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.


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.

Can EHealth in Australia be private?

March 7, 2011

I spent Wednesday in Melbourne attending the workshop arranged by the ACHR and GAP on the paper by Associate Professor Leanne Rowe "Primary Health Care and The Private Patient Journey: Towards a new generation of private health care in Australia”.

The goal of the event was to get the full range of stakeholders in the room to discuss how private health insurers, private hospitals and primary care could work together to deliver better healthcare.

The first challenge was in defining who is a private patient in Australia. We agreed that the patient who is admitted into a private hospital for a procedure by a private practicing clinician whose procedure is paid for by a private health insurer is a given. As we start looking at the average patient who rocks up to their GP clinic, it can be well argued that they are also effectively a private patient. Whilst their insurer may well be the federal government trough Medicare, from the perspective of the patient and the provider, especially in the much more common non bulk billing practices out there now, it is a series of private transactions.

So the private patient remains a mysterious entity. In a fee for service model as we currently have in Australia, effectively every health transaction is a private transaction between a provider and patient.

How does ehealth play in the private healthcare transaction world? In reality technology has been used for tracking transactions for many years. Even the least technically literate practice is likely to have some sort of electronic system for billing, be it a basic MYOB accounting application, or a specialised healthcare system. Accounting took up technology very quickly, it made a lot of sense to them. With the advent of services like HICAPS for private insurance billing and ECLIPSE for Medicare billing healthcare providers also took advantage of it.

However the same capability to manage clinical information for private patients and sharing it with their care team hasn’t had the same uptake.  We keep on hearing about silos in healthcare, and the silo mentality around healthcare data propagates this further. I hope that the Personally Controlled Electronic Health Record may be the critical factor that breaks these silos. To do this, it needs to be adopted not just by patients, but also by providers, public and private. I believe the best way to do this is add a little carrot, maybe a couple of cents extra for transactions that have also sent data to, or used data from the PCEHR. In a private payment world, maybe those few extra cents will drive adoption in the beginning when there isn’t too much data there. Over time as the data builds up, clinicians will see value in the data, and will be more likely to use it without the extra incentive. Its the beginning which is the hardest, so makes sense to spend a bit of money up front to get adoption ramped up quickly.

Does healthcare really need broadband?

February 27, 2011

This week I attended and presented at the Communication Alliance’s Broadband and Beyond conference in Sydney. It was a actually a hard decision, as at the same time over in Orlando Florida the 50th annual HIMSS conference was being held, and I was originally going to attend that. But I believe that it is really important to keep the message around technology enabled healthcare strong in Australia, so there I was.

For those of you not based in Australia, the government has committed some $40 Billion to provide a fibre to the premises network to the majority of Australia, with a very fast wireless and satellite alternative for the rest. In this case the majority is 93%, and if you have any experience of Australian geography, you will realise this is a big deal. The rollout is being done by NBN Co Limited, an entity formed by the government to do so. You can read more about them on their web site.

The Broadband and Beyond conference had a number of speakers from various sectors, but what was interesting, especially on the first day was the number of times healthcare popped up. My old friend Professor Michael Georgeff spoke about the CDM Net project he has been running, which has used broadband connected healthcare workers to improve the compliance of people with chronic disease to evidence based care plans. Ian Opperman from CSIRO showed how broadband was used to connect hospitals separated by distance and adverse geography to share resources such as specialists, and I spoke of the work we have been doing in home telehealth with elderly people with chronic disease and the various other inflictions of age.

So the question arose, do we really need a 100Mb connection in everyone’s homes to deliver healthcare. There are some very cool examples of health applications being delivered on peoples I Phones, which uses relatively low bandwidth wireless signals, so why are the NBN folk and many of us in the industry so insistent that the NBN is necessary to deliver the healthcare services of the future?

The problem is that in healthcare we have always innovated to make do with what we have. When all we had was phone lines we used phone based health monitoring services to deliver care. It wasn’t optimal, actually some of the research suggests it wasn’t even effective, but it was all we had at our disposal, so we made do with it. With some tweaking and compromise we made it work for some people, and then used that as an example of how we can deliver services more cost effectively. Sure it was cheaper than sending a nurse out to the patient’s homes. It was more convenient than getting the patient to go the healthcare worker, but it was a compromise. When we started getting some better connectivity, usually some very basic type of data connection, we added to the service. We put in some rudimentary data collection tools, some direct from devices, others where we asked patients to key in their blood sugar readings or other data. We had some very rudimentary educational content we could push down, mainly text. Yes it was a bit better than the phone system, especially when we decided to use Interactive Voice Response (IVR) on the phone to try and make it more efficient. Seriously has anyone had any luck with those systems getting basic customer service yet alone healthcare?

Today we have some better connectivity, and some very cool stuff is happening in healthcare. The CSIRO example of remote consultation between emergency departments The ability to not only monitor vital signs but also see a patient in their own homes via video conferencing. Once you take away the need to compromise on bandwidth you enable healthcare workers to find better ways of connecting with their patients in a way that makes life better for patients and also for themselves.

Healthcare is all about communications, and human communication is a high bandwidth low latency activity. The only way we can deliver the same quality of service as we are accustomed to in face to face healthcare is through a network that is high bandwidth and low latency. To me that sounds like what the NBN wants to deliver to all Australians. Can we deliver healthcare without it, possibly, but many people will have to put up with significant cost and inconvenience to do so, because we will have to compromise the quality of our service to do so. However, if we have access to high bandwidth, low latency, always on and reliable connectivity, then I believe we can deliver much of the healthcare we deliver today in expensive carbon consuming buildings directly into people’s homes at a time that suits them.

The idea that getting healthcare no longer needs to be a hassle is very intriguing. Imagine what would happen if people accessed healthcare when they needed it rather than have to make decisions about whether it is too much trouble for them, their family and their caregivers to try and get access to the same service? Just maybe they will get healthcare earlier, rather than wait for things to go wrong. Maybe they will be able to play a more active role in their own healthcare, because we haven’t waited till the pain is too great, or the tumour too big, or the artery too blocked. If by utilising the connectivity inherent in those tiny glass fibres we may be able to shift healthcare from a reactive service to a proactive service.

So my answer to the question of whether healthcare needs broadband is that we can struggle on with our current way of doing things without it, as long as we are willing to accept that as a result many people will miss out on the skills and value of our healthcare workforce, because they are in the wrong place. Or we can change the system, connect it via broadband, change the way we work and deliver more services to more people in the comfort of their own home or community. It really depends on whether we believe investing in good infrastructure to enable us to provide a better service is a good idea. I say yes, but if you are happy with the way things are now don’t complain when you or a loved one are told you have to wait.

Wireless Health and Real Health… What is the difference?

February 22, 2011

On Friday the 18th of February I attended the inaugural Wireless Health conference at beautiful Bondi beach in Sydney. If you have to go to a conference, Bondi in summer is the place to go. The conference was organised by the folk of BCS Innovations, a local consultancy that has spread its wings to the US market.

I was asked to give the opening presentation, focusing on innovation in wireless health. I may have disappointed a few people because I started my talk by criticising the name of the conference and how the term “Wireless Health” is a misnomer. If any of you were offended, I apologise, but with my tongue a little bit in my cheek.

Over the last decade or so we have seen a bunch of new names be conjured up for the use of technology in healthcare, the ubiquitous ehealth, the more recent mhealth, health and medical informatics, health IT and so on. The problem with this varied and seemingly random use of new prefixes and suffixes for health is that it forgets what we really do. We provide care to people with health issues, so first let’s stop talking about health as a term in isolation, and talk about healthcare. Secondly in focuses on the technology component not the service delivery component.

So once I got that off my chest, I proceeded to look at who needs healthcare, why they need it and how we currently deliver it. The recent COAG announcements about yet another reshuffle of hospital funding models remained in my mind, so I emphasised the need for us to stop thinking of hospitals as the nirvanas of healthcare delivery, and start focussing on the needs of the classical patient. Like it or not, healthcare is something we increasingly provide to those who are getting older. The bell curve of services versus age is way over to the right. So we need to better understand what they want, and deliver it as a customer friendly service. Whilst in retail they may say “the customer is always right” you very rarely hear the same said about patients.

Following me were 2 very smart gentlemen from the USA, Dr Stan Pappelbaum and Jay Kunin, both from the San Diego area. Dr Pappelbaum was the CEO of Scripps Health an innovative health provider in the southern California region. He spoke about the transformation occurring in the USA under Obamacare. It has its problems, and the funding is in doubt thanks to the recent congressional elections, but 40 million more people are now eligible for health cover, which to us in Australia sounds like a good thing. Jay Kunin had a more technical background, having worked with the original developers of Electronic Medical Records in Boston many years ago. Like me he disagreed with the term wireless health (which is why I called him a smart gentleman). He emphasised the need for innovation not just in gadgets but also in business models.

In the afternoon we got to hear from Peter Farrell, one of the original founders of ResMed, an Australian medical device success story. Peter is not known for pulling his punches. He did provide us a great insight into what is needed to go from a good idea based on research to a thriving business with presence around the world.

The enthusiasm of the participants was very satisfying, especially for those of us who have been involved in this space for a long time. The inevitable question arose of why it has taken off yet. This led to the old blame game, it’s because the doctors are resisting, it’s because the government fears change, it’s because the data is not strong enough. All are seemingly valid reasons. For my 2 cents worth, I think it is because we don’t pay healthcare workers the right way. We know what good practice looks like, we understand the need for delivering to evidence based care plans, but we still reimburse for piecemeal fee for service treatment. Whilst we maintain that payment model, we will keep the current system. Health care workers are both astute managers of their and their families’ wellbeing, financially and socially. Sure they understand the flaws in the system, but if that is what they need to do to put food on the table and pay the mortgage, well that is what they will do. No one can blame them for that.

Medicare Locals came up again in the recent announcements from the prime minister. She said we would double the number of Medicare Locals out there. Considering to the best of my knowledge there are none now, that doesn’t mean much. However when we start to get our heads around what a Medicare Local is, we may start to see it not only as a tool for improving collaboration and improving quality of care, but also as the first step in a revamping of our reimbursement model. I watch with great interest.

Why does change work at St Vincent’s Hospital Sydney?

February 18, 2011

I attended the NSW HISA event at St Vincent’s hospital in Sydney this week where we heard about their 5 year odyssey to implement an Electronic Medication Management System on their wards. The speaker Silvia Fazekas presented a wonderful example of why what is recognized as the most complex change management project in the entire ehealth space, medication management has been successful there while it has failed in many other places around the world.

To me the main difference was in the people. As I commented during the presentation, there is definitely a degree of personality involved in change management versus process. Yes you can develop a change management methodology, but unless it is delivered with the sort of passion that Silvia demonstrated in front of a packed out room, it is very hard to do.

Silvia pointed out the need for strong executive leadership, and St Vincent’s has been famous for it’s executive leadership from it’s early days when 5 nuns came over from Ireland to set it up. Today it’s CIO David Roffe is well recognized as one of the healthcare CIOs who understands that his job is to make life better for his clinicians and their patients.

So passion seems to be the most effective way of ensuring success in change management, and unfortunately it is a hard thing to bottle. If we could clone people like Silvia, then we could roll it out across the country. So the next best thing is to develop contagious passion, and that comes from above and below. Executives who can talk with passion about how health reform will improve our lives is a great start, but we also need users to talk about their needs and wants as far as their healthcare is involved, and get those stories out.

Passion based marketing of EHealth may well be what we need to do to make it successful. It may seem low brow but in reality human being respond to emotion more than they do to logic, and nothing is more emotional than healthcare.

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.

EHealth Policy Roundtable USA versus Australia

February 3, 2011

I was fortunate enough to attend an invitation only roundtable event held by the Health Informatics Society of Australia (HISA) with the Menzies Centre for Health Policy at the University of Sydney.

One of the directors of the Menzies Centre is Professor Stephen Leeder was my dean of medicine when I studied at the University of Sydney. I have attended various events by the centre for many years, and it is fair to say that it the peak health policy think tank group in the country.

The forum was hosted by Robert Wells from the Australian National University and was attended by some very interesting and influential folk.

I was asked to talk about my experiences with the US health care system and in particular with ehealth.

The key issues I wanted to emphasise were threefold:

Meaningful Use allows the US system to focus on a common goal for providers of healthcare, providers of systems, payers and patients. Linking the adoption of ehealth technology to the meaningful use criteria, which are predominantly focussed on clinical and population health outcomes. They are staged and attainable, and very importantly widely publicised. The money is tied to their attainment, and while there has possibly been some watering down from the original goals, which demonstrates that the system is responsive, they are still major enhancements to the quality of care and public health for the majority of Americans.

Bending the Curve is a term gaining a lot of airplay in the United States. Whilst the USA has the most expensive care around the world, some reports would suggest that the quality of care that it is not of the highest quality. I referred to a great article by Atul Gawande a couple of years ago called “The Cost Conundrum” where he looked at the heterogeneity of care in the USA. In particular he used as an example MacAllen Texas, a town with the second highest healthcare costs in the country and not particularly impressive health outcomes. Bending the curve relates not just to slowing down the costs of healthcare, but the discrepancy in quality and outcomes of care within a very diverse country. This is an area where ehealth can play a critical role, because it allows the information to be captured and shared effectively. Rather than respond to studies based 5 years in the past, near real-time reporting allows people to focus on bending the curve at a local level quickly. The key learning is that you have to publicise the problem, not just in the medical press, but also to the lay press and to anyone who will listen so that you can bring them along for the journey of healthcare reform.

Accountable Care Organisations, a new concept introduced to the USA recently provide a concrete model that people can deliver to. ACOs are reimbursed for improved efficiency and health outcomes, and are designed to facilitate collaborative care models. But importantly they don’t define in detail how health care providers form their ACOs. This allows for innovation but with some specific focus around the needs. The ACOs have allowed physician and other healthcare provider and payer groups to develop innovative ways of delivering on the need for greater efficiency and quality of care within the current reimbursement models. One way of doing this is providing focussed services to high need populations, leveraging technologies like home monitoring where it makes sense. Again Atul Gawande’s writings in the New Yorker, the article “The Hot Spotters” in the January 2011 edition focuses attention on the need to identify high risk populations and develop solutions for them leads to more efficient effective care. These solutions need to focus on the individuals with the problem, and the population health and cost benefits will accrue.

The USA in undertaking major healthcare reform, and we have watched how messy that has been. In parallel, and thanks to the fact that the ehealth investment is funded by economic stimulus funding rather than funding linked to healthcare reform it is also undergoing a major enhancement in its use of information technology in healthcare. Much is catching up, but there is a lot of underlying innovation, which will affect us worldwide. So it is very important we watch with great interest, and leverage from their investments in Australia and elsewhere.

I would love to hear your thoughts.

Harvard course comes to an end

January 29, 2011

As I sit at Boston airport waiting for my flight home I reflect on the last day and a half of the Harvard Leadership Strategies in Healthcare IT course I just attended.

Thursday started with a panel of hospital CIOs from the Boston area, three of the four were MDs, a uniquely Boston experience I would suggest.

Great insight into how they implemented EMRs in their hospital system, and survived.

It seems being a medico actually helps, but it basically requires the same soft personal skills that make a good doctor to be a good CIO, you just don’t call it bedside manner.

The next session was by CRICO, basically Harvard’s malpractice insurer. However they are pretty unique in that  are not a commercial insurer but basically a risk management research group within Harvard that not only covers malpractice costs, but actually analyses them and responds. They showed us some very impressive results. Their rate of paid claims was one-third the national average, their premiums up to one tenth the similar coverage in Miami for some specialists, and one fifth for obstetricians. They demonstrated how health IT enabled workflows significantly decreased risks for  various real life clinical scenarios including picking up abnormal test results.

In  the afternoon we heard from the CEO of EClinical Works, an EMR vendor who seems to be going gangbusters in the USA. His point of view was very interesting, and pragmatic.

We heard from the HIE in Massachusetts run my Mick Tripathi at finally we heard from Dennis Giokas of Canada Health Infoway.

Friday was a short day, starting off with three physicians telling us their experience in implementing EMRs warts and all, and ended with five of us from the course describing our issues.

The calibre of people attending the course was amazing, French professors, Canadian Standards gurus, American Physicians, government folk from Ghana, a very fascinating mix. Meredith and her colleagues who organised things kept us on schedule and moving like clockwork. John Glaser and John Halamka were great as moderators and never let the ideas slow down.

I highly recommend the course and look forward to the second week in May, by then there won’t be any snow on the ground so I may get a chance to walk around a bit as well.


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