Posts Tagged ‘ehealth’

Does Australia need another EHealth Strategy? The need for ehealth education for all doctors.

October 21, 2013

Last week I presented at the Menzies Centre for Health Policy conference at the University of Sydney.

My topic was “Does Australia need another EHealth Strategy?”

The focus was on the need for clinicians to be educated in ehealth, as it influences almost every aspect of healthcare delivery today. Without a well educated and supported group of people with a real healthcare background, we will not be able to deliver a real solution that utilises technology to deliver better healthcare.

Below are my notes for the presentation. I look forward to your comments.

Australia’s healthcare system is recognised as world class by any international comparison, and it use of information technology has been also been commended by many international think tanks. So at first glance it would appear that Australia is doing OK in the world of ehealth. Like most things there are two sides to this argument, and whilst I do not want to take away from Australia’s success to date, I propose that in fact we need a radical rethink of the national ehealth strategy to enable us to improve our healthcare system and take advantage of the improvements of technology that are taking place whilst ensuring the quality and safety of our healthcare system.

First, let’s define what we mean by ehealth. If we use the definition used by the WHO. The define ehealth as the transfer of health resources and health care be electronic means. Simple enough, take a doctor, or other health professional, add a computer, and the result is ehealth. Today that basically means that almost every healthcare interaction from primary care through secondary care, acute care in a hospital, public health interaction, all the way through to healthcare funding at the highest level is to some degree affected by ehealth. Very few if any healthcare transaction today does not have the involvement of a computer somewhere in the process. In reality ehealth is probably involved in several steps, which is why it is very important that we have a cohesive strategy about its use.

What do we mean by strategy. It is both a policy and an actionable plan to deliver on a goal using the resources we have available. A strategy needs a goal, and to be relevant to healthcare that goal needs to match the goals of the broader healthcare system. I put it to you that an enviable goal for ehealth, and the healthcare system in general is the Triple Aim of the Institute of Healthcare Improvement. To improve the patient experience of care, including quality and satisfaction, improve the health of populations, and reduce the per capita cost of health care. I believe that at any health interaction all healthcare providers will have at least one, most likely two, and possibly all three of these goals in mind. In the chain from patient to provider to payer all three of these aims should, at some stage, be top of mind for someone in the system. I believe ehealth should share these aims.

Australia has made attempts at developing a national ehealth strategy before. In 2008 the federal government embarked on an ambitious program to develop an ehealth strategy and integrate it within the broader healthcare and information technology strategy of the nation as a whole.  It was an idea worthy of congratulations, and also some early celebrations.

Prior to that ehealth strategy was left pretty much in the hands of the people implementing the technology. As it was deemed they had been successful in implementing ICT in other domains, it was assumed that they would be able to deliver it in healthcare as well. To many people healthcare was put up as just another industry that would benefit from the transformative powers of technology to make it more efficient, more accountable, and more effective. To this day we hear the comparisons, usually in derogatory terms, between banking and healthcare. We can do our banking on line, or through a hole in the wall, why hasn’t healthcare delivered the same value from ICT?

For some aspects of healthcare that analogy makes sense. If we look at the payers then to a large degree that transformation has occurred. However when it comes to actual delivery of healthcare we are looking at a much more complex interaction than any banking or retail transaction that involved not just the transfer of data, but also some very advanced decision making involving anatomy, physiology, pathology, psychology, sociology and even a bit of economics. Balancing the various sciences and arts involved in healthcare delivery has been recognised as far back as Hippocrates who said, “there is art to medicine as well as science”.

The main problem with our ehealth strategy to date is that we have failed to recognise this art aspect of healthcare, and have feverishly worked on the data side of things in isolation. Data is important, and it is critical that we recognise its value, but in relation to the healthcare interaction, not in isolation. This is an appreciation healthcare providers develop over their professional careers, which unfortunately we have not captured in our current ehealth strategy.

Let me use the Personally Controlled Electronic Health Record as an example of this. It was one of the main aspects of the recommended ehealth strategy that was taken up and used to spearhead ehealth in Australia. From a data perspective it makes a lot of sense. One point of reference for all information relating to a patient’s health history should enable all providers to collaborate more effectively. From a data base expert’s perspective, that makes sense. However from a clinician’s perspective it offers a different potential, and from a patient’s yet another. The challenge is to develop a system that meets the requirements of the key players, the patient and the provider. To do that they need to be actively involved in the development, and they weren’t to the degree they should have been.

I don’t blame the government, or even the developers of the system for this. I think we need to recognise as healthcare professionals that we should have been much more vocal and collaborative early on and taken charge of this project, and ehealth in general, and not let it be delivered to us by unrelated ehealth agencies.

We saw similar issues in the development of telehealth recently as well. We let the bureaucracy responsible for payments take control of the strategy and implementation, and as a result saw a system designed to meet one of the triple aim’s goals, reduce per capita cost, but without paying more than lip service to the other two.

I put it to you that the greatest failing of our ehealth strategy has been our failure as healthcare providers to take control of it. In hindsight we complain about what we have received, but in reality we should have been leading the initial thinking about the strategy, the development of the strategy, and the implementation of the strategy to ensure it delivered on its promise.

But it is not as simple as that, very few problems ever are. The greatest impediment to clinical leadership in ehealth is lack of skills. We are not taught the basics of ehealth or technology at medical school. It is assumed that because we have an email address we understand the intricacies of health informatics. We have no career path for those clinicians who do have an interest in the area, no recognised post graduate training, certification, job prospects. Whilst we have progressed well in many other aspects of healthcare science and policy, we have not in ehealth because we do not recognise the need for proper education and career progression for healthcare providers in this area.

Other countries have. In the USA you can receive board certification in clinical informatics, and there exists the equivalent of a learned college for such professionals. Hospitals have positions for Chief Medical Informatics Officers, and Chief Nursing Informatics Officers, and department dedicated to the delivery of better health outcomes through ehealth. In Hong Kong when they developed their ehealth strategy they developed large clinical coordinating committees led by clinicians provided with support to develop a strategy and implement it.

In Australia we need to foster the education of our healthcare professionals on the role of technology, how it can be used, and how they can be more involved. This requires that they all have at least an introduction to the science of health informatics and the opportunity to integrate it into their clinical careers. I am not suggesting that we need an army of health informatics academics, but we do need many more health informaticians from the ranks of the various healthcare providers to enable us to develop and implement a strategy that will deliver on the triple aim for patients, providers and payers in the healthcare system.

The Art and Science of Digital Medicine from TedMed Sydney 2013

April 30, 2013

I recently had the privilege to present at the inaugural TedMed Sydney event held on April 20 2013 at the University of Sydney. This was a satellite event for the larger TedMed event being run in Washington DC. It was a particularly exciting as I was speaking back at my old Alma Mater, I studied medicine at the University of Sydney. To make it even more special I was speaking in the same session as Professor Martin Tattersall. Professor Tattersall is a legendary physician at the Royal Prince Alfred Hospital where I trained. He is recognized for his clinical skills and his humanity. He was the oncologist who looked after my mother during her 2-year battle with lung cancer, and I will never forget the kindness he showed her and us during that time.

The problem with TED talks is that the go very quickly. I had prepared a speech, but on the day the adrenaline kicks in and the clock ticks down, and I suspect I may have missed a few of the salient points I wanted to say. So below I have my prepared notes, which I hope emphasise the point I wanted to make. When the video becomes available I will post it too, so you can compare the two.

The Art and Science of Digital Medicine

Dr George Margelis

I love gadgets, I am unashamedly a geek. My first Personal Computer was back in 1981, a Sinclair ZX81, since then I have gone through multiple iterations, and today I have 3 computers and 2 tablets on my desk with 3 redundant internet connections. So as you can see I am not a Luddite.

Today, to paraphrase Marc Antony in Shakespeare’s Julius Caesar, I have come not to praise technology, but to bury it.

Over the last decades many entrenched myths have developed about technology and healthcare. They are based on good intentions, and a common desire to do the right thing. However the net effect has been wasted money, wasted energy, and wasted opportunity.  But that is not the worst of it. The real problem is that people who we could have helped, if we had done it right, were not being helped. We were breaching the very basis of the Hippocratic oath, First do no harm. We thought we were doing the right thing, but in practice we weren’t.

The first myth is that technology will save the healthcare system. We have heard that it will save the healthcare system billions of dollars, prevent thousands of medical errors, solve the challenge of chronic disease, and even stop childhood obesity. Because, as my technology colleagues have told me, these are just the fault of a flawed healthcare system run by greedy doctors and poorly managed patients, all of which can be solved by the right app on their phone.

They are Wrong. Healthcare is a complex endeavor, balancing human physiology, psychology, sociology and economics. Technology is a powerful tool we can use to effect many aspects of healthcare, but ultimately healthcare is a very personal endeavor. No app or device alone will change that. In fact, technology has the potential to amplify our problems in a way humans just cannot. For the technologists their desire to simplify everything to data flows is their greatest weakness.

The second myth is that the development of new technology, that is new gadgets that we see being released on a regular basis will drive innovation in healthcare. New tablets, phones, sensors, imaging devices will lead to innovation. Again wrong. Innovation in healthcare is very different to invention. Each new gadget, is a new invention. It is only an innovation when someone does something better with it. A faster chip, a better screen, a new program are all great inventions, but until someone takes that capability and delivers a healthcare outcome using it, it is just another shiny bauble by the bedside.

The gadgets are not our enemy, they are our tools. As with any tools, in the hands of the right person they can make beautiful art, and in the wrong hands they can create havoc. It is our responsibility as the healing profession to ensure they are used well. The challenge we face is that the technology for gathering information has overtaken our capability to utilize it. It is up to us to speed that up, and at the same time simplify it. We hear about big data, it is up to us to turn it into good data.

That is where you come in. The doctors, nurses, allied health workers, medical administrators. You need to identify the problems, and use the gadgets to make the improvements. You need to take charge, and stop believing that the latest device will solve your problems, because the people who make that gadget have no idea what your problems are

However, it is not all about the doctor. The greatest change in healthcare is the rise of the E-Patient. The E has many meanings. Empowerment is the key to better healthcare, so the Empowered Patient is one of those meanings. The key to power in the past has been access to knowledge. For centuries locked away in medical libraries and arcane journals that knowledge has now been freed by the power of electronics. So the Electronic Patient is another meaning, because thanks to the internet and the computers that have made the world’s knowledge available via the press of the button the doctor can no longer hide behind their shield of knowledge. Again, the electronics is but a tool. The real innovation is in people making that knowledge available and accessing that knowledge, and using it to improve their health. A journal article in itself will not make anyone healthier, but accessing it and changing your actions based on that evidence will. Technology can make the knowledge more accessible, but like the proverbial horse to water, it can’t make you drink from the fountain of knowledge. Education can, so the third E is for the Educated patient. Not in the classic K-12 sense, but in health literacy. No doubt the two are related, but unless we ensure the health literacy of our population is improved all our efforts in healthcare reform will be wasted.

The E-Patient along with the E-Doctor and the E-Health system can change healthcare. By combining the art and science of medicine with the art and science of technology we can develop solutions to our healthcare problems. Separately medicine and technology cannot. Each can make a difference, but when combined, with a deep understanding of what we want to achieve, the potential is limitless.

To do this we need to develop a clinically focused innovation model that combines the two. Doctors need to understand technology, and technologists need to understand healthcare. We need to make sure we are working towards a common goal, healthier and happier patients. To do this we need to collaborate. This sounds simple enough, but we come from very different worlds. For us to collaborate, we must first cohabitate.  We need to bring technologists into our domain, the hospital, the clinic, the labs. We need to introduce them to who we work with, our patients and their families.

They need to understand how we work, how we think, and how we accept that sometimes, despite our best intentions, we can’t solve all the problems. The art of medicine is as much to know when to stop, as it is to keep going.

In technology there is only one direction, forward.  We can learn from that, and develop the burning desire to continuously improve what we do. We can learn to measure more, analyse more, think more before and after we act.

At the intersection of doctor, patient and computers lies the brave new world of digital medicine. It is our responsibility to take charge of it and mold it into a tool that can deliver on the triple aim: Improve the patient experience of care, improve the health of populations, and reduce the per capita cost of healthcare. We can’t do it alone, but we can lead it, and it is our responsibility to do so.


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