Archive for the ‘Telehealth’ Category

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.

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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.

Telehealth Innovations at Ehealth Week in Brisbane

August 2, 2011

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.

Why Ehealth is an International Issue

April 12, 2011

Cisco recently released a very interesting report titled “The Health of Nations” which provided a perspective from health leaders from 16 countries

The paper has some very interesting insights into the healthcare systems of these countries. It points out that countries like the USA and Denmark, despite spending more than the international average on healthcare have lower than average life expectancies. It also looks at the consumer satisfaction of a country’s health system. Countries like Italy and France which have very high rankings in the WHO surveys have lower than average satisfaction rates by their citizens. The key message is that no healthcare system has actually delivered to its full potential, and there remains large untapped potential for healthcare systems to transform themselves into more efficient, effective, and accessible services going forward.

No surprise, being a technology company, the report talks about the role of technology in delivering this potential. However what it did point out to me was that there was a disconnect between what the key policy makers see as the major issues and what is being done on the ground to deliver on these reforms. Whilst the three key issues remained equitable access, efficiency and quality of care, practitioners on the ground keep talking about the blow out in costs of services. So they focus on cutting their costs of service, with the resultant decreases in access to service and challenges to their quality. As a result the system seems to get into a self defeating circle, manage costs at all costs and then do something heroic to enable equitable access; usually through short term expensive programs to shrink waiting lists or deliver on certain measurements of access to care that are not very relevant.

The other issue that was raised universally was the uneven distribution of healthcare professionals. Geographically they locate around urban and metropolitan areas, whilst unfortunately disease tends to spread itself out over less differentiated geographies. Human nature being what it is, once one has reached a certain point in their professional careers they tend to conglomerate with their peers. You can try and provide incentives for healthcare workers to live and work in regional and remote locations, but as healthcare professionals reach middle age, at the point where they are reaching the peak of their clinical careers, they also tend to make decisions about where they live and work based on more than just the needs of the community. It is hard to take your family away from the metropolitan community where you did your training, and move them out to the bush. I take my hat off to my healthcare professional colleagues that have had the courage to do that, but the statistics tell us they are in the minority.

However this is an area where technology really does become the enabler. To the data going down high speed fibre or wireless connections distance is not a problem. Video conferencing is part of the story, and in a fairly simplistic way can act as a surrogate for physical co location. However the advent of new technologies such as remote patient monitoring, mobile sensor technologies, data analytics and such like provide a new option as yet unexplored. What if we started to rethink how we deliver healthcare? Sure the model of Hippocrates still works in places where there are lots of physicians with time to spend with patients. But what if we asked our healthcare practitioners to think about how they would provide services if they did not have a lot of time. What information is relevant to them, or which will help them in their decision making. Do they really need to poke and prod a patient if they have access to relevant clinical information? Is Sir William Osler’s saying that listening to the patient will give you the diagnosis work better if we have a more structured, computer driven way of asking the patient the questions, rather than the relatively haphazard human systems we currently have today. Whilst all medical students are trained to do a systematic history of a patient, one of the first things they stop doing when they become time constrained is that full systematic history taking. However a computer doesn’t have that same restriction. It will do the full systematic evaluation all the time. It knows what questions it has asked, and which it hasn’t. So would a clinician’s time be more profitably used evaluating that information rather than obtaining it? In an ideal world we would gather and analyse the information, but alas few clinicians live in that ideal world.

So how do we move to a system where clinicians are rewarded for using their analytical skills rather than their collection skills? We have done that in the world of pathology. We don’t pay family doctors for taking blood, but we do pay them for looking at the results and discussing them with the patient. What if they could do the same thing from information gathered through monitoring systems that not only capture physiological information, but can also information on symptoms and other subjective responses. I believe we could make the health system much more efficient, because we will free up time currently spent gathering information for actually doing something with the information. I also believe that the systematic use of such technologies in the home will give us access to better information. How many patients walk out of their consultation with their doctor and on the way home say “I should have told the doctor about that other issue, but I forgot to bring it up during the visit”? I know I have done it myself, and I am a trained physician. What about those niggling pains or concerns you have which seem better when you finally get to see the doctor. With the right systems in place we can capture that information and provide it to the healthcare provider in a usable format so they can make their decisions.

There will remain times when you need a one to one personal consultation with your healthcare provider. That option should always remain. But there are also many times when you don’t, where by just sharing information in the right context better quality care can be delivered more efficiently. We need to provide our healthcare providers the opportunity to explore those opportunities. The only way to do that is to unshackle them from the current direct fee for service model and allow them to deliver care with different reimbursement models. The Medicare Local in Australia or the Accountable Care Organisation in the USA may be one way of doing it. What we need to do is make it easier for them to explore these types of opportunities.

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.

Tele-what? At last informed journalism on telehealth.

January 8, 2011

 Check out the op-ed piece by one of my favorite bloggers Neil Vershel in the Columbia Journalism Review titled Tele-what?

I have known Neil for a few years, first met him at MedInfo in San Francisco in 2004 if my memory is correct, and have caught up with him over the past 6 years on my visits to HIMSS and other ehealth events in the USA. Most impressively he made the long trek over to Australia in 2007 to attend MedInfo in Brisbane and after that the Third International Conference on Information Technology in Health Care: Socio-technical Approaches in Sydney. Few bloggers and journalists make the effort to find out what is happening outside their direct sphere and the internet. Neil does!

Neil’s piece was a response to a Los Angeles Time piece published late last year in response to an article in the New England Journal of Medicine which looked at the results of a “telemonitoring” randomized control trial run by Dr Sarwat Chaudry from Yale University.

First let me emphasise that I am a very strong believer in the use of evidence based medicine. My old medical school at the University of Sydney was a big proponent of EBM and throughout my career I have been as obsessed with the evidence of efficacy and efficiency as any other clinician. But one of the very important things you learn when studying EBM is the need to evaluate the evidence and compare it to your clinical situation. Unfortunately the NEJM paper was so far removed from good practice of “telemonitoring” of heart failure patients in 2010 so as to be clinically useless to me, and I suspect all my peers.

Yes I work for Care Innovations, the new Intel GE joint venture that is developing solutions for just such situations. Yes we have a great solution in this space, as do some of our competitors. But what is important are the models of care that are developed as a result of these new technologies, not just the gadgets themselves.

The study by Chaudry and his colleagues used Interactive Voice Response technology, something that was pretty cool a few years ago when it first came out. The problem with the model was that it required the patient to pick up the phone, go through an IVR script and report their results to the system, which the clinician then reviewed and responded to. Of interest is the fact that by the end of the 26 week study 45% of the patients on the “telemonitoring” arm had stopped using it!

The problem is that the model of care was not patient centered or participatory. It was a throwback to the bad old days of when you gave the doctor information and they told you what to do. Only in this case the clinician was an electronic voice on the end of a phone that you had to call. A more progressive model of care would have gathered the information directly from the devices, displayed that information to the patient in a relevant way, given them access to information about their condition and what their results meant in the context of their condition, delivered the relevant information to the clinicians, and enabled the clinicians to respond in a reasonable amount of time in a way that was relevant to the patient. Some would be happy to get an email or a text message; others would like to speak to a real person. The beauty of modern technology is that all those models of care can be provided with technology you can buy today.

Patient centered care is about developing models of care that are relevant to an individual patient, and one thing you learn early in your clinical career is that all patients are individuals with their own needs and wants. Squeezing them all in to a one size fits all system that actually removes the human element of communication and collaboration is not the solution. The good news is that based on the work in the Chaudry paper we can no go forward and develop new models of care that utilize new and evolving technologies and compare them to the baseline of Chaudry’s paper on 2010. It is a first step, but healthcare innovation means we need to keep developing new ways of using the technology to make the lives of our patients better.


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