented before about the confluence of US and Australian health policy, despite the two very different systems. However I have never before received education in Australian history and the economic incentives that affected it from such a journal.

In a very interesting article titled “Shipping Prisoners to Australia and Population Health Responding to Health Care Reform” by Dr Dale Block from Williston Florida, I learned about how an almost ancient form of “Pay for Performance” for ship captains basically reversed the high mortality of convicts transported to Australia in the 18^th century. It seems even then, the correct use of positive incentives based on economic return could be used to drive behaviours that led to better health outcomes, in that case for convicts being transported to Australia. The author then takes that analogy to the use of economic incentives for better population health in the USA. A very interesting link, especially for those of us “down under”.

The analogy is not lost when you start comparing the US Accountable Care Organisations with the Australian Medicare Local concept. The central treatise of the article is on the value of Population Health Management, based on the work of Dr Ann Scheck McAlearney from Ohio State University. Dr McAlearney describes the various initiatives available to meet the goals of population health management. It seems population health management has replaced the old term disease management which has now become a subset of population health management. So much so that the journal previously titled “Disease Management” has been renamed to “Population Health Management”.

One of the defining factors of population health management is the need to target defined populations. Once this has been done, and in itself this is not a trivial task, they then need to determine the appropriate strategy for that target group, implement it and then evaluate the effect of that intervention. There is a strong role of information technology in this cycle as it is critical to have good baselines from which to determine the effects of the intervention, and also to be able to “fine tune” the intervention based on real time data.

The paper goes on to describe the need for engaging physicians, which has become the mantra for healthcare change management, based on two deliverables. One is better outcomes for their patients, and the other is respect for theirs and their patient’s time.

I found this paper very interesting, especially as I prepare for the upcoming Australian Disease Management Association conference in Canberra. I can see how in effect the PCEHR project in Australia needs to be perceived as a population health management initiative rather than an individual data record initiative. We should start with identifying the population who will benefit. Older patients with chronic disease, pregnant women, and children with underlying conditions that are likely to affect them in the future. We then need to determine what the intervention is. The intervention is not the PCEHR, it is the tool upon which we will base the intervention, or at the very least capture the data about the intervention in. The intervention needs to be a systematic intervention aimed at decreasing the effects of the disease process, delivered via the PCEHR if possible. We need to implement this, and this is where we have scope for innovation. How do we develop tools that can link in to the PCEHR to deliver these interventions is a grand new adventure for us all. Finally we need to ensure that the data we capture is available to our research colleagues to evaluate. Whilst we may have a gut feel that we are doing good, in reality the truth is in the data.

Linking back to the start of the article and the British sea captains who changed their systems once their incentives was changed from a fee for service model of paying for heads boarding their ship to a pay for performance pay for the heads getting off their ships alive, it can be argued that only by reimbursing based on achievement of population health management goals can we change the behaviours inherent in our healthcare system. That seems to be the goal of the ACOs in the USA, and the GP fund holders in the UK, maybe it also needs to be the goal for Medicare Locals in Australia. If that is the case, then the PCEHR provides us with a unique tool for capturing that information in near real time, making it accessible and transparent so that researchers can evaluate it, and even patients can look at it and help them make decisions. In that case the PCEHR becomes more than a record system; it becomes a tool for health reform. That shines a whole new light on this ambitious project which I hope we all support.