The More Things Change - The More They Remain the Same

The following is an article - unchanged - I wrote in late 1999. It is amazing to see how little has changed!

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Opportunity Lost – Health Information Technology in Australia : 1970 – 1999

In 1986 I was walking home late at night from a large public hospital having just lost the battle to save the life of a young man whom my colleagues and I had been working on for a number of weeks. As I mourned the loss of this young life I, not unnaturally, wondered was there anything I should have done, I had omitted – or were there things I had done that had led to this sad ultimate outcome. A search for such certainty is a natural and appropriate activity for any responsible and caring clinician, but as I later came to realise, attainment of such certainty is ultimately not achievable, or even approachable, without automated help. As I walked I comforted myself by recalling that, while I was in charge of the Intensive Care Unit for that week, others had been in charge in previous weeks and they had all helped and offered advice and skills during the last few days. That the final outcome was not totally on my shoulders offered some comfort.

Why raise this story? The reason is that at the time of this story I was, as you might say, at the peak of my clinical powers. I had been trained for nineteen years since I had left school, had two clinical fellowships and a PhD and a little over a decade’s practical experience. But I was still unsure. As I reflected further I realised there were two elements forming my dilemma - firstly, that total certainty was impossible and secondly that the management of the knowledge of medicine, and especially its dissemination, was far less than perfect.

Move on to the present day – what do we see? We see a profession that has even less certainty and confidence than 15 years ago. There is evidence of a progressive loss of public confidence in the profession, the cost of medical professional indemnity insurance is soaring, professional satisfaction seems to be waning and all agree that the national public hospital system is in a mess. Worse still, thanks to the work of people in the field of clinical quality improvement , we now know for certain that the quality and consistency of care are far below what the ordinary man would see as acceptable levels. Indeed public expectation for perfection is now so high that when the College of Anaesthetists released their recent report on anaesthesia related deaths for the period 1994-1996 that showed some 135 deaths related to anaesthesia from over 8 million anaesthetics provided (1 per 63,000 procedures), there was intense media and public concern. That such an extraordinarily good outcome should be seen so negatively shows how far we have moved since the days, less than 50 years ago, when death rates of 1 per 2,000 procedures (Beecher & Todd, Annals of Surgery, 1954) were seen as totally unpreventable.

All this is made worse, as far as the ordinary doctor is concerned, by the escalating pressure from Government to take steps to improve quality and consistency, while reducing costs. Meanwhile, these doctors are not being provided with the supporting and enabling tools to achieve the desired outcome and are paid on a basis that provides very strong incentives to deliver quick care to maximise the doctor’s income.

In 1997, while working with the IBM Consulting Group on a study for the Commonwealth Health Department, a colleague and I analysed the benefits for the total health budget that could be realised if some small technology enabled improvements were to be implemented. We costed the impact of the fully funded introduction of a General Practice Clinicians Workbench with the sole function of providing electronic prescribing. (This involved using a computer to keep track of the medicines a patient was on and then, as required, producing prescriptions for that patient. The computer was able to both produce a neatly printed legible prescription while at the same time making sure what was being prescribed was both reasonable and safe – a side benefit for the doctor is that repeat prescriptions can be produced very quickly and easily). The cost was estimated to be in the order of $100 million over two years, with the direct cash benefits to the Government flowing from the reduction in prescribing errors and their sequelae of the order of $800 million over five years (the economic life of a desktop computer).

In addition to the benefits specifically related to Electronic Prescribing, there are a range of benefits which will flow as Electronic Prescribing is essentially the “pathfinder” application leading to the use of computers in other aspects of the patient consultation process. A now dated review (Sullivan F & Mitchell E, BMJ 311: 849 1995) of the worldwide experience, and the UK experience of the impact of the $A100+ Million the UK NHS spent almost five years ago on primary computing, reached the following conclusions based on a review of all available literature:

· On the downside, Use of a computer during consultations in the UK occurs in 55% of consultations and this use lengthens the consultation by between 48 and 90 seconds.

· But among the good news was that use of the computer improves immunisation rates between 8 and 18% and that;

· Use of a computer also improves the carrying out of other preventative tasks by up to 50% (eg mammography, Pap smears etc).

· Additionally it was found that use of the computer did not have a significant negative impact on patient satisfaction.

To obtain such major improvements in preventative activity would be of considerable importance in having Australia reach the goals set in the Health 2000 Initiative, and would represent immense overall value to the community as a whole (probably as important, if not more so, as the financial benefits identified above).

Sadly we find ourselves in a situation where, some four years after the study was given to Government, we are still moving at a glacial pace, nothing fundamental has happened and an opportunity cost of almost a billion dollars has been incurred through inaction. Even more worrying is that the present Federal Minister, Michael Wooldridge, has been saying publicly and privately that something needs to be done for at least three years and has been vociferously supported by both the AMA and the College of General Practice. Yet it appears that no coherent action has been taken or even planned.

If confirmation was required of the basic correctness of the general assertion that having doctors use computers to assist them deliver improved care, one has to look no further than the ‘Mother Country’. In the UK – a country not famous for being at the very forefront of IT Innovation – they have recently committed (September, 1998) through their strategy “Information for Health - An Information Strategy for the Modern NHS 1998 – 2005 ” to spend $A2.4 billion over seven years to achieve the following objectives:

· a lifelong Electronic Health Record for every person in the country.

· round-the-clock on-line access to patient records and support of best clinical practice, for all NHS clinicians.

· a National Electronic Library for Health to keep doctors and nurses, and other clinical professionals up to date with the latest clinical research and best practice at the time they need it.

· delivery of integrated seamless and properly co-ordinated care for patients through GPs, hospitals and community services sharing information across the NHS information highway.

· fast and convenient public access to information, advice and care through online information services and telemedicine.

· more effective use of NHS resources by providing NHS planners and managers with the information they need.

It is clear the UK sees this investment as a strategic move to dramatically upgrade the effectiveness of their national health system, and it is equally clear they would not be prepared to provide the scale of funding planned if they were not certain they would achieve major improvement both in financial and clinical outcome terms.

Back home, however, we find ourselves in a situation where we have an obvious and worsening problem – information overload for medical professionals, a ready solution in the form of automated clinical desktops, and the public in the middle are getting care of a quality and consistency considerably less than is possible. As a side issue, we also see spiralling health costs, related, in part, to a failure to leverage the efficiency and quality benefits obtainable from structured and properly planned implementation of appropriate technology. The fact that expenditure on technology to support the front line care givers may, on occasion, be dramatically more effective than simply hiring a few extra doctors, nurses or administrators, has clearly escaped many of the health system’s leaders.

So what, you may ask is actually going on, and why is the situation allowed to continue? The answer, I fear, is a combination of factors, but at the top of the list there must clearly be some degree of lack of professional and governmental leadership. Additionally, as is always the case there are some financial and structural issues as well as what may simply be termed the ‘well it doesn’t look too broke, so we won’t fix it yet’ attitude of those in the health system. This is despite the increasing concern of the public at large.

Let’s start with money. We have here an instant problem. Implementation of the systems and infrastructure to achieve the UK NHS goals would be quite expensive, probably $250+ million over 1-2 years. While a very compelling business case can be made that the money would be recovered many times over – no-one in authority seems to have a strong inclination to authorise that scale of investment. Sadly, even with an unassailable business case straightforward action in this area is not easy because of the Byzantine complexities of health funding in Australia, sourced as it isfrom federal, state, private and personal sources.

Easy you say, have each doctor pay for their computer etc as they are the user and all will be well. Maybe just sweeten it a bit with a payment or two for some specific computerised information on a monthly basis and they will all be off and running.

Think again – our health system – at the GP level – largely rewards not quality of care but rapidity of care – the faster you can get them through the more you make! Worse still, using a computer slows you down a little to boot. The final blow to GP enthusiasm for automation is, of course, that while there may be some small benefits to offset the inevitable slowdown caused by automation the major benefits derived from the system (e.g. less drug interactions caused, higher vaccination and screening rates etc) are for the Government and the patient. The doctor is no better off, except for the feeling of practising better medicine, and has all those ongoing costs – even if the initial leap, and expense, has been taken.

A third option might be to have the patient pay an extra 20 cents, or whatever, a visit to have the guarantee of being reminded when the next vaccination and screening procedures are due and being warned before taking potentially incompatible medicines.

Without denying that there are a number of GP’s who, for their own reasons, decided to computerise some aspects of their practice (50%+ with accounting and about 15% for some clinical functions), the step that will really make the difference is to ensure that there is a fair and equitable split of the benefit between Government, patient and GP. This can be most simply achieved, in my view, by developing a rebate for computerised activity on the part of the doctor and use of some appropriate federal funds to develop and appropriate secure health information network infrastructure (The Health Insurance Commission has wanted to do this for years –as have the telcos). An example may be an extra 50 cents rebate to the doctor for each patient encounter that is properly recorded in an approved computerised system. In this way the patient receives all the automated alerts and warning important for ensuring the quality of their care and the practitioner does not feel pressured to rush through the computerised parts of the consultation. As an inevitable side effect of this we reduce adverse drug events, improve vaccination and cancer screening rates, have prescriptions that pharmacists can read and have much enhanced medical record keeping which can later feed into research and teaching. I see this is a very small price to pay for a dramatic and sustained improvement in the quality and consistency of care in key priority areas.

In summary, Australia Health Information Technology is in a Mexican Standoff. Those who want the benefits don’t want to pay, for whatever reason, and those who need to use the technology for the good of their patients mostly won’t do so without some financial incentive to ensure their incomes are not reduced. The logjam needs to be cleared by some decisive leadership and development of a clear forward strategy that all stakeholders can be comfortable with and see is in their interests. Fortunately it is clear that there are a range of rational and effective national strategies that could be developed which would make all the stakeholders winners, and thus minimise implementation difficulties. The background work has all be done, it is clear the benefits are there to be had, all the pilot studies we need have been conducted and evaluated and the time for decisive coherent action has arrived. If ever my younger colleagues are to feel confident and sure of their capabilities to face the knowledge and information challenges of the new millennium the time to start is now. I hope someone will act soon, for all our sakes.

David G More – October, 1999

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The only thing that has changed is that the evidence for all the claims made above is now vastly stronger!

David