No sooner have we had NEHTA tell us how much we can save from e-Health but now we have a second entrant to tell us something different and even more incredible.
The Australian Centre for Health Research has just published (April 2007) a 19 page document entitled “E-Health and the Transformation of Healthcare”.
For those interested in reading the full document it can currently be found at the following URL:
http://www.achr.com.au/pdfs/ehealth%20and%20the%20transofrmation%20of%20healthcare.pdf
The headline claims from the executive summary are as follows:
“The impact on the individual can be imagined; the cost to the nation is immense. In Australia, it’s estimated that improved knowledge sharing and care plan management for patients with chronic disease would generate direct savings to the health care system of more than $1.5 billion per annum. Savings to the community from associated non-health care costs are of the same order. And increased workforce participation and productivity could add a further $4 billion per annum to the economy.
For the patients, home monitoring could reduce emergency room visits by up to 40%, hospital admissions by 30-60% and length of hospital stays by up to 60%.”
All I can say is “Here we go again!
”The argument made in the paper is:
• Disease Management (DM) and similar process improvement processes work
• Technology and ICT is an important enabler of DM
• If we approach Chronic Disease with technology there is a huge benefit possible.
This is all true as far as it goes. There is also no doubt – from a huge range of studies mentioned in other reports not cited here - that Health IT can make a difference. However the evidence as I read it does not support the proposed approach.
The paper does however get one point exactly right in the following:
“The Paper raises one final, important point - that of incentives. There is a cost to building this connectivity and information sharing but there is a mis-alignment between those who pay and those who receive the benefit.”
And rightly suggests who should pay
“Another important component is for the major beneficiaries of more efficient and effective health care (that is, governments, private insurers, and employers) to provide incentives for the use of electronic services, broadband health networks, and best practice processes.”
Of course we have yet to see any offers from Government etc to really ante up what is needed!
In summary the suggested approach is:
“ We should focus on three important areas:
1. get healthcare providers connected to one another
2. track health events across the continuum of care
3. create a broadband network of health services
In business, most high priority and high volume communications are handled electronically. But in health care, high-importance communications – e.g. referrals and hospital discharge summaries – are created using paper and pen and delivered via fax, letter and even by hand.
This is the point where we should begin – simply, aim to get referrals and discharge summaries to be delivered electronically in a convenient and secure form.”
To be polite this is a spectacular over-simplification of what is needed to achieve substantial benefit. Sure, - I have always been very keen on aiding the flow of key clinical documents electronically – but for a lot of good reasons this should be done in a secure, standardised, managed fashion and not as seems to be suggested here by provision of simple connectivity.
Likewise the second and third focus areas are dramatically more complex than identified in the paper.
The document has a ready, fire, aim feel to it. It is of note that the only Health IT benefits study that seems to be cited is this one while there are many other much deeper and much more recent studies readily available:
DMR Consulting, “HealthConnect Indicative Benefits Report”, Final Version, February, 2004 (extrapolated to latest chronic disease data). This can be found here:
http://www.health.gov.au/internet/hconnect/publishing.nsf/Content/C50C3B807441ADBACA257128007B7EC4/$File/hcibrv1.pdf
This document was so unpersuasive as to the available benefits of HealthConnect that the Commonwealth commissioned a review by the Boston Consulting Group (April 2004) and this review resulted in the change of HealthConnect from a funded strategic program to nothing more than a “change management strategy”.
Let me be clear about the problem I have with all this. Realistic estimation of the value of benefits from Health IT requires a clear exposition of what technology is to be implemented and how it will then provide benefit. To not have a Strategy for what is to be done, an Implementation Plan that describes how it will be done and a realistic Business Case that identifies both costs and benefits no one is going to care to take notice of, or action, unsupported claims of benefits.
We have seen two claims for major benefits that can be derived from Health IT (This present one and the study mentioned in NEHTA’s recent presentations). It seems passing strange that the two studies identify largely different sources of benefits and seem to come up with wildly different estimates of what is achievable.
The flaw in both studies is that they don’t proceed from a deep understanding of the business of Health Services Delivery and are not informed by what is needed at the clinical coal face. Only once the requirements and problems of the sector are clearly identified can a strategy to deploy technology to assist be developed and have a chance of success. Implicit in the strategy will be the benefit opportunities that will need to be firmed up. This is what then needs to be refined through the development of the implementation plan and business case which will reveal where investment makes sense and can make a difference. The last step (not the first) is to estimate the quantum of benefits and develop the approach to be used to capture them as implementation proceeds.
As I have said before the work required to convince the hard heads in Treasury to invest is substantial and needs to be a comprehensive package (Strategy, Implementation Plan, Business Case and Benefits Realisation Plan).
Without this work being done to a high quality I predict just nothing will happen.
These half baked studies do more harm than good I believe.
David.
3 comments:
The headline claims which you refer to in the Executive Summary must be questioned.
So too should the two projects referenced in support of the author’s arguments be given closer scrutiny.
It would have been helpful and informative if a reference and ‘link’ to information on the Tasmanian eHealth Collaborative Project had been provided and cross-referenced in the end notes, particularly as Australian Centre for Health Research (ACHR) is an active participant in the project.
The same can be said for the WA Project referred to in an article in The Australian by Karen Dearne on 22 August 2006, ‘Health network Fragile’, in which she wrote “The federal Health Department's flagship Eastern Goldfields health broadband project has delivered "an extensive list of lessons learnt", but little else.” A reference to the Evaluation Report completed on this project would have been wise when using the project as an example in support of the author’s arguments.
There are many points made by Professor Michael Georgeff, CEO of Precedence Healthcare, that were an incentive to read beyond the executive summary of his “E-Health and the Transformation of Healthcare” dissertation. I will come back to those but I do share the view of your anonymous contributor that his reference to the Eastern Goldfields project in which he is a participant is more than interesting as a reference.
There is a project that became so consumed with the implementation of technical infrastructure that it forgot about chronic disease management and prevention and collaborative care for most of its chequered history.
The Intelligent Disease Management Service (IDMS), the new baby at risk of disappearing with the bathwater will drown because there is no overt consideration for disease prevention at the expense of the all too late “wellness monitoring for people with chronic disease and complex needs”.
The power of an Internet is unquestionable, the economic benefits of better compliance with care plans are credible, the tenet that SME’s involved in health care solutions should be subsidised by government is particularly acknowledged and warmly supported, and the need for widespread use of electronic referrals and hospital discharge summaries is a truism.
Where I run into difficulty with this paper is with the view that with a feverish technical “connectathon” systems will serendipitously produce a new world order that will see bits of health data gel into meaningful health information to improve the life of the diseased.
Small chance, methinks! To believe that out of the porridge the information management pathway for health care delivery will emerge without the support of standards-based health information, a credible primary health care Shared Electronic Health Record, a patient acceptable information privacy strategy, and semantic interoperability between systems is not believable.
There was a fleeting reference somewhere in this article to consumer access to clinical information. That’s where the power of the Internet will be greatest when both the healthy and the chronic disease sufferers have a way of getting engaged with their own patient health information that is tuned to their own health status from the comfort of their own desktop PC. Who has a better business case for optimising the health care they receive than a patient? Armed with the appropriate health risk information and electronic tools to support engagement with credible health care providers at their fingertips they are the ones who will lead the charge.
Provide this internet-based patient portal without standards–based approaches will defeat the initiative. Expecting that these standards will just precipitate “out of the ether” is fanciful.
In concluding, I am not sure whether Michael was advocating a HealthConnect data repository revival or something else, but whatever it was I have a sneaking feeling that the real transformation in e-Health lies somewhere between his view and those of NEHTA…and there seemed to be quite a gulf between the two approaches… Did I miss something?
Good to see that John Johnson has also decided to put his name to his comments (hi John - I noticed the reference to the baby and the bathwater.)
This is a complex topic, and I feel motivated to respond with a number of broad points rather than enter a debate on all the details. In summary:
* I don't think anyone would argue that there are some billions of dollars (annually) of potential savings available through improving the management of chronic disease
* The quoted savings figures do not need to be attributed to ICT to make a case for doing something
*Attribution to ICT is problematic and arguably as expensive as just getting on with it
*There is a case that ICT can assist in managing chronic disease, and this is what the bulk of Prof Georgeff's paper is devoted to
*The traditional approach to making a business case has failed us in our quest for an EHR – we need an innovative approach
*The Internet has provided both necessary infrastructure and a new paradigm to work with
*Standards are important and NeHTA's approach to standardisation is compatible with Prof Georgeff's proposals. In fact I believe they are co-dependent
*The infrastructure proposed to support IDMS could be used to support other initiatives, including health promotion and prevention
Supporting arguments follow:
The savings figures are variable and highly dependent on the model used to derive them. The point is that there are clearly savings to be made and benefits to be had. It is necessary to establish this to justify any effort at all. As David More points out, the problem of realising these benefits is highly complex and highly dependent on local factors, particularly the success of local implementation.
We need to find a way of allowing successful local initiatives to proliferate. The fact is that we have been trying to implement shared EHRs for more than 20 years without success using the traditional approach of making a business case and developing a comprehensive top down plan including detailed benefits realisation strategies. This has not succeeded. Perhaps it is time to try a different approach.
To back this up I use a sort of "thought experiment":
Imagine the IT infrastructure required to support the measurement of the cost and benefit of hip replacement as a treatment for fractured neck of femur. In Victoria, we have a casemix funding model for such interventions based on a quite well established costing model that gives a formula for the cost of the intervention, which is implemented in the patient administration system (the benefits are not really measured - they are assumed.) This system stands alone in the hospital using a separate database, and deidentified data is transmitted to the funding body. Apparently there is a business case for this, because the Victorian Treasury has recently invested in just such a system.
In an ideal world, this would be followed up with appropriate discharge planning and communication with the GP to ensure that complications are kept to a minimum. It is generally accepted that this would be beneficial, but processes for this are patchy, and electronic communication supporting this is the exception rather than the rule. The business case for the actual intervention does not rely on such communication, and there is correspondingly little action from orthopaedic surgeons and other hospital based medical staff, or governments, to address the issue. There is evidence to support the notion that improved discharge planning and handover improves outcomes, but it is difficult to make a business case for the development of the infrastructure (and standards) required to support this application beyond localised and incomplete solutions. There are many examples of successful implementations limited to a particular environment, but it has proven difficult to replicate these local outcomes outside their breeding ground.
Overall, it is extremely difficult to identify healthcare cost or outcome benefits and attribute them to broad ranging ICT initiatives such as those required to assist in chronic disease management. In fact, I think it is so difficult that the cost of gathering and analysing the required data would approach or exceed the cost of implementing an infrastructure such as that proposed by Prof. Georgeff. I think the sensible thing to do in this situation is to reconsider the approach to making a business case. Firstly, I think it is important to establish a case for taking some form of action. I think this is the real point of the savings figures that are frequently quoted. Here are some more:
The Productivity Commission report on National Reform Agenda (2007) estimates Direct Healthcare Savings for better prevention/management of chronic disease could be $4 billion annually.
The same report estimates better prevention/management of chronic disease could be worth an additional 175,000 FTE to the workforce or approximately $5.4 billion annually to GDP from increased workforce participation and productivity.
It is important to recognise that I am not claiming that these benefits could be realised simply by implementing an ICT solution. They are a statement of the potential savings that could be made through improving management of chronic disease. I don't believe the DMR report was faulty on the grounds of potential identified savings, although I agree that the fact that it attributed so much of these savings to the EHR was silly. If a traditional business case were easy to make, then I'm sure that DMR or some other wise consulting firm would have nailed it by now. There has been plenty of motivation, both in potential opportunity (there are on the order of billions of dollars per annum in potential savings available to encourage action – I don't believe this is still at issue providing it is recognised that not all these savings would be a direct result of ICT initiatives) and in direct government funding. I think most of the difficulties relate to the expense of gathering reliable data to measure benefits in a way that can be directly attributed to the implementation of ICT initiatives.
A separate argument is required to make a case that ICT can be used to assist in improving the management of chronic disease. I believe that the main focus of Prof Georgeff's paper is that an innovative approach is needed to break the deadlock we currently find ourselves in, and allow us to start implementing scalable solutions that can be replicated across the country.
The internet provides us with some opportunities;
Firstly, a telecommunications infrastructure supported by a base layer of widely implemented standards that makes it possible to implement systems that transcend the traditional healthcare silos
Secondly, some examples of successful applications that break the traditional rules for business cases and that provide a new paradigm for implementation of ICT solutions that cross traditional organisational (or personal) boundaries.
I think that a major component of Prof Georgeff's message is that the hardest part of the battle is to establish connectivity. He does not argue that standards are unimportant, or that it is enough to simply connect people and let them sort it out for themselves. I think he is arguing that we need to start somewhere, and that none of the benefits of the Internet paradigm are available unless the players are connected. He goes further, and says that:
“None of this is difficult, either technically or from a change management perspective. The information may be non standard, incomplete, and may, in some cases, be difficult to interpret. But this will drive users to adopt standards and, as they do so, more and more of the information will become understandable and more and more will become machine interpretable. Incrementally, a full EHR will emerge.
In reality, more complexity is required behind the scenes. Authentication and control of access rights require some sophisticated software, as well as agreed processes and authorities for controlling digital certificates and providing unique identifiers for consumers and providers. Privacy and consent must be carefully handled, allowing consumers and care providers to determine what is and what is not shared. There must be facilities for audit and non-repudiation must be guaranteed. But none of this is a barrier—the solutions already exist.”
(page 13, 2nd and 3rd last paras)
I have always believed that the best standards are those that are tested through implementation. I don't believe that Prof Georgeff is arguing that standards work is unimportant. I think he is arguing that standards will not be successful unless there are drivers for people to adopt them. A national standards body such as NeHTA is a critical part of the whole story, and I don't think that this is inconsistent with Prof Georgeff's approach at all. I think that the approach is to use the standards we have now (especially TCP/IP along with the necessary security standards!) to provide an environment that allows standards for content to be tried in practice, with those that succeed being adopted and promulgated. This will be an ongoing process, as it is with other standards on the Internet. As such, I don't believe that there is a gap between Prof Georgeff's approach and NeHTA's. Rather, I think that they are interdependent, NeHTA needs feedback on implementation of appropriate standards, and Prof Georgeff's approach requires a set of basic standards to promote connectivity and interoperability. There are some particularly important standards relating to identity management, digital certification, technical security including encryption, and security management (not forgetting physical site security) that are essential when considering using the Internet for healthcare information.
John Johnson, you know that prevention and health promotion are topics close to my heart. Here is a reprise of my “thought experiment”:
Let's look at the infrastructure required to measure the benefits of providing health promotion, preventive screening and primary care. The aim in this case is to stop people from suffering from the fractured neck of femur in the first place. It is interesting that these approaches are already employed and funded by government (the "Go for your life" campaign in Victoria is an example) even without a traditional business case. Anyway, in order to make such a case, we would need to establish a longitudinal health record for everyone containing summaries of contacts with healthcare providers and collecting information relating to behaviours known to be associated with lowering of risk for fractured neck of femur (it would arguably be beneficial to collect everything we can – who knows, something outlandish like a history of eating cashews could be suspected of involvement one day.) This would allow us to look at the lifelong profile of people who required surgical intervention for fractured neck of femur and compare it with a similar cohort of those who did not. Hopefully, this (or other similar data mining exercises) would allow access to information supporting a clear business case. The moral of this story to me is that (going beyond the specific example and looking at the broader primary care environment) the infrastructure is required to make the business case for building the infrastructure. This is like a Zen koan. And I don't think Treasury likes them very much – too New Age.
This does not mean that the infrastructure required to support something like IDMS could not be used to support health promotion activities, just that we have to start somewhere, the potential savings for Chronic Disease Management are well studied and generally accepted, and it is at least conceivable that some of the benefits and savings could be attributed to ICT initiatives.
In summary, I believe Prof Georgeff's approach is not to focus solely on getting truckloads of money out of Treasury for a killer solution that solves all the problems, but in setting up a framework (involving technology and incentives) that, like the Internet, drives innovation and private sector investment. It would also, by supporting development and implementation of standards and best-of-breed applications, support dissemination of best practice models of care into the health system.
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