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.

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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.

Does Australia Need More Geek Doctors?

July 12, 2011

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

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

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

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

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

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

When Industry meets Government, what can we hope for?

June 13, 2011

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

Notes for the AIIA Victorian Government Ehealth Forum

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

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

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

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

Complex Decisions and Innovation

May 21, 2011

Day 5 started off early again with a talk by Tonya Hongsermeier on Complex Adaptive Systems. A Complex Adaptive System
is made up of a large number of self-organizing independent agents that seek to maximize their own goals but operate according to rules and incentives in the context of relationships with other independent agents. She provided a god set of examples of the transition from linear through complicated to complex in healthcare. Linear is ordering a test, complicated would be doing a simple colonoscopy in a low risk patient, and complex would be managing a septic patient. The issue arises on how to get people to understand they are in a complex adaptive organisation and how to manage the relationship, and utilising the technology to remove some of the complexity where possible. An interesting thing was the healthcare modified data information knowledge wisdom pyramid, where the knowledge starts as know about to know how. The role of good decision support is to provide the most likely solution as the easiest option to select. However this logic is not linear.

The next speaker was Roberto Rocha on Translating Knowledge into Practice for Continuous Improvement. Improvement requires complex CDS, it’s not the simple stuff that is causing the problems, however the deployment needs to be simple.

The goal is science-driven health care or a learning healthcare system to enable moving from reference to action and ultimately to executing

After the break Kenneth Mandl spoke on HIT Architectures for Health Care: Innovation and Transformation. Ken is from the Children’s Hospital in Boston which has done some very innovative things, including Indivo, the basis for many personal health record systems including Dossia. He spoke of the need for a Learning Healthcare System as the goal for health informatics. He spoke of the App Store for Health concept and the need for user interface development and allow people to choose the interface that works for them. Rather than just interoperability he suggests substitutability should be the next stage. They even have set up a Smart App challenge. He went on to talk about how the Personal Health Record may be the disruptive innovation and compared it to the current HIE models, which have been unsuccessful. He commented on the Australian PCEHR project as a very positive step, and whilst it faces some technological and sociological challenges, it does move us forward. A great example of linking the PHR to online disease specific social networking sites, in this case tudiabetes.org showed that people were keen to share their information and also enter their data.

The next session was on the governance of clinical decision support. Governance leads to a common vision, coordination and transparency, and provide the organisation the ability to manage expectations and be agile enough to respond to unanticipated demands. Within Partners, which is a collection of world leading providers, which raises its own governance issues, he described the journey of getting to a stable governance model and the various issues involved, which led to much discussion. He was followed by Dr Goldberg who discussed how CDS is integrated with EHRs. He described the various currently available CDS tools, and how they affect the systems they are running on. Some early results from the use of Smart Forms which combine CDS logic with user interface design and prompting of behaviour have been shown to be very beneficial.

The day was wrapped up by Blackford Middleton looking at why we need leadership in health IT. The provider’s dilemma is that we still hurt people while delivering healthcare, and the variation in healthcare remains huge. The question of how HIT saves money, and it essentially comes from improved effectiveness, reduced duplication, taking away reworked, be they test or administrative tasks. The improved quality of care decreases the costs associated with adverse events. Data sharing reduces redundancy and associated labour costs, telehealth reduces costs, and the PHR improved admin efficiencies. He went through the masses of data available, much of it from work at Harvard. From the purchaser’s perspective, the rapid growth in costs with 25% of the cost being administrative costs. The evidence for CDS is great in places where it is done well; the challenge is how to scale it out to the rest of the country, if not the world. We need to research more completely what we need to do, where CDS can intersect with HIT usage.

The wrap up discussion pointed to the differences and similarities between the US experience and mine in Australia and others from Canada. We all recognise the issues of cost, but we also recognise that the value of clinical expertise needs to be supported. There was much discussion of where to next, and what else we need to cover. Telemedicine came up as did personal health records, so it seems Australia is heading in the right direction.

Overall it was great session, very informative and the faculty were very helpful. A special mention for Blackford Middleton who went out of his way to be inclusive, was full of knowledge, and showed great interest in what is happening around the world. It would be great to get this course delivered down under for our health folk to understand what is needed to make ehealth happen. They emphasised it is a journey, and they need to persevere.

Innovation and Improvement the Harvard Way

May 20, 2011

Day 4 started with the head of patient safety from Partners talking about the value of experimentation in patient safety development. Much of this was driven by the work of David Bates which showed that when Brigham and Women’s Hospital experimented with CPOE in the 90s they showed huge decreases in medication related adverse events. Since then they have experimented with some other things, tiered Drug Drug Interaction alerts have led to significant increase in uasage of these alerts. Before the experiment there was an over 80% over ride rate, but with the tiered system the rate for tier 1 was basically zero because you could not over ride it, but the tier 2 events where clinicians had the option to override, the positive response to the alert doubled. They experimented with barcode usage and showed huge improvements. The willingness to experiment differentiates them and demonstrates their leadership. Starting with a hypothesis and testing it seems to be the key secret, and giving people the freedom to think of hypothesis. Experimentation drives innovation learning and improvement.

The second speaker came from the Harvard Business School Richard Bohmer, a physician and a Kiwi. Amazing how many areas doctors have gotten into at Harvard. He started with a claim by Brent James from Intermountain Healthcare “Our business is clinical medicine”. He looked at the changes needed from a management perspective. Terms such as changing production mode seem out of place in a healthcare discussion, but he actually made it sound reasonable. Some interesting stuff from 1984 which looked at the role of uncertainty in physician practice. He emphasised the need for well developed science in healthcare, almost like an engineer. He spoke of the four habits of high value delivery organisations. Specify, design, measure and learn.This talk was teh highlight of the entire event, it seems the guys at Harvard Business School are thinking about healthcare in a way few others can.

After the break William Lester an engineer who decided to go back and study medicine spoke on Population Management with Health IT. Another brilliant speaker with amazing information and to use the quaintly American term “we were drinking from a fire hose”. He dived into the issues around disease management, something close to my heart. Population/patient selection, metrics and clinical effector activity was the core theme. His quote “It’s all about the workflow, silly” followed by “It’s the technology, silly”. In reality it is both, it’s how you link them up. Engagement is the key for bringing providers onboard, and you need to use every tool you have, including leveraging their competitive streak.

The next speaker was from a 300 provider clinic who spent $24 Million on setting up their EMR, and showed how it improved their clinical and financial success. It came down to thinking about how they use, providing clinicians with some flexibility, but not too much, and as they had a large capitated population they were able to drive continuous improvement clinically and financially. The interesting statistic was that they expected a big hit in productivity on implementation, what they actually experienced ws a 15% drop for 2 weeks followed by a return to above their baseline.

After lunch Partner’s head of Quality Data Management, basically the guy who was responsible with what they do with the huge amounts of data they have collected in their data warehouse. Yet again a physician who still does some clinical work and in the rest of his time massages a huge data warehouse to drive improvement within Partners which seems to be the secret to Partner’s success. He was followed by Micky Tripathi from the Massachusetts Ehealth Collaborative who spoke of the experience of getting a HIE type structure up and running in HIE type clinical data exchange.

The final session was a panel of two thought leaders from non healthcare arenas. Richard Swanborg from ICEX and Tom Koulopoulos from Delphi looking at innovation. Tom defines innovation anything that creates value and change behaviour.It is teh gretest enabler of behaviour change, he used the mobile phone as an example. He now sees industries using IT as the centre of their innovation, not of the IT, but of the business. He spoke of the three eras of how we use IT. It started with information, went to integration, and now moving to predictive analytics. Innovation was the key message.

It was a very interesting day, and as much as it hurts me to say, the Kiwi Richard Bohmer was the class act.

HIEs EHRs and CIOs Day 3 at Harvard

May 19, 2011

Day 3 kicked off early with a talk on Health Information Exchanges by Julia Rose Adler-Milstein which in light of the article released that week in the Annals of Internal Medicine by the speaker on the adoption of HIEs in the USA was very relevant. I guess that is the beauty of being at Harvard, an article gets published on Monday and on Wednesday the author is talking to you about it. The big issue is the sustainability of HIEs and to date they have been basically grant funded. Only 1/3 of operational HIEs are currently covering their own costs. With the advent of the HITECH act there is now some incentive for providers to be involved, based around Meaningful Use funding which is believed may positively affect their sustainability.

The second speaker was Karen Bell the chair of the Certification Commission for HIT in the USA. One thing that continues to amaze me is how many people involved in HIT in the USA are actually medical doctors. She made some very interesting points. Whilst culture change is recognised as a major issue, we cannot discount the technology issues, and it is important to keep both in mind. The other issue that arose was that much of the HIT program in the USA is economic stimulus based, and it has different timelines and goals than clinical improvement people. Certification is all about provider assurance and protection, and in the USA there are over 700 products currently certified. The other issue is interoperability and the holy grail of data portability. The basic federal compliance is meaningful use, but products need to do more than that, so CCHIT also certifies for enhanced functionalities above and beyond meaningful use. Very open discussion about the issues and the need for standards.

This was followed by a panel of 3 CIOs from Boston Children’s, Boston Medical Centre and Newton-Wellesley Hospital talking on their experiences on driving quality and safety using IT. An interesting thing is the length of tenure of these folk; two have been CIO for 15 years and the other 10 years. The need for behavioural and cultural change came up again, but it was interesting that they saw meaningful use as a driver to produce this cultural change as it unites the disparate parties involved. A question arose on how the meaningful use stuff disrupted their flow, as they were all actively doing stuff before HITECH came around. Timing was the major issue; they had to change their priorities to make sure they had access to the stimulus funds. The key issue was the link between demand management and governance. How do you chose what can be done versus what needs to be a done. How they managed new projects was interesting, prioritisation was based on need and costs, and those most likely to be done were needed but cheap. Another interesting comment from one of the CIOs was how they wished they were not best of breed as it is now causing them huge issues. The idea of best of suite came up as an option, but there is strong push towards consolidation. Cloud computing came up, and it was interesting that one of the CIOs pointed out that healthcare is a more employee friendly industry, and some decisions are being driven by the effect of going to the cloud would have on their staff.

An issue I raised was what the interaction there was between the CIO and the CMIO. The one medical CIO admitted that for 5 years he did both roles, but realised that there was a need to separate the two roles, and now they have a formal CMIO who interacts directly with him. For the non medical CIOs there was a comment that the role of the CMIO is probably one of the least well defined roles in their organisation, and the reporting mechanism tends to drive their activity.

After lunch the next module starts focusing on Continuous Improvement through HIT. It is being run by Dr Blackford Middleton, another health informatics luminary. The scenario was painted of the issues we face, on the background of financial turmoil, and legislation which is not designed around sustainability. One of the issues is that clinical information is very expensive, because we get it via very expensive means, physicians and healthcare providers. We need to find a way to do it more cost effectively. He spoke about the Clinical IT vision, with common consolidated information for all patients, with consistent decisions support, identification of high risk patients and patient access. He spoke about ruthless standardisation as a way forward.

Tim Ferris from the Massachusetts General Physicians Organisation spoke on clinical leadership for high performance medicine. He started off with the 20 “no brainers” for high performance medicine, including things like patient and physician portals, virtual visits, incentive programs, quality metrics and more. His group has 100% adoption of EHR, which is very impressive in the US, and is now focussing on getting 100% of their patients actively online. They are working on defining episode process standards, with IT playing a pivotal role. He dived deep into how they developed their stroke care plan, and looked at how they drove the change within their group.

The day ended with dinner in the Harvard Faculty Club, very swish, makes me feel like a Harvard educated expert, well at least Harvard educated J

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.

Back in Boston for more Meaningful Use

May 17, 2011

I’m back in Boston for the second part of the Leadership Strategies for Information Technology in Health Care being run by the Harvard School of Public Health. This time we are actually on the Harvard campus which is a real buzz. Amazing how many big name facilities are within walking distance here. In my short stroll to buy some Harvard branded gifts for the family I walked past the Harvard Medical School, Brigham and Women’s Hospital, Boston Children’s Hospital, Beth Deaconess Israel and Dana Faber Cancer Centre, all on Longwood Ave within a couple of hinder metres of each other. You feel smart just walking down the street!

After the last few weeks talking about the PCEHR and telehealth in Australia it was back to hear about the meaningful use concepts. The first session was run by Dr Ashish Jha, the Associate Professor of Health Policy at the Harvard School of Public Health. The first session was an update, and started with a seminal paper from the NEJM titled “Cottage Industry to Postindustrial Care — The Revolution in Health Care Delivery” by a collection of health luminaries including Don Berwick and Brent James. It starts with the statement, “U.S. healthcare is broken” and talks about the need for transformation. He then introduced us to some very interesting work on the adoption of ehealth in the USA. Despite the rhetoric, it’s still struggling, with comprehensive EHR adoption sitting at 10.1% in ambulatory care and 3.6% in hospitals. He even gave us a glimpse of data being published that day in the Annals of Internal Medicine on Health Information Exchange Organisations or RHIOs as they used to be known, with amazingly low adoption, none meeting the expert panel criteria of comprehensive RHIO, and only 3% of hospitals and 0.9% of ambulatory practices meeting stage 1 meaningful use. There is lots of room for improvement, and a fascinating discussion across the room of why. Change management and training came up many times, and the 2 Australians and several Canadians in the room had their views.

He was followed by Dr Thomas Sequist from Harvard Vanguard on Strategies for Improving Ambulatory Care Using an EHR. He discussed the need for effective clinical decision support tools that drive behaviour of clinicians and patients. Good discussion of whether the PHR which at his facility has a 30% adoption by the patients may be the right tool for delivering this. He discussed how they used their EHR to drive colorectal cancer screening, diabetes management and chronic kidney disease patients. Combined use of innovative technology and direct mail concepts. The topic of adoption came up, and I pointed to the work of our own Dr Chris Pearce on the role of the computer in primary care practice. Seems we are ahead of the pack in a lot of things.

In the afternoon Dr Peter Almenoff from the Veteran’s Affairs Administration spoke on the utilisation of large data bases to improve quality of care and efficiency. The VA with now decades of data from their EHR system have been able to drive some amazing progress is improving both outcomes and process measures by leveraging its information assets. Lots of graphs and statistical talk, but basically with their dashboard they can drill down to who is practicing outside the norm, and work on finding out why.

The final session for the day was by Dr Christopher Roy from Brigham and Women’s on IT for Tracking Critical Labs. Again the Aussies get a mention, with Professor Johanna Westbrook’s work coming up for special mention. Some very interesting statistics, 41% of patients discharged from hospital had results pending on discharge, and 48% of those results were abnormal, with 9% being deemed actionable by their physician. 70% of hospitalists and 46% of primary care providers were unaware of these potentially actionable results, 25% of hospitalists and 46% of PCP were unaware the test were even ordered!

Another fascinating day with some of the luminaries of ehealth. Things are moving slowly worldwide, but the US guys have been leveraging meaningful use to great effect.

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.


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