Today I had the pleasure of presenting to the Productivity Commission Caring for Older Australian public inquiry.
For those of you not in Australia, the Productivity Commission is the Australian Government’s independent research and advisory body on a range of economic, social and environmental issues affecting the welfare of Australians. Its role, expressed simply, is to help governments make better policies in the long term interest of the Australian community. It has been tasked with developing options for further structural reform of the aged care system, and recently published its draft report. In my view there was very little in the report around the use of technology in aged care, so I took the opportunity to present at one of their public hearings today.
Below is the text of my oral presentation, let me know what you think.
First let me commend the Productivity Commission on its review of aged care services and for taking the initiative to drive such a wide ranging review of this important area. The intergenerational report showed us the issues we are facing with a large and rapid increase in the ageing population. As someone on the tail end of the baby boomer generation I think it is important to recognise that this ageing tsunami as some people have called it is not a bad thing. The alternative to ageing is far less palatable for those of us entering that phase of our life. It demonstrates that the various health and social policies of the past decades have to a large degree had the desired effect, of improving the health and wellbeing of the population. The consequence of that is a population that is getting older and human physiology being what it is, requiring aid. Whilst I find the work of Ray Kurzweil fascinating, I don’t quite believe that in the next couple of decades we will reach the singularity he describes, where effectively we become immortal as a result of the confluence of medicine and technology, but I do believe that the upward trend in longevity will continue.
To introduce myself, I have been involved in healthcare professionally since 1979 when I first enrolled in University. My initial qualifications were in Optometry and I then went back and received qualifications in Medicine. Even before that I had a view of the world of health and ageing, being a member of an ethnic community in a working class suburb where it was normal for those migrants of my parents’ generation to bring their elderly parents out to Australia to live their last few years with family and with access to a healthcare and social welfare system deemed by them to be the best in the world.
Having worked in clinical practice over two decades about 10 years ago I recognised the need for a new set of skills and became actively involved in the world of technology as it related to healthcare and aged care. For the first five I worked with a local company that was developing personal health solutions for use over the internet, including the provision of a personal health record system. For the last 5 I have worked for one of the largest information technology companies in the world, Intel Corporation, which is predominantly known for providing microprocessors, but which also has one of the largest research groups in the world looking at how technology affects society, with a very strong emphasis on its role in healthcare and ageing. Much of what I am to describe is based on the work of Eric Dishman, and I must admit some is plagiarised, with his permission, from his submission to the US Senate committee on Health IT Policy which was exploring the Meaningful Use of IT in Real Lives of Patients and Families.
Let me start with two assumptions:
- Aged Care and Healthcare are very closely linked as demonstrated by the correlation between age and use of health care services. One cannot separate healthcare from the provision of services to the aged and that good healthcare is a prerequisite for good aged care.
- Our goal is to provide to older Australians the ability to live with maximum independence in an environment of their choosing, and they have told us they prefer where possible in their own homes and communities, safely and with as high a quality of life as possible.
Based on those assumptions I believe one shortcoming of the draft report of the Productivity Commission was the omission of a detailed examination of the role technology will play in the short to medium term in enabling us to deliver better quality healthcare to ageing individuals as well as providing opportunities for enhancing their independence and quality of life.
The Australian government is in the process of implementing a relatively comprehensive ehealth policy which includes modernisation of information delivery in our primary care and hospital sector. Initiatives like the upcoming MBS items for telemedicine services, the Personally Controlled Electronic Health Record, the implementation of Electronic Health Records in our hospitals and standardisation around the data sets that need to be transferred between providers is important. I am sure it an area covered by my colleagues involved more deeply in that space.
My area of interest over the last few years has been on how we can provide technologies, predominantly into the home that enable people with the vagaries of ageing to stay in their home safely and for longer, whilst also alleviating the stress for caregivers, in particular the informal care provided by family and friends. The importance of the informal care providers cannot be forgotten as we face a serious challenge to our health provider workforce.
Over the last decade my colleagues at Intel have been doing active research in how these technologies can be used in the home environment. This involved actually testing technology, often in prototype, in the actual homes of people and receiving not only their feedback, but actually observing their usage and documenting it. A few things stood out.
Firstly, despite everyone’s perception the adoption of technology by the aged was not an issue if the technology was designed for their situation. Just dropping a Personal Computer in their lap was not a successful way of doing this. But developing devices that served a specific purpose and were easy to use, with interfaces that took into account visual and tactile capabilities were taken up easily. We often found satisfaction scores in the 90th percentile. The beauty is that with the currently available technology developing such systems is not as expensive or difficult as it was.
Secondly, where there was a benefit to the individual or their families, then a large majority of the elderly were willing to accept some potential loss of privacy and confidentiality to enable them to receive better care and services. I remember a quote provided to one of our researchers by a frail elderly man who lived in a nursing home.
“I’m at the point in my life where someone has to help me get dressed and go to the bathroom, so do you really think I am worried about someone discovering whether or not I have taken my medications on time? If your technology could help me get back some independence, it’s a risk I would be willing to take.”
There are numerous examples of how technologies can assist the elderly in maintaining their independence. I will table some reports from our research group for your reference, and am happy to provide direct contact with the researchers if you require more information.
We found that there were some fundamental capabilities that the use of technology in the homes of aged people provided:
- Empowering individuals with tools to help them make sense of, and to do their own care
- Collecting real time biological and behavioural data and trends in the home with alerts for out of the normal situations
- Facilitating virtual visits with health care providers when appropriate via a range of media
- Enabling social networking, awareness and care support for family and friends who are nearby or distant
- Personalising care plans and educational content for each individual based on their needs, preferences, data and capabilities
- Triaging precious medical resources to enable the right amount of care to occur in the right place and time
To accomplish this I believe we have to change some of the ways we think about providing care. Whilst in an ideal world all these services would be provided by a smiling caring human being in person, the supply and demand situation tells us that is not possible. So we need to look at how we utilise technology to scale out the limited workforce effectively, whilst maintaining high quality care.
Effectiveness and efficiency are the two buzz words. In a pilot study we did with Hunter Nursing Agency last year we showed that using technology in the home of patients with advanced chronic disease we were able to improve the efficiency of a home nursing workforce significantly, and also provide as good, if not better care into the homes of these patients. The greatest challenge we faced in that project was not patient or clinician adoption, it was availability of reliable data connections. So I would commend to the Productivity Commission that probably one of the greatest enablers of these solutions is the government’s National Broadband Network initiative which will ensure equity of access to these technologies to all Australians.
Selecting those who will most benefit from such interventions is the key to delivering this service effectively. Each individual has their own unique needs. However if we can provide technology that is flexible, and that can scale up or down the services it provides dependant on the needs of the individual, I believe we can provide this personalisation.
I suggest the best way to do this is not to rely on proprietary single purpose devices such as those used in the past. Rather use technology based on the same principles as the personal computer that can be adapted to people’s needs. When the PC first came out in the early 80s it was designed as a business machine. However because of the way it was designed, new software could provide new solutions for different people. Today the same hardware can be used by a nuclear scientist, a doctor, an accountant and a game playing 6 year old. That flexibility comes from not designing proprietary devices that can only perform one task. They may be cheaper in the short term, but they lock you in to a very limited future. I commend to the commission they have a look at the Continua Alliance, an international collaborative of over 230 organisations whose focus is providing usable standards for the new home health technology industry.
Also recognising the unique needs of older Australians is important.
Chronic disease is an issue facing a large part of the ageing population. Its effective management can provide quick returns for all involved. Home monitoring and intervention have been shown to make a significant difference to users well-being and dramatically decrease the associated costs.
Medication management is also a major issue, and here use of technology, not just for reminding people to take their medication, but also using the opportunity to educate them about their use can provide significant benefit.
Social isolation is a major problem, often leading to depression and associated issues. Using tools to enable individuals to speak to and see their families, much like many of us have become used to using Skype, but in a way that makes it easy for them can help. It doesn’t just have to be with people they know. Controlled social networking amongst the aged themselves with tools like Facebook, but with interfaces designed for ease of use for people not born with a mouse in their hand. All these tools are available today, and will be facilitated by the upcoming boom in connectivity offered by the NBN.
What we need to do is support their implementation. This doesn’t mean doing another small scale pilot, this means providing support for their wide scale roll out so that we can start to see their effects in the wild.
To summarise, I will paraphrase my colleague Eric Dishman’s recommendations to the US Senate as I believe they are also relevant to us. To deliver high quality care to aged Australians utilising the relevant technology we have to do 4 things.
- Get Connected: All providers, and that includes family friends and the individuals themselves need to be able to electronically share information. That is facilitated by the NBN and the PCEHR projects currently underway in Australia, so we are taking a running leap at the problem.
- Get Decisive: We must provide tools that enable providers and individuals to make informed decisions based on best practice, and on available information. We need to be able to flag variations, breakdowns and areas for improvement.
- Get Coordinated: All members of the care group, formal and informal need to be able to know what the other is doing as it relates to the individual who is ultimately in control of that information flow.
- Get Personal: A proactive prevention oriented system of care that personalises care plans based on an individual’s requirement, based on their health status, preferences and resources, that shifts care and responsibility to the individual and their family, with the appropriate tools, and to the home where appropriate.
Technology is not a magic bullet for all of aged cares issues, but its judicious use based on common goals of providing individuals with the highest possible quality of life and delivering an efficient and equitable care system will be beneficial for all involved.