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.

What Broadband Giveth Health Taketh Away

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?

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.

Relighting the Ehealth Fires

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.

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.

Telehealth Innovations at Ehealth Week in Brisbane

It’s ehealth week in Australia with the annual Health Informatics Conference in Brisbane starting today, and yesterday the Australian General Practice Network Ehealth conference on Monday with a range of other events including the Nursing Informatics Association amongst others. I was asked to present to the AGPN forum on innovations in telehealth. Before me Fionna Granger from the Department of Health and Ageing spoke about their program. For those of you who don’t know Australia recently launched a $600M+ initiative to reimburse specialists and some other healthcare providers to use telehealth. It was an exciting initiative, although I have to admit it does have some limitations. But, as the say the first step is the hardest, and Australia has taken that first step, so we need to be thankful for all blessings.

Below is the script I had prepared for my AGPN presentation. As always I did change it a bit on the day, but the basic message stays the same. The innovation we need in telehealth is not in devices, but rather in models of care, education and policy. However we can’t forget the technology, and we have to avoid the temptation of picking a shining new proprietary video conferencing tool when we now that industry standard PC technology can provide us with a solution we can use today, and that can grow with us in the future.

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I have been asked to talk about innovations in telehealth. I guess I am credentialed to talk about that, having spent the last 6 years at Intel, one of the world’s largest technology companies, and the last 30 years neck deep in ehealth and technology. My first foray was in 1981 when I was writing clinical applications for the Apple II at the UNSW, and I won’t bore you with the rest of my history.

There is a cliché that is being bandied around a lot now, and it says that it is not about the technology, but more about the culture, and the change management, and the people and so on. Let me start off by saying that I both agree and disagree with that statement. I disagree, because seriously, if you get the technology wrong then you are paddling upstream big time to try and get anything to work. Those of us who bought BETA video recorders will know about that. The technology is critical, and it needs to be an open platform, not a closed proprietary solution, otherwise you will be finding yourself in a few years trying to flog off devices you paid thousands for today on EBAY for a few bucks, or more likely as I have recently done, put them outside for the council clean up. Today, with the government about to hand out $6000 to doctors to get set up for telemedicine consults, you need to seriously consider your technology purchases.

Having said that, there is no shortfall of innovation in telehealth technology, and I don’t want to speak to you today about the latest and greatest gadget, because tomorrow there will be a better one. What I want to talk about is the needed innovation in telehealth, and to me that comes in three areas.

Clinical Models of Care

Education

Policy

Telehealth is a very broad term, and I prefer the concept of Virtual Care, i.e. providing care, something we as clinicians are the experts in, to people who are not sitting in our rooms, or in the hospital bed to which we are standing next too. Delivering care when we are physically not there. We have seen that from July 1 this year there is some reimbursement around video consultations, which is a good step forward. But if all we do is replace the current system of delivering care, one person at a time to a strict calendar based on 15 minutes consultations, then we have really failed to understand the power of the technology we now have at our disposal. What we need to do is look at the way we actually deliver care and adapt it to the power of the technology solutions we now have available. Let me give you an example. Today we manage our diabetics by having them see us on a fairly regular basis, often booked weeks in advance, where we evaluate their status, determine whether we need to change their medications, ask them a few questions, and if need be refer them for some further evaluation. What if we could use the technology to track their progress automatically, looks for any relevant changes and be notified of them, respond in near real time to any issues they face, be alerted of any issues with their medications, their management or their personal status in such a way that we could provide them with the service they need when and where they need it, without necessarily having to change how we currently work. Even better, imagine if we could do this and still get paid, not have irate patients sitting in our waiting room for hours, and cut our own expenses in running our surgeries by 50%? This is the innovation we need in new clinical models of care based on continuous management of populations at risk. The chronic disease epidemic we keep hearing about, the silver tsunami of ageing. If we develop clinical models of care designed to take advantage of available technology, ranging from the phone in our pockets, to the analytical capability of supercomputers to identify trends and respond to them, we have an opportunity to improve the quality of life of our patients, manage the increasing costs of healthcare, and also make our lives better and more productive, and we may even be able to get back to working reasonable working hours.

Second is the issue of education. Telehealth, ehealth, clinical informatics, call it what you like is not taught to clinicians today well. Geek doctors like me are basically self-taught, and that means that in reality we just don’t know what we don’t know. We are well intentioned, we make the young guys at Dick Smith a fortune in commissions as we buy every new gadget that comes along to experiment with, but we do not have a structured evidence based education on how to best use this technology to deliver health outcomes. That needs to change, the same way we are taught how to use a stethoscope to listen to heart sounds we need to be educated on how to use technology to do a better job delivering and documenting healthcare.

Finally, policy. The Department of Health and Ageing has an ehealth branch, we have NEHTA, and now we have the Department of Broadband playing in healthcare. However we have very few if any medical practitioners, with the obvious exception of our good friend Mukesh and his merry band of doctors, really driving policy. We need more involvement in driving policy around reimbursement, quality standards, adoption practices and the various issues we face in the use of technology in healthcare. Be it through consultation, or I believe just empowering us to make our own decisions without the requisite red tape and paper work we continue to face, policy innovation is critical.

So to summarise, the technology is important so don’t paint yourself into a corner with limited scope solutions, open up the world of innovation by sticking to flexible solutions that can expand with your practice. To be blunt, don’t buy a dedicated proprietary piece of video conferencing technology to get your $6000, rather get an open standards high powered PC that will enable you to take advantage of the advances in software that await us. Then drive innovation by thinking differently about how you deliver care, and can do more of it virtually, get yourself the right education, and events like this are a great start, and finally let your politicians know that we really are good smart people so let us deliver the best healthcare we can with the technology without them telling us how to do it.

Does Australia Need More Geek Doctors?

I admit, I am a geek doctor. Started playing with computers about the same time I started university training as a healthcare professional, and throughout my professional career I have used computers, and enjoyed it. Back in the early 80’s we had to write our own programs to make the computers we had do anything vaguely useful. As my first degree was in optometry, and I started practice in 1983 I wrote a program which allowed me to automate the process of sending out reminders to patients who were due for another eye test. Before that we literally went through our files and hand wrote those reminders to patients. It was revolutionary at the time. I even managed to keep a copy of their prescription on my computer, at that time a Commodore 64 and over time was even able to print out that prescription. Seems archaic, but in 1983 that was pretty cool. I started going one step further and doing something we called graphical analysis of patients results, where we looked at the ratio of people’s eye focussing capability to their ability to converge their eyes, looking for latent weaknesses that suggested they would have problems with prolonged reading, or paradoxically it ended up also predicted people who had problems using a computer for long periods of time.

OK, so enough history. Why do I ask if we need more geek doctors. Well it seems our UK colleagues have identified that they need more geek doctors over there. Now to be more polite the preferred term is CMIO, Chief Medical Informatics Officer. It is a term born in the USA, and has been around for quite a while over there. They even have their own professional body, AMDIS, the Association of Medical Directors of Information Systems. I have been fortunate enough to meet some of its members, including Dr Bill Bria and their CEO Richard Rydell. These guys run the Physician Symposium at HIMSS in the USA every year, which is still one of the best events I have attended.

The UK has realised that one of its major failings was not engaging clinicians in implementing IT systems and information projects. The knee jerk reaction was to hire some, and assume the job was done. Whilst some of their hires were stellar folk, I include Dr Mike Bainbridge and Dr Simon Eccles amongst those, it was a stop gap measure. Unfortunately here in Australia we seem to have similar issues. At a national level we have Dr Mukesh Haikerwal leading the clinical leadership team at NEHTA, and I am the first to say he is doing a great job. He has a group of able clinicians in his team, albeit mainly unpaid volunteers from what I have seen. However when you go down another layer there is a distinct lack of people with clinical background or credentials involved in the delivery of health related IT systems. In actual fact, if you survey the geek doctors out there, many of us are working in industry, some of us not even in the health IT related industry. There are some exceptions, and I hope they don’t mind me naming them. Dr David Doolan in the Hunter region of NSW, Dr Craig Margetts in Queensland, and Victoria even has a doctor as their health CIO in Dr Andrew P Howard, as did Westmead Children’s Hospital for a number of years in Dr Ralph Hansen. However the bulk of healthcare entities do not have an official geek doctor, who sits at the right level to advise and be involved with ehealth projects.

I recently did a 2 week course over at the Harvard School of Public Health on IT in healthcare, and was astounded by the sheer volume of geek doctors in and around Boston. People like Dr John Halamka, Dr Blackford Middleton, Dr David Bates, Dr Ashish Jha, and very many more who have active roles in determining the IT strategy of their organisations, and in some cases the whole country. They had instituted proper training programs for doctors and other healthcare professionals to go through to become official geek doctors. They had structured career paths that these geek doctors could follow. It was geek doctor heaven.

So to answer my own question, I believe we do need more geek doctors, or Medical Informaticians if we want to be pedantic about the name. We need to make it a career path that our brightest students can consider. I have a son doing his HSC this year, and as we look at what courses he can do next year at University, he asked me how I ended up where I am. There were no courses for geek doctors then, and even IT wasn’t really taught at University in those days. Now he can choose to do IT or healthcare but there still doesn’t exist a path to do healthcare IT.

So if you are a geek doctor and have an opinion, let me know. If you think I am just looking for my next job and that geek doctors are not needed let me know. But let’s start the discussion before it is too late. Let’s not let all our good geek doctors be hired by the USA and UK who have recognised the need for them.

When Industry meets Government, what can we hope for?

Last week I had the pleasure of being the industry person sitting between Peter Fleming from NEHTA and Peter Williams form the Victorian state government department of health on a panel at the AIIA luncheon. As always the food was great, the conversation stimulating, and fun was had by all. I thought I would share my prepared notes with you for your comments, even though I must admit I did diverge from them in the interest of time.

Notes for the AIIA Victorian Government Ehealth Forum

So first to put my views into some context. Over the last 30 years I have been in involved in Ehealth in a number of ways. Whilst enrolled at the UNSW in 1979 at the school of optometry where we were fortunate enough to have an Apple II Pro computer I was involved in writing some early clinical applications. I couldn’t afford an Apple at that stage, so I bought a Sinclair ZX81 and ported some of those clinical applications onto it in the early 80s. In 1983 when I graduated and went into practice I wrote my own optometry clinical and admin system on a Commodore 64 and upgraded it on to a CP/M system in 1985 when I saved up enough money for an Osborne 01. I was the classic geek clinician, who wrote the world’s best application for a total market of one, and the customer was a really cheap bastard. After a while I went back to med school and whilst a power IT user it was more in my ability to actually hand in a word processed document, which was a rarity then. I got involved again in IT half way through my course, in a company that imported and customised more general software, took a couple of years off Uni to make some money. For those young folk in the room, back then we put 100% mark up on hardware and 500% on software, so it paid for the house and family, and I went back to Uni to finish my course a few years later. I then started working in the NSW Health system in the 90s and was a user of the still in use clinical systems at those hospitals for a few years. After that I went into the private hospital space, and became the guy who buys software as we upgraded our hospital PAS and billing systems. Then I got the bug to go back into development, after all the dot com boom told us all you needed was a snazzy piece of software and you would be a billionaire, so we developed online tools for patients, including back in 2002 a Personal Health Record which would probably now be called a PCEHR. Unfortunately there was no money in it then, so 6 years ago I got a job at Intel, the world’s largest microprocessor company as part of its Australian health group. In that role I had the great pleasure of working with pretty much every software vendor and every large healthcare provider because generally their software worked on our hardware, so it was a very symbiotic relationship.

So I think that gives me pretty much a 360 degree view of the Ehealth world from pretty much every stakeholders perspective. I won’t go back to the ancient history, but looking over the last 15 years there has been some very interesting changes. In the 90s the state governments and their public hospitals were the big customers. Yes GP land was computerising, and there was some money there, but the real big money was in hospital EMR solutions. NSW led the way, in pockets, and Victoria also had some cutting edge plays in pockets. There were a few players mulling around, ranging from small mom and pop shops through to companies better known for making airplanes, and pretty much everything in between. Ehealth was still a rudimentary concept, it was predominantly automating the administrative part of the system, knowing when a patient came in, who they were, which bed they were in, and who to bill. Clinician involvement was minimal; again mainly geeks like me who thought they knew the answer to everything, and reminisced of the good old days with our Commodore 64 which could do a database and also play space invaders. Then real clinicians starting to ask whether they could use the new gadgets to do something useful, like look after the patient. So we put pathology online, because that was pretty straight forward, and then we starting putting some test requests on line, and then we even started doing radiology on the system, which worked fine within our own network. We moved to an enterprise model, because now we had a lot of users who needed the system, and our CIO colleagues in the banking world had managed to get their systems up and running, although Peter may be able to tell us more about how painful that really was. ERP was the buzz in the business world, and the EMR became the healthcare equivalent. The debate around best of breed versus single vendor came up, integration tools became critical as each part of the hospital started using its own little solution, several hundred millions of dollars was spent, and to some degree in some places we came up with a workable solution. Of course by then the users started getting smarter and demanding more, like not just reports, but decision support tools and real time data analysis. Each state made a decision, some better than others. We witnessed the first time a state government took an EMR vendor to court in a very messy situation. NSW decided on a single vendor solution, SA did the same but with a different vendor, Victoria straddled the line by selecting a vendor but giving the hospitals choice on whether they used them. At the time we all thought the world was crashing around us, it was a massive change management program, a word none of us even knew existed when we started the journey. When the dust settled NSW had one of the largest EMR deployments in the world, however by then the bar had been lifted and if you use the HIMSS Analytics definition it is not really a full EMR. SA decided that the solution was OK but needed to be changed, Qld was still recovering from their first attempt and was seriously talking about their next attempt, and herein Victoria some hospitals had a good system, some a not so good, and others none at all. In reality, whilst we cry foul about the experience it mirrored every other large scale enterprise deployment in several other industries in the world. The classic two steps forward, one step back and a couple of body blows along the way. It was tied up in state procurement processes and what like, which is another story. But where it worked, and let’s not forget on a worldwide basis we are actually one of the success stories, it worked pretty well.

However around 2004 what was predominantly a state government thing started getting federal interest again. There had been some attempts to provide a unified eheath solution, many of us remember Health Connect but it didn’t start getting serious till the formation of NEHTA in 2004 or there about. The early NEHTA was all about herding the cats, developing the standards and getting the unruly masses of vendors to use them. I think it is fair to say that to some degree personalities came into play, and there were issues, but no one really disagreed with the idea. But it was not an overnight success, mainly because the problem was not that easy, and couldn’t be solved in isolation from what was happening in the rest of the world. Things really started getting interesting after 2007 when the new federal government decided that IT was going to be the great democratising force in healthcare, ala Facebook for Health which was one of the outcomes of the 2020 summit. Now we had a huge shift from the ERP type world of the hospital EMR deployments to a system that had to be suitable for individuals but scalable to an entire country, which had to be as sexy as Facebook, and yet as secure as the ATO, and which no one else in the world had delivered. Innovative yet risky, based on cultural demands not technologists specifications, and if it worked would revolutionise healthcare here and around the world. The fact it happened to coincide with the plan to wire up the whole country to high speed broadband was fortuitous.

Now the Ehealth world is stepping into new uncharted territory, and the gentlemen by my side have the enviable task of building the information superhighway through that territory. From a user’s perspective it is fantastic, because if all goes to plan I will have a system, as a clinician and as a potential patient that will make my care better, safer, more efficient and all that. As a developer, it is a great new challenge to develop the new killer app in healthcare. As someone who buys software, well someone else is paying in the form of the federal government so the finance guys are happy, and as a vendor there is money out there for work to be done, so all I have to do is make sure I convince them I am the right company to give the money to and life is sweet. So it sounds like Nirvana, and to be honest compared to some of the last couple of decades it is. But it’s not done yet, there is risk, some people will get their fingers burned, some companies will close down or be gobbled up, some people will die because some mistakes will happen, some clinicians won’t like their interface and won’t be willing to pay to develop their own, some people in government will be happy with the progress, pretty confident the opposition, whoever they are at any time will find huge faults with the system. But we will have moved some steps closer to a high performance safety enhanced healthcare system, which is the envy of many other countries around the world. We will have spent a lot of money, not all well. But I believe we will see a huge beneficial outcome for us all, and looking around the room, those of us with greying or receding hair will be the major benefactors.