Archive for the ‘Primary Care’ Category

Is telehealth dead in Australia?

October 23, 2012

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

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

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

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

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

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

What healthcare can learn from the Cheesecake Factory

August 18, 2012

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

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

May 30, 2012

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

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

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

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

What is Innovation in Healthcare and whose job is it?

April 28, 2012

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

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

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

Australia, Convicts, US Public Health and the PCEHR

August 17, 2011

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 18th 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.

Quality Safety and other stuff from Boston Day 2

May 18, 2011

The second day of the second session of the Leadership Strategies for Information Technology in Health Care started with another cold rainy day in Boston.

The morning session was led by Dr Ashish Jha, and unfortunately Dr David Bates had to go to Paris, so Dr Jha covered his stuff as well. As you are probably aware David Bates is THE EXPERT in quality and safety informatics, and I have had the pleasure of hearing him speak, and meeting with him a number of times in the past. I have to admit Ashish Jha did a great job driving the discussion amongst the 50 plus attendees from around the world, so while I would have loved to hear David Bates again, I was just as impressed by Dr Jha.

The first half of the morning we discussed Meaningful Use and its relevance not only to the USA but also the rest of the world. There was some concern by a few members of the group that the seemingly unreasonable time frame and demands. The opposite argument was raised of it setting a benchmark for action, and otherwise we would still be trying to define the problem. A very lively discussion limited only the amount of time we had ensued. It was daunting listening o folk from some of the world’s leading institutions talking about how it has affected them and their facility.

The classic safety papers were discussed in the next session. The 2005 paper by Han et al on the increased mortality on introduction of an EMR in a paediatric hospital triggered much discussion about how poorly we actually understand and document current workflow, so when we introduce big changes to it is when we first realise how important the current workflow is. The introduction of an EMR which required physicians to leave the bedside to go to the computer may have been the reason mortality rose in this paper. Pretty good case for making the technology fit the workflow rather than the other way around.

After morning tea the folks from CRICO RMF, who are essentially Harvard’s malpractice insurers, but do a lot more than just legal stuff. The RMF stands for Risk Management Foundation which as a fascinating discussion in itself. They are very active in developing how systems need to be developed and used to drive high quality safe practice, because that is less likely to get you sued. They brought up some very interesting points about what the new record is, how things like the ability to copy and paste information has led to a whole range of new issues about the authorship and validity of the EMR. A great example of how copy and pasting a troponin result across multiple days was in direct conflict with the actual results. The notes said it was high, the path results showed it wasn’t, but the clinical care was driven by what was in the notes, which was copied and pasted from the admission examination. Even so called smart paste has issues, because things like abdominal tenderness captured by the system was not highlighted because the smart paste focussed on the EKG so lack of chest pain was the decisive information. The patient ended up needing an emergency hernia repair, the signs were all there, but the cardiologist using copy and paste made everyone else miss it.

They then went on to talk about the effect of workarounds. Partners has an enterprise allergy tracking system, but discovered that the value of the system was challenged by the fact that in a 15 month period over 93,000 allergies entries were entered as free text, even though there was a system in place to capture coded allergies. About 5 percent of these were anaphylactic reactions, not just mild itching, but not captured ion the system designed to prevent this. When they looked at why this was so, it was basically a design issue, the box for selecting the coded entry was blank, so people just typed into the other box below it. However in the allergy list there was no way of identifying free text entries versus coded ones, even though the free text ones would not trigger an alert. With some simple User Interface (UI) changes they have dropped the non coded allergies from 20% to 8% over 12 months.

An interesting discussion arose about how copy and paste notes have led to some clinicians no longer using the notes as they are just a collection of copied data. The point was raised that documentation is driven by billing requirements rather than clinical requirements, so that may be what causes all the problems. Glad that t=in Australia I don’t have to document for the billing system, yet!

In the afternoon we looked at Clinical Decision Support. A good question was raised, what is a good or acceptable rate of over riding alerts. No answer but an interesting statement, poor decision support is worse than no decision support at all! Another key learning, all decision support is local, so listen to your users. The other great rule is that less is more, i.e. simpler is better! Another interesting statistic was the NNTR, Number Needed To Remind for an alert. Suggested that for patients with Coronary Artery Disease, the clinician needed to be reminded 4 times to start aspirin. Question arose that in actual fact response is better than that, but the information is not captured.

An interesting concept of tiered alerts was discussed, and an interesting experiment was shown of how a tiered alert had 2-3 times greater effect than non tiered alerts. It was an interesting concept, some alerts cannot be over ruled, but you have to make sure that their use is managed, and they should be rare, others can be over ruled but you need to do something, whilst level 3 was a little red note on the screen, which was probably ignored most of the time.

The golden rule for CDS is to make desired behaviours easy, undesired behaviours difficult.

The final session was a panel by the quality and safety managers from three of Boston’s major healthcare facilities, Massachusetts General, Brigham and Women’s and Harvard Vanguard. They are all doctors, one of them is also a lawyer, and they all have a strong background in policy. Costs management came up, meaningful use came up, and the discussion was enthralling. Personal Health Records came up and their adoption is an issue. Harvard Vanguard has 30% of their patients actually using the PHR, which is an astronomical adoption rate.

End of the day, shopping and downtown and dinner with my old friend Dr Ron Ribitzky who has been travelling the world driving ehealth adoption.

Are Medicare Locals Accountable

March 29, 2011

I recently came across an interesting article in Hospital & Health Networks online magazine titled “Chasing Unicorns: The Future of ACOs“.

The Accountable Care Organization is to a very large degree the US equivalent of the Australian Medicare Local, and I love the quote used by the author of the article:

“The accountable care organization is like a unicorn, a fantastic creature that is vested with mythical powers. But no one has actually seen one.”

As the government announces the wave 2 ehealth sites in Australia, I am starting to feel like our US colleagues, what is this new health service model we are talking about really look like. As we try to picture what a Medicare Local looks like we are unfortunately limited to our experience of how we deliver healthcare, and trying to squeeze the new models into our old mindsets. The challenge with that is that we still think of bricks and mortar constructions of healthcare delivery, with some technology in place to expedite the administration of the service. I think we need to start thinking differently. Why can’t a Medicare Local or ACO be a virtual entity, living in the connected world, with possibly a bricks and mortar entity acting as the administration, i.e. where the cheques are mailed to if needed. The goal would be to have the patient’s homes as the “bricks and mortar” of the model and use the technology to deliver services directly into the patient’s homes. That would mean that doctors don’t need to invest in expensive real estate that they only use for 40 hours a week, they would be able to work in a virtual environment and find a time that suits them. It would mean that patients would have access to expertise outside the direct geographic area, maybe even half way around the world they would be able to link to a doctor when they need it, even if it is 2AM at the patient’s home.

The idea of virtual organisations providing services is not a new one, but it is something we haven’t embraced in healthcare. In Australia we have some of the basics in place for delivering such a service in place, or being prepared. National provider registration enables us to deliver care across the whole continent, irrespective of where we are located. The National Broadband Network will ensure that every home has access to a fast reliable data delivery service, and the upcoming changes in the MBS to enable direct reimbursement for remote consultations provides a reimbursement model. What we now need to do is redefine what a Medicare Local can deliver in such a remote setting. The obvious first step would be in managing patients with chronic disease, recognised as the most expensive and least well managed segment of healthcare.

I look forward to seeing the first virtual Medicare Local or Accountable Care Organization, I believe it will demonstrate that we are starting to realise teh full potential of information technology in healthcare to do more than just store information, it can actually be a powerful tool in delivering healthcare.

Aged Care and Productivity

March 28, 2011

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.

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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:

  1. 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.
  2. 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:

  1. Empowering individuals with tools to help them make sense of, and to do their own care
  2. Collecting real time biological and behavioural data and trends in the home with alerts for out of the normal situations
  3. Facilitating virtual visits with health care providers when appropriate via a range of media
  4. Enabling social networking, awareness and care support for family and friends who are nearby or distant
  5. Personalising care plans and educational content for each individual based on their needs, preferences, data and capabilities
  6. 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.

  1. 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.
  2. 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.
  3. 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.
  4. 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.

High Quality versus High Cost care

March 10, 2011

A recent editorial in the New England Journal of Medicine asks who is “Daring to Practice Low-Cost Medicine in a High-Tech Era” raises some very interesting questions on whether we are necessarily doing the best thing for outpatients when we take advantage of “the vast array of new tests, new pharmacologic agents, and new diagnostic and therapeutic procedures” currently available. The author notes that “most doctors are intensely risk-averse” which is true because we are looking after people’s lives. He goes on to say “we don’t tolerate uncertainty” which I guess links to our scientific training and usually inherent mind set.

This started me thinking, is health technology playing a role in driving this behaviour? Does the ability to order with the click of a mouse makes us more likely to order a test than having to write it down on a piece of paper. My experience is that with decent clinical support tools, the computer actually gives you an opportunity to think about what you are ordering, and if done properly may even stimulate thought patterns around test and drug ordering we had turned off a long time ago. We can influence doctors ordering, but they will still remain risk averse.

The other thing I started to think about is why are we so risk averse when we manage patients in the community. It could be because we are largely isolated from their daily activities, so when we do have them in our rooms, or in the hospital we try and do everything we can for them. Let’s manage all their physical conditions, and while we are at it let’s add some medications for their depressed mental state, because they seem to be sad after waiting in our crowded waiting room to see us and be told about everything that is wrong with them.

What if we had a better idea of how they were in their own home environment. Rather than bombard them with a lot of questions about their body, their mind, and their social life in in one sitting, what if we could ask them relevant questions at relevant times. How did you sleep, first thing in the morning not at 3 in the afternoon, or while they are lying in a hospital bed waiting for a test result.

It seems to me that tools that enable us to communicate more regularly, if even in small bursts, and not necessarily in real time may give us a better understanding of the patient we are dealing with. Then we can practice high quality and still low cost medicine, because we can afford to be a little less risk averse. After all we know in pretty short time how whatever we are doing is affecting the patient, and we can respond appropriately. We can find out what their blood pressure is at home on a normal day, not after catching two buses in peak hour to get to our rooms.

Can we do this and still deliver high quality care? As long as the model of care allows us to interact with the patient as required, without penalizing us for doing so, then I believe we can. What does that mean, well today we get paid for spending 15 minutes with the patient and trying to solve as many problems as we can in that visit. What if we got paid for managing them differently, a base amount for planning and a fee for service for each interaction, more for long interactions, less for short. Why do those interactions need to be in person, when we can do a lot of it remotely, via video if we need to see the patient, or just by asking them the right questions via some other means. Flexibility is the key to gathering good information, use the right tool for the right information and you get better information.

Then there is the whole question of patient self management. How do we share some of the burden of care and associated risk with the patient in a way that makes them feel like they are getting high quality safe care, but also efficient care. It is hard in a country like Australia with the government covering much of the cost of care, but today we are finding more and more of the cost being diverted back to the patient. Just this morning there was the announcement that new drugs being added to the PBS will be limited, so patients will have to decide whether they are willing to pay for some of the new drugs themselves.

To help us reach the goal of high quality low cost healthcare wee need to enable the clinicians to manage the risks associated with the care more effectively. That means giving them tools for managing and monitoring their patients, and importantly reimburse them for doing it. We also need to facilitate the communication between the patient and the clinician, where it makes sense, from the patient’s home, not from the clinic or the hospital. Keep those facilities for the people that need them,, and manage the bulk of the healthcare needs where it is located, back out in the patients community. Finally we need to educate the patient about their condition, their treatment, and how to play a more active role in managing their health. Not just campaigns telling them to lose weight and stop smoking, but targeted relevant education provided in a way they can use it.

Home telehealth solutions, especially those that take advantage of the improved communication infrastructure provided by broadband can do that today. Yes they cost something to put them in place, but if they enable us to move to a model of high quality low cost care, then they very quickly pay for themselves. Until such time as they are properly utilized we will continue to pay for inconvenient and unnecessary consultations, risk averse behavior and high cost and high inconvenience medicine.

More Health Reform and Less Healthcare

February 15, 2011

Well it seems that the Australian government has decided that the health reform agenda announced in 2010 wasn’t going to get through in 2011, so on the weekend we saw yet another attempt at health reform in Australia. As the federal and state leaders debated the need for a national central pool for hospital funding, another thing seemed to have slipped through, and probably didn’t get the attention it deserves.

Medicare Locals have been increased in number, and hopefully in importance. Primary care is critical to healthcare reform, but more importantly we need to move away from the idea of super clinics where patients go, to virtual clinics in people’s homes where a large part of healthcare can be delivered.

There is a strong similarity between Medicare Locals in Australia and Accountable Care Organizations in the USA. Both are still fairly nebulous, but we are starting to see some definition around them, more so the ACOs than the Medicare Locals, but then again we were always fast followers. They both have the same aims, provide high quality yet cost effective care to targeted populations that are currently both the most expensive and in need of the greatest care. As we explore this opportunity we find that in effect that population is either elderly, or suffering from a chronic disease, or even more likely both!

At the upcoming HIMSS conference in the USA there is a lot of discussion about how ehealth would enhance ACOs. It would be nice if in Australia we explored the link between ehealth and Medicare Locals a bit more. The PCEHR is a good first step, but it is not by any means the end. Working off a common data set sure expedites collaboration, but making healthcare a less episodic and more continuous activity will make a much bigger difference to the outcomes.

What do I mean? Well today we use healthcare services episodically, either when we are sick, or when we have a pre booked appointment to see a clinician. How much better would it be if the system captured information continuously, both subjective and objective, and made it available to the care team to respond to? That would be a much better model of local care than a super clinic, turn the patient’s home into part of a virtual clinic. We should be looking at Medicare Locals as just such an opportunity, not a new bricks and mortar building, but a new way of thinking of care, with reimbursement tied to outcomes and patient satisfaction.


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