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Tuesday, July 17, 2007

NEHTA has the Allocation of Its Resources and Efforts Wrong!

I was reflecting on a rather interesting series of messages in the GPCG_TALK e-mail list on the transfer of medical records between practices which were using different software – and it occurred to me that the importance of this topic was significantly underestimated in more than the obvious way. My concern centres around the lack of focus and standards setting for GP and Specialist Ambulatory Care / Office systems. Why the concern? The answer is that it is these systems which will have the biggest impact and benefit for our health system.

While we have yet to see the actual report NEHTA claims that the benefits from adoption of more E-Health can be found in the following areas (From May 2007 presentation):

Major sources of benefits

1. Benefits from appropriate use resulting in service substitution

2. Better clinical decision support in:

- Prescribed medications

- Referrals

- Clinical ordering (pathology & imaging)

3. Electronic consultation substitution

4.Reduced rate of population chronic disease progression

5. Reduced hospital costs

6. More efficient community pharmacy processes

7. Improved medication adherence

By the estimates contained in the same presentation it looks to be that between 60 and 65% of the benefits are to flow from improved clinical decision support.

It is also clear from the NEHTA benefits study (of which we have only yet seen a few slides) that there is, on their part, an assumption of major planned change in the connectivity of practices and in the expectations for consistency and safety in clinical practice. This can only happen if the systems on the edge of the health system (i.e. used by GPs and specialists) are much more capable than is the case at present.

The Australian Medical Workforce – when last counted in 2004 (Published in 2006 by the AIHW) was made up of the following active clinicians:

Primary care practitioners - 22,011 (40.8%)

Hospital non-specialists - 6,202 (11.5%)

Specialists - 19,043 (35.3%)

Specialists-in-training - 6,710 (12.4%)

The targets for decision support are the 40% who are GPs and probably roughly 2/3 of the specialists who are in other the fully procedural practice and are in what I would term are in office based practice (In the US called ambulatory practice). This amounts to well over 60% of practitioners.

The other obvious target is community pharmacists to provide a back-up review of the drug related aspects of clinical activity.

So just what a NEHTA’s plans to upgrade and improve the computer support of those who can make a major difference – rather than those who are hospital based and are a much smaller part of the problem?

With its penchant for telling everyone else how to standardise, communicate, process health information and data –and now knowing where the ”paydirt“ lies – what about a major switch of focus to improve GP and Pharmacy Computing?

A very good place to start may be to work with DoHA to identify how best to support GP / Specialist / Pharmacy computing and start working on standards for decision support, usability etc for ambulatory practice. A mandatory standard to ensure all practice systems are able to import and export clinical data in a usable form could be a very useful additional work item. It could be enforced easily through payment / non-payment of Practice Incentive Payments based on compliance with the portable record capability standard.

Additionally, if the work on identifiers and SNOMED CT is going to have any useful impact in the foreseeable future it needs to be linked with a decision support and discrete data messaging upgrade for all the 40,000 or so front-line clinicians.

Why is this major and obvious focus not on the agenda at all? We don’t need a Shared EHR any time soon, we need individual practitioners with effective systems first!

I certainly plan to make this point as clearly as I can to the Boston Consulting Group Review of NEHTA.

David.

3 comments:

Knight said...

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Jon Hilton said...

I agree with you about the need to refocus priorities, and that refocusing on "office" based practitioners is important. I would go further and say that we need to go beyond medical practitioners too. Community nursing, allied health (physiotherapy, occupational therapy, etc) have information needs also, and can provide information that is extremely important, especially for people with chronic disease. I would also suggest that home based care is important, as are home care workers.

Regarding your proposed remedy - I think you're partly right, but believe that we need to provide some infrastructure to support the use of the basic standards you propose. I agree we don't need a full shared EHR. I think we need to consider a different approach - a simpler, broader (ubiquitous if possible) information service.

I argue that we should focus on providing a simple, ubiquitous system that supports the "virtual teams" of healthcare workers (including GPs and specialists) who share the responsibility for looking after those with chronic illnesses. Of course, pathology, radiology and pharmacy providers are part of the "team".

The infrastructure would link with existing systems where possible, but could be used stand-alone via a simple browser interface. The important components required to support this are standards and infrastructure for identity management for consumers and practitioners and a ubiquitous and inexpensive telecommunications network.

It would aim to provide (at a minimum) a "live cross reference" between patients and practitioners, so that a practitioner could look up a patient and see which other practitioners have been or are currently involved with that patient, and how to contact them.

For instance, a GP would be able to see using an online browser (for one of their recently discharged patients) the clinical discharge summary (which hopefully will include pathology and medications information) and in addition, the fact that a community pharmacist has been scheduled for a visit next week, that there is a nurse visiting weekly for the next three weeks to manage wound care, and that meals are being delivered for the next three weeks.

I argue that practitioners knowing who else has been or is already involved is the first and most important step in providing decision support, and would go a long way towards realising the major sources of benefit:

1. Benefits from appropriate use resulting in service substitution
2. Better clinical decision support in:
- Prescribed medications
- Referrals
- Clinical ordering (pathology & imaging)
3. Electronic consultation substitution
4.Reduced rate of population chronic disease progression
5. Reduced hospital costs
6. More efficient community pharmacy processes
7. Improved medication adherence

Such basic infrastructure would help drive standardisation of systems that could link with it and provide a platform for more comprehensive sharing of detailed clinical information. For example, ideally, we would like the pathology results and medication lists to be "automagically" transferred between systems, but if the systems are not capable of this, surely it would be helpful to know who to contact to get the results?

Who knows, such information may be useful in coordinating healthcare activities at the start of life as well - but this is not my area of expertise.

I will also really go out on a limb and say that such infrastructure would be useful in supporting the minority of otherwise healthy people who are unfortunate enough to require serious intervention from the healthcare system.

Have we missed anybody?

Anonymous said...

You claim that NEHTA has wrongly allocated ‘its resources and efforts’. That is a very big claim. Is it right, or is it wrong? It’s one or the other.

Most health informatics experts would say that you are right. Your claim begs the question, that, ‘if you are correct, how much time and how much money have been wasted, and more importantly who is responsible’?

Your concern centres on “the lack of focus and standards setting for GP and Specialist Ambulatory Care / Office systems.” And your concerns are underpinned by your view that, “it is these systems which will have the biggest impact and benefit for our health system”.

Many of Australia’s best HealthIT experts have been saying exactly that, and for a very long time indeed. In other words an awful lot of people have been saying exactly what you are saying!

So this therefore begs the question, ‘did The Boston Consulting Group get it wrong’? Someone did.

If it wasn’t BCG then it had to be NEHTA, and that should surprise no-one.

I’d suggest it also explains why you and so many others who know what they are talking about have not been heard!