Archive for the ‘Innovation’ Category

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.

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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 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.


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