Guest Contribution – Patrick Gallagher – e-Health Veteran and Consultant.

Our guest today is Mr Patrick Gallagher. Pat has been involved in all sorts of activities which have focussed on trying to actually have e-health deliver on its promise. He is presently the principal of his own consulting company that has clients both here and overseas. He is also the chair of Standards Australia’s IT14-10 Committee on Health Industry Supply Chain.

Contact:

Casprel Pty Ltd
e.commerce, e.health, e.change
Process, Practice and Technology solutions and advice

He can be reached at casprel-at-attglobal.net.

Take it away Pat!

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A prescription for many ills:

Take 3 chains with confidence

For a long time I have been informally debating my admirable friend David More on e.health matters. Not that we disagree on the big picture, just the pathway to the end of the rainbow. He is intellectually rigorous in all things, based on clear planning and detail, while I am impatiently, a step at a time, just do it, guy.

David contributed an enormous amount to the issues I feel strongly about, when way back in 1996 he led the team that produced the pivotal study and report on the emerging application that has become known as electronic prescriptions. The report, commissioned by the then Health Department became commonly known as the IBM Report. I have always thought of it as the David More Report.

So when David asked me to contribute to the Blog and have a good old rant, where to start, and where to end, wasn’t hard to decide.

Hereyago David – my serve

The average dictionary has a half page of very different meanings of the word ‘chain’. Mostly to do with metal, jewellery, groups of retail stores and so forth; the meaning referred to here though is that of ‘continuity and coherence’ of activity to a common end, or working together ‘in a set series of steps towards a shared goal’.

And the foundational chain this article will discuss is the health sectors very sick supply chain. Noting that a supply chain is not a freestanding function, but a service to some other function.

In the health sector an efficient supply chain needs to be a fully linked activity to the clinical chain that in turn comes together in the recording and financial chain and all linked in the interest of patient care.

Our health system today still has by and large, three separate systems. As such, the focus on health records of some sort remains firmly focused on the top down approach. That is a medical history linking back to clinical activity by recording some standard of terminology with little regard to how the consumed or used product will be linked-in to the end process. The most typical is the discharge summary in a hospital, or the prescription in any and all pharmacy situations.

In computer-speak this is the seamless exchange of common data between interoperable systems. Or, moving data from one machine to another machine without a human re-working and re-keying the data.

A simple series of data processing steps that retailers do, oh so well, while the health sector does it all oh so badly.

Direct comparisons of information management in the supply chain practice and other business processes between say a ‘Colesworth’ and a hospital are stark indeed.

A similar eye opener is to compare the performance of a hotel organisation to an average hospital, where the difference in information management outcomes is night and day. Yet the underlying start and end point of accommodating a guest and a patient are very similar.

Pundits are quick to say health, and hospitals in particular, is a complex beast. Certainly the events in a hospital are far more important and sensitive than what one does while relaxing in some hotel on holiday or when on business. But is the information gathering and sharing more complex? No it isn’t.

What is complex in a hospital is the tribal-like disparate relationships and Chinese-walls that prevents all of the common data being captured and used universally. By means of seamless electronic reticulation. Big words that any hotel would call routine information sharing of core data.

Mountains of anecdotal evidence aside, my own experience some years ago was to be asked eleven times for my basic details of age and address in a six-day stay. Simply archaic.

For something that is relatively simple the machinery of supply chain management is a deep, if not totally boring, mystery to many health sector administrators.

Perhaps it is a situation where clinicians are perhaps too intelligent to be bothered by the simple art of supply management. Something they feel is better left to the guys in cardigans to do perhaps.

Yet, having the right product available for clinical use is a fundamental part of patient care and is therefore something that should be done efficiently and in an interoperable manner.

Leading to the question of - ‘when is the supply chain a clinical chain matter’? In every sense and certainly in terms of patient safety the answer is - all the time.

When it comes to money the picture gets quite grubby. There is any number of global studies over the past ten years that constantly tell the story of wasted funds related to poor supply practices. The largest examples are in the USA where it is estimated that up to 15% of product purchased for a patient is never used by or for a patient.

If that is true then the proportional '‘waste'’ in the Australian system would be around $2 billion per annum.

Moreover the USA reports estimate that 90 000 American are victims of lethal episodes of medical misadventure a year. Incorrect product usage or error in product selection comes second only to misdiagnosis in accounting for most events.

Wrong product usage is clearly a supply chain factor, or more correctly a unique product identifier factor. Management requires a ruthlessly efficient cataloguing maintenance service to underpin the supply chain data exchange, of the many steps between source of supply and point of consumption or use.

Why is this so bad still in 2007?

The usual explanation is the conga line of experts who always say that health is ‘complex’ and that’s that. All too hard.

Emphasising that patient care, privacy of data and security of information exchange is paramount and is different to any other sector. But these are parameters that many sectors of the economy manage daily; the ATO, Defence Department, the banking industry and insurance sectors to name a few. And do it for a far larger audience than just those of us that are sick

Electronic Information exchange is a practiced and reliable art outside health. Why not inside health? Management of information isn’t complex; the problem lies with people. Hospitals are indeed complex, consisting as they do of complex communities of interest with everyone’s individual discipline or interest at the forefront of the common interest.

Again an overly simple analogy is the hotel comparison. When a guest is processed anywhere in a hotel the staff practice is to see the guest as ‘our guest’.

In a hospital the more common view is – ‘this is my patient’; and my patient’s information is mine to use and protect.

Of course what has made this situation worse, over the past decade or so, has been the silly implementation of closed-off proprietary computer systems. Systems that, again in jargon-speak, are non-interoperable.

Yet, still, the focus of our interoperability saviours is on the technology. Usually explained with such gobblygock that it all ends up as useless pap. But with a lot of well remunerated advisers happily waiting for the next ‘study’ tender to be announced.

Meanwhile it isn’t technology that is non-interoperable; rather it is people and their behaviour that needs to change. And in changing things for them, it must be made better, more convenient and not less so as is often the case.

So in 2007 in the average hospital the computer links between supply, pharmacy, wards, theatres, pathology, radiology, administration and accounts are all too often a set of separate chains of babble.

It is scandalous that is 2007 we still have a mismatch in information structures that can only be made interoperable by a human re-writing (just awful) or re-keying (plain silly) common data between systems and in so doing make mistakes. That in turn makes the situation more farcical than it ever needs to be in this day and age

Anecdotal tales, tall and maybe true, of patients getting bills months after they are discharged are infamous. But in reality this is more or less to be expected because while a Hilton chain can do ‘it’ instantly the hospital takes months to reconcile the product-related ‘minibar’ bills from many sources with different systems essentially recording the same things in a different manner

So let us take a quick benchmark of your world:

· is the supply chain system integrated into the daily clinical care system

· to patient records, and

· to accounting procedures?

Answer yes and there is not much point in reading further.

Answer no and the pressure on how to fix the problem will only intensify in how to meet the challenges of seamless information exchange as the demand for e.health applications grows.

That is to do ‘it’ once, and electronically share the information, without unnecessary re-keying and re-working of common data. In our health information chains it needs to be an everyday, commonplace happening as it is elsewhere.

The one underlining-driving factor is the ‘Internet’ word. It is the Internet that is, and will continue to drive change more than any politician, or bureaucrat, consultant or computer sales person ever will.

The business use of the Internet requires standards to exchange common content data, in a common template for a common purpose with a common set of rules. As opposed to say using the Internet by an individual buying a book or booking a seat on an aeroplane, online.

The frustrating fact remain that Australia is a leader in worldwide health informatics standards setting, while we remain hopelessly delinquent in the critical mass use of the standards we develop.

Take electronic prescriptions. A medical application that links a product from a prescriber to a dispenser to a patient, to a record and onto a payer.

A classic case of the supply chain meeting the clinical chain and ending in the reporting and accounting chain for the good of a patient.

The prescription as an application touches more Australians than any other procedure, yet the public have not been made aware of the benefits to be had by electronic processing of this most basic service of the health care system.

Consider this. Ten years ago Australia was the leading developer of ISO facilitated e.script standards. Meanwhile in 2003 Standards Australia published the complete set of e.commerce document standards for the health supply chain. Moreover eight years ago an eminent committee of thirty experts agreed a template for standardising product databases and catalogues in Australia. Where is all this collateral in actual use? Well, almost no where.

Meanwhile in Denmark, in Holland and in the UK, 90%, 70% and 50% respectively of prescriptions are now routinely exchanged electronically over the Internet. And Scandinavian hospitals can reconcile a medical mini-bar bill at time of discharge

Are we crazy, lazy, dumb or just blissfully unaware?

Or is it disunity? It is shameful to say that this country still spends time and money squabbling between government jurisdictions and clinical branches, only to ensure that nothing happens in improving (supply-related) patient care outcomes.

And this is not to mention the impact on patient care by being unable to share patient data between practioners, their service partners and their payers.

However the worse crime is the huge sums of money unavailable every day due to ‘shrinkage’.

‘Shrinkage’ is a corporate word used to describe the nasty and the useless outcomes of bad supply chain and inventory management.

Retailers know their shrinkage to a decimal point and is held ideally at a touch over 2%. That is 1% staff theft and 1% shop lifting and a bit of supply error.

Not that many hospitals know their shrinkage, but it is between a ‘good’ of 5% to 8% and a ‘bad’ of 12% to 15% and sometimes an outrageous 20% plus.

Most of this loss is not theft; it is poor management of funds invested in the procurement cycle. There is almost no visibility of inventory. If the problems aren’t known every day how can the problems be fixed? In fact there are twenty-two reasons for shrinkage and only 4 of them are theft related

So the mention of $2 billion above being awash in black holes is not an exaggeration. Not when you consider that the national spend on product procurement is $20 billion PA. Just do the maths.

The short answer? Let us stop talking, meeting, reporting, PowerPointing and pontificating and just do it. Start the e.health evolution at the bottom and work up, a step at a time.

It is worth mentioning the workplace in all of this. Shrinkage in all its forms causes knock on problems.

First there is the hassle and inconvenience for nurses who have to do another person’s job to make sure that patients have constant product availability.

Secondly in the blame game it is always the powerless who cop it. A scandal hits the media and the brown stuff spins out of some Elite’s fan straight at the nameless scapegoats. Yet these poor sods are stuck with technology that is in tune with a 1950s mindset.

One bright spot that policy makers and experts all ignore is the Australian Defence Force, Surgeon General’s PILS system (Pharmaceutical Integrated Logistics System). For which I am unashamed to give the ADF a commercial plug.

PILS has over 40,000 pharmaceutical, medical device and OTC products in one shared catalogue online to sixty sites. The catalogue is to a global standard template, using global standard unique product identifiers.

Product can be tracked and traced (by batch number and date) from a manufacturer right onto a serving member, giving a full medical record at the end. The prescription process is fully linked from prescribing, to dispensing and to recording, by the unique product identifier.

Reporting can be done instantly by dozens of categories and sub-categories - by product, person, place, procedure, practice, performance and payment.

This is Commonwealth IP, at worlds best practice in health supply/clinical linkage, and is freely available for benchmarking. Yet nobody is interested to learn what has been learnt and what can be done, step by step. Humph.

If the ADF can manage this routinely why isn't it routine elsewhere?

Humph indeed.

Are our policy makers and administrators blind as well as dense? Of course not. Perhaps just too busy looking down, from the top, which is the wrong way to make things happen. Looking up is the way to go.

This is all about patients. Patients are at the coalface. Seems obvious that the focus should be in harmonising the integrity of data captured, data use and data sharing, from that point of service and consumption - in, out and then up. Not the other way around

It is more than enough to make one sick and thereby one needs to keep taking the tablets until someone else comes along and fixes it all.

Seriously though, so much for continuity and coherence in linking information chains, let alone working together in a set series of steps towards a shared goal to share the common data for the common good, in a common sense manner.

Double humph to it all.

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Comments are welcome!

David.