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Monday, August 27, 2007

Minister Abbott’s E-Health Report Card – Hunt the Spin!

The following are the prepared notes for a speech the Health Minister gave last Monday – reviewing the progress that has been made in e-Health in the four years since the Minister took up the reins.

My comments are inserted in the text in italics.


An E-Health Report Card - Speech Notes for the Australian Health Summit, Sydney

20 August 2007

In November 2003, my first scripted speech as Health Minister concerned e-health. I stated that an electronic health record, communicated electronically among health care providers, would mean safer, better, more convenient and more efficient health care. For doctors and other professionals, it meant less repetitive taking of histories; for governments and other funders, it meant less duplication of diagnostic tests; for patients, it meant more access to their health records and more capacity to manage their own health; for everyone, it meant fewer potentially disastrous mistakes because of avoidable ignorance.

Failure to establish an electronic patient record within five years, I said, would be an indictment against everyone in the system, including the Government. I hope to be judged against that somewhat rashly declared standard; not because it is likely to be fully met but because it would mean that, come next year, I remain the Health Minister!

Clearly the Minister has a high level understanding of the benefits of e-Health – sadly he really has not made substantial progress in reaching his desired end state for e-Health

Back then, my thinking was that people in the health system were at least as capable as those in the finance system. If EFTPOS could link billions of bank accounts and financial institutions around the world, it should surely be possible for every Australian patient’s file to be copied, indexed, stored and securely made available to the patient and authorised treating professionals via the internet. In retrospect, I had underestimated the difficulty of shepherding independent professionals and insular institutions through the thickets of patient privacy and sheer force of habit. Still, although not yet very obvious to patients, much has been achieved in the past four years.

It is a worry that the Minister takes just three paragraphs to start blaming clinicians, rather than understanding that all successful change needs to deliver benefits to those who are asked to change, or the change will be resisted. In a fee-for-service professional payment environment the incentive to use technology, which typically slows a practitioners productivity – at least initially – is very low. Given it is patients and the Government who stand to benefit from more Health IT use, the payment and incentives need to come from those who will benefit.

Since the late 1990s, the federal Government has provided more than $700 million – or about $40,000 per full-time doctor – to support the use of information technology in general practice. There are still doctors taking case notes on cards, hand-writing prescriptions and relying on receptionists to find files in cabinets in the time-honoured way. There are also hospitals such as the Epworth East where each bed is equipped with a computer screen and keyboard so doctors’ and nurses’ notes instantly integrate into patients’ records. Some health funds are beginning to offer their members personal health records that will enable the storage of diagnostic test results as well as treatment records and general health information. Doctors especially still tend to be much more enthusiastic about clinical than administrative technology, even though both are equally necessary for effective clinical practice. Even so, a rightly conservative but highly perceptive profession is adapting to change because it’s in doctors’ own and their patients’ best interests.

Last year, according to data published in the Medical Journal of Australia, 94 per cent of general practices had a computer (up from 15 per cent in 1997 and 70 per cent in 2000). Of GPs with a computer, 94 per cent used it for prescribing, 82 per cent to write referral letters, 70 per cent for some medical records functions, and 68 per cent to create management plans. Of GPs with a computer, 33 per cent had fully computerised their patients’ medical records while 78 per cent of GPs worked in practices that used computers for scheduling appointments or recalling patients.

This is good news – but clearly there is more to do!

Cultural shifts take time but over a decade the computer on doctors’ desks has gone from expensive paperweight to an all-but-essential part of medical practice. Of course, it’s one thing to use a computer for internal practice purposes; another to make use of IT for ordering tests or sharing information. Last year, only 53 per cent of GPs with a computer used it for email. Still, progress in this area makes e-health possible if not inevitable.

As well, the Government’s $100 million investment in HealthConnect has helped to facilitate the electronic transfer of admission and discharge information between some GPs and public hospitals in Tasmania, South Australia and Western Australia. In Sydney’s west, up to 50,000 patients at Westmead Hospital are being offered a Shared Electronic Health Record accessible to their specialists and GPs. In Bendigo, a link between GPs, specialists, allied health professionals and community care providers is improving the management of chronic disease. These trial projects, among others, are exploring potential best practice for what should become standard arrangements in the future.

Neither Healthelink (the NSW Site) or the Bendigo site have been evaluated as yet. The earlier $100 Million investment was essentially totally wasted – and given all that has been published is a summary report that essentially said it looked promising but did not work as yet.

The federal Government has also invested in initiatives to support clinical practice such as electronic publishing of the Pharmaceutical Benefits Schedule and the Medicare Benefits Schedule. The Government has worked with the states and territories to remove legislative barriers to electronic prescribing and referring. It has negotiated a subscription to the online Cochrane Library to provide Australians with free access to evidence-based information on best practice.

The federal Government has committed $69 million to providing broadband access for GPs and pharmacists. More than 90 per cent of pharmacies have broadband and 78 per cent of doctors work in General Practices with broadband access. The most recent Pharmacy Agreement gave pharmacists 40 cents a prescription for using PBS Online, a real time record keeping and eligibility checking system.

The federal Government has committed $98 million to Medicare Australia for services such as EasyClaim. At participating practices, a card swipe can provide patients with their Medicare rebate on line from their doctor’s surgery. The Government is now talking to the AMA about incentives, similar to those offered to pharmacists, to encourage privately-billing doctors to give this convenience to their patients.

These are really just general investments in the provision of basic infrastructure. The EasyClaim project is, of course, stalled as the AMA has realised that use of the system will increase practice workloads and costs, for no financial reward. Increasing practice costs – without re-imbursement – was never going to be a winner!

Finally, the federal Government has committed $79 million towards the National E-Health Transition Authority (NEHTA) which is developing unique IDs for patients and providers and developing a common language so that particular terms have the same clinical meaning across different record systems.

These comments are interesting. It would have been difficult for the Minister to say less about NEHTA – especially given it is spending $79 million on it over the next three years. Hardly an enthusiastic endorsement of what NEHTA is doing.

It would be fair to say that policy-makers have been impatient to see an operational return on these investments rather than a proliferation of trial projects and pilot schemes. A particularly successful one has been the Shared Electronic Health Record trial in the Katherine region of the Northern Territory involving nearly 12,000 patients. This has been an important means of delivering better health care to a mobile population subject to high levels of chronic disease. This Shared Electronic Health Record currently includes a health profile (with blood type, chronic conditions and allergies), an individual event summary (visits to the GP, emergency department presentations and hospitalisations) and pathology results.

This is very interesting – as when the project was evaluated a year or so back the level of usage and clinical content was not as is indicated here. It would be good to get a new public evaluation of progress to date here – so we can assess how sensible further investment is. It could be that great success has been achieved – and if so it would be good if this information was shared. Without such sharing I remain just a trifle skeptical.

Today, I can announce that the federal Government will fast-track the roll-out of a Shared Electronic Health Record throughout the remote parts of the Northern Territory. This should help to ensure that the health issues identified through child health checks are properly followed-up. A comprehensive health record is absolutely necessary if the goodwill and hard work of visiting and resident professionals is to resolve identified health problems and prevent their recurrence.

With consent, the Shared Record will be accessible to any authorised health professional in the NT. This means that after the initial health check, a patient’s health information will be available to professionals in general practices, community health centres or hospitals, so that effective follow-up care can be delivered. The Shared Record will support ongoing care by triggering recalls and reminders as children advance through life.

A child with a Shared Record will have his or her health information updated, if the infrastructure is available, at the point of the health check. A child without a Shared Record will have one created, if the infrastructure is available, at the health check. If the infrastructure is not available, a paper record will be created at the health check and the information will be used to update or to create a Shared Record. One way or another, all remote area indigenous children will have the opportunity to gain a Shared Health Record.

A good idea – and suggested on this blog within days of the ‘Emergency Intervention’ being announced.

As the British Government has discovered, it’s much easier to spend money on health IT than to produce a functioning e-health system. So far, despite its 15 billion pound budget, the NHS HealthSpace is far from fully operational. On line access to a full electronic primary health care record is still only being trialled in a limited number of practices. Few practices offer their patients on-line booking or prescription re-ordering. Only some patients have some access to a limited range of specialist records.

I think this is more dismissive than current progress suggests – and I suspect this is because of concern as to how much it might cost to do things properly!

In Australia, the Government eventually decided against creating a single, national comprehensive electronic health record designed and managed by officials. The ordinary difficulties associated with government projects are magnified, it seems, in such a protean field. The Eclipse experience shows how hard it is for governments to design systems for a myriad of users rather than to encourage people to devise systems which work for them.

Has anyone told NEHTA that the National Shared EHR has been cancelled? I note how long it has taken for this decision to become public. Pity there is no clarity regarding what is now planned in the area of clinical information sharing.

In health IT, the Government’s role is to remove regulatory barriers, provide incentives for change, promote “inter-operability” of systems and explain to the public how and why e-health can improve their health care experience. Its job is not to build complete systems from scratch or to impose uniform infrastructure on health providers but to make it more realistic and affordable for healthcare providers to move into the IT age.

In the short term, the Government will introduce more Medicare items to support telehealth services. There’s already a rebate for psychiatry consultations over the phone. The Government is considering a rebate for dermatologists consulting remotely with patients in GPs surgeries via a diagnostic camera. The Government will foster the development of one or more secure repositories for personal Electronic Health Records. It will begin to link the various existing illness or health registers so that information on significant diseases, screening and immunisation can be incorporated into a patient record. Eventually, this work will provide a foundation for much more effective monitoring of the performance of drugs and health devices.

It’s likely that, in the next two to five years, the Government will make access to Practice Incentive Payments or even the MBS itself subject to best practice in health record-keeping. For instance, team care plans should be a standard feature of primary health care for people with chronic disease and complex care needs. It would be almost impossible to create and monitor these care plans effectively without the use of IT. In the years to come, effective use of IT should be as much a part of professional practice as the provision of suitable premises. It could be expected, even mandatory, in much the same way as continuing professional education.

This is the sort of approach – the so called “pay for performance” approach with an Australian flavour – which might work. Of course there are all sorts of hurdles to be addressed and all sorts of issues about the sort of information collection infrastructure that may be required.

In the near future, routine follow-up after an initial consultation, subsequent consultation as part of a broader care plan, and lifestyle modification advice for people with chronic illness could readily be delivered by phone or over the net. Of course, some issues would have to be resolved first, such as whether these items could only be provided by the patient’s usual doctor or whether a face to face consultation would be required prior to tele-consultations or e-consultations. Clearly, this would be more feasible for some specialities than others and there are complex billing arrangements that would need to be sorted through. Still, it’s hard to imagine that health care delivery in the years ahead won’t make much better use of convenience technology.

To help meet these challenges, the Government has established an e-health Ministerial Advisory Council. It’s chaired by Roger Allen, a former Deputy Chairman of Austrade and IT entrepreneur. It comprises leading representatives of medical and health organisations and is meant to ensure that government e-health initiatives are actually making a difference to health practice not just providing business openings for the IT industry. If e-health doesn’t help practitioners and patients, it’s hardly worth doing.

Oh dear – another committee. I wonder where this E-Health Ministerial Advisory Council fits in between AHMAC, ACHI, NEHTA etc. I wonder is this Council have a go at developing a plan – some-one sure needs to!

A pre-requisite for a functioning e-health system is secure messaging. From next month, the Government will be working with Divisions of General Practice to offer GPs public key infrastructure. This will provide them with the ability to transfer information and images safely and securely between computers. Participating practices will receive a CD to download the necessary software and individual GPs will receive a PIN plus a personal data stick for their computer to verify identity. This offer will also be made to allied health professionals registered with Medicare. The system will provide users with the assurance that information comes from a trusted source and has not been tampered with. It will enable GPs to order laboratory tests, X-rays and other diagnostic procedures, prescribe drugs and other remedial treatments, and issue recalls, reminders and referrals confident that the information will not go astray or be misused.

As long as this is highly usable and works well this is a great idea.

The Government will also provide expanded access to on-line health information through the purchase of additional access licenses for recognized health learning resources. This will give health professionals throughout Australia accessible, authoritative and up-to-date information and should help to promote best practice health care. The Government will work with the professions to identify the clinical guidelines, on-line journals and on-line reviews that can best help.

Excellent idea – just spread the NSW Health Clinical Information Access Program nationally would be a good start!

The Government will soon to go tender for organisations to facilitate, in a particular region or community, a comprehensive e-health environment. Successful organisations will be expected to work with local GPs, aged care facilities, hospitals, diagnostic providers and other health professionals to ensure that they can electronically share information. Importantly, payment to these organisations will depend upon the volume of clinical information electronically transmitted.

This adopts a key suggestion this blog has been on about for a good while. Start locally and simply and progress at a pace those involved can accept and utilise.

Finally, I can announce today that by early next year, every Australian will be able to access his or her comprehensive Medicare claims history on-line. Patients will have secure access via the Internet to a full record of their Medicare rebates. There will also be a layman’s guide to item descriptors so that patients can readily appreciate the services they have received. Within 12 months, there will be similar arrangements to allow patients on-line access to their PBS claims history.

The first step towards a Personal EHR for Australians. Good idea and, strategically , possibly the core of a Shared EHR that might work.

The new measures announced today will cost about $25 million in total over the next three years.

Note this is an investment of a little over $8 Million a year. Given the Australian Health Budget is about $80 Billion a year – pretty trivial I must say.

These measures will not, of themselves, mean that every Australian has a personal, securely accessible comprehensive electronic health record by the 2008 deadline I once set. Nevertheless, it is substantial progress and is starting to be noticeable to patients. I am reluctant to set a new deadline but am confident that, within a few years, most Australians will be able to access a comprehensive electronic health file that is kept automatically updated by health service providers.

Since 2003, the Government has learned that the best can easily be the enemy of the good, at least in this area. As a funder and organizer, the Government looks likely to achieve far more than it could as an e-health builder and director. As is so often the case in Australia’s health system, the Government has turned out to be much better at funding services that other people deliver than at delivering services itself.


Thus far the Commonwealth has hardly funded or organised anything in e-Health to any significant degree. I wonder will that change as the election approaches?

Final comment – the quote “best can easily be the enemy of the good, at least in this area” is very true – sad that NEHTA does not realise this and get on with providing some practical easily implemented solutions to major the problems we all understand. I would not want to be accused of “reading between the lines” but I have the distinct feeling NEHTA is not much in favour with the Minister. If they were would there be a new Advisory Council now commissioned?

All in all this really is a very sad report card – and has hardly moved much from my earlier report card which is found here.

As ever the issue is that the Minister is articulating a dis-coordinated set of little initiatives which will make little difference in the absence of a coherent National Plan. Another missed opportunity!



Anonymous said...

You said “Has anyone told NEHTA that the National Shared EHR has been cancelled? I note how long it has taken for this decision to become public. Pity there is no clarity regarding what is now planned in the area of clinical information sharing.”

You will find your answer in Dr Reinecke’s presentation last Friday at MEDINFO 2007 (slide 6). It lists one of NEHTA’s key deliverables in the 2005-2008 work program as ‘Designing a national system of shared electronic health records for authorised practitioners and individuals’.

Also slide 20 points to ‘The Next big step - SEHR’ ….. “ Designing a national system of shared electronic health records for authorised practitioners and individuals”.

Someone isn’t listening or doesn’t understand. Could it be you? Could it be him? Or could it just be a matter of semantics and interpretation?

Dr David G More MB PhD said...

The Minister said:

"In Australia, the Government eventually decided against creating a single, national comprehensive electronic health record designed and managed by officials."

Who do you believe? NEHTA or the Minister. Sounds like a "no" to me.


Anonymous said...

The operative words are ..... designed and managed by officials.

If one deletes those specific words I could believe the Minister. If one retains them I could believe NEHTA !

Dr David G More MB PhD said...

I guess it depends if on your view of the relative influence of NEHTA and Minister Abbott. My experience is that Federal Cabinet Ministers tend to get their way!

Given the way NEHTA seems to be sidelined in this speech (3-4 lines out of 400+ in the speech) the NEHTA claim to be the "peak e-health body" seems a little flimsy.

My view - we have policy conflict at the top level that is doing no-one any good.


Anonymous said...

"Oh dear - another committe" you said.

Do not be despondent. Look on the positive side. Perhaps this committee will be different. If it is loaded, as most Ministerial Advisory committees are, with the ‘leading representatives’ it more than likely will become bogged by politics. No different from past committees. If however, the Chair has been appointed but its membership not yet cemented, there is hope that a different ‘type’ of committee may emerge - practical, pragmatic, politically astute - expert in health and IT across the public and private domains. The Chair is well qualified to lead such a committee.

Anonymous said...

If NEHTA is to be believed (and I don't for a moment suggest that this is the case), does anyone think it is the appropriate agency to actually build a national shared EHR solution? Neither do I! Long, bitter experience must surely inform us that the government does not build efficient, large-scale IT systems; in fact the public sector is littered with the remnants of many ignominious failures. NEHTA should stick to the basic job of specifying the building blocks for a national EHR and let industry build it based on a commercially viable model. So far, it has not even managed this job with any degree of competence or efficiency. If NEHTA is unable to get comparatively simple individual (patient and provider)identifiers out the door for $98 million (an obscene amount in its own right for these two tasks), what hope have they got of developing a national EHR solution for anything like an affordable price?

Dr David G More MB PhD said...

While I agree in part I have a problem with having Standards set by an organisation that has no practical implementation experience and expertise. Trying to work out what they are actually useful for gets harder each day for me as Medicare Australia takes over the identity system etc. (see the Australian IT Section today)


Anonymous said...

And another thing. I notice that the Minister announced the deployment of "data sticks" to doctors to allow them to authenticate themselves on-line. Surely Tony (or Tony's advisers) are awake enough to know that the Department of Human Services (representing a whole raft of government agencies) is planning to role out smartcard based tokens for on-line authentication. With national government smartcard infrastructure not far away (at least in government timing terms!), why on earth would Medicare Australia (one of the key DHS agencies) roll out a different technology?

Anonymous said...

Yea, I agree on 100% standards. I should have said "NEHTA should stick to the basic job of participating with the rest of the industry in the specification of the building blocks for a national EHR and let industry build it based on a commercially viable model".

Dr David G More MB PhD said...

Re the data sticks vs smartcards etc. The problem is - as always - lack of a plan - so we get random decision making.


Anonymous said...

Today's Australian refers to a legislative amendment tabled in Parliament on August 16 designed to unlock access to Medicare data ...... in effect, circumventing the law currently in place. Apart from the rights or wrongs of such an amendment surely it is all very premature!

Dr Reinecke is quoted thus, “a universal identifier services operator, expected to be Medicare Australia”, and “The operator will be responsible for building and running the service in line with its contract with NEHTA”.

Does this mean Medicare Australia will build and run the service under some form of contract with NEHTA? Or does it mean NEHTA will build and run the service?

If the latter, NEHTA will need to have access to the Medicare data. If the former, why must NEHTA have access to the Medicare data?

Perhaps someone could please explain.

Dr David G More MB PhD said...


I think we still lack enough detail to be sure just what role NEHTA will have in the final service. They have said that because they are a 'transitional authority' they should not operate the service in the long term as I recall.

I agree that if Medicare Australia (MA) is to deliver the service there is no need for NEHTA to have access to any data. They and MA do have to sort out all the privacy and security issues.