National Health and Hospital Reform Commission. Interim Report Feb 16 2009

In this blog our focus is in the e-Health domain. Others can address the rest of the report.

First to note the report is available from the NHHRC website.

Under the third key element of the proposals called:

Connecting care: comprehensive care for people over their lifetime

And under the subheading:

Creating strong primary health care services for everyone

We find the following. (Page 8)

“Finally, in our Interim Report we argue that creating a robust and integrated primary health care service will require the implementation of a person-controlled electronic personal health record. Across Australia’s range of community- and hospital-based health care settings the sharing of information is limited, fragmented or non-existent. This results in high dissatisfaction from patients, exasperation from clinicians, adverse events and sub-optimal care.

An electronic health record that can be accessed – with the person’s agreement – by all health professionals and across all settings is arguably the single most important enabler of truly person centred care. It is one of the most important systemic opportunities to improve the quality and safety of health care in Australia. We will explore the prerequisites and incentives to allow us to reach this goal in our final report.”

Under the subheading:

Restoring people to better health and independent living

Under this we don’t seem to have anything on Telehealth

Under the heading:

Facing inequities: recognise and tackle the causes and impacts of health inequities

And the subheading:

Delivering better health outcomes for remote and rural communities

We have the following (Page 16):

“Here we highlight two:

• Telehealth and telemedicine are used in Australia as an avenue for bringing health care to people in remote and rural areas, but they are not being used to their full potential. With limited exceptions, current Medicare arrangements require that the patient be present for a consultation and that only one provider can bill for a service with the same patient at the same time. Under these arrangements, if a telehealth consultation with a metropolitan specialist is arranged and the rural specialist or general practitioner accompanies the patient, only one of the doctors can bill for this service. These outmoded funding arrangements need to be changed.

• All state and territory governments provide a patient travel and accommodation assistance scheme to help people in remote and rural areas to access specialist medical appointments and treatment. But there are significant differences among the jurisdictions in eligibility and operation. We propose that a patient travel and accommodation assistance scheme be funded at a level that takes better account of the out-of-pocket costs of patients and their families and facilitates timely treatment and care.”

Interestingly, in the Next Steps section we find the following (Page 27):

“Some of our proposals are less advanced than others. Our work in the key areas of e-health and workforce, for example, needs further development for our final report. In other reform areas we have presented options, seeking discussion of possible approaches.”

Under the major section:

Reform Directions

We find:

2.9 We support the development of a person-controlled electronic personal health record. We will explore the prerequisites and incentives to allow us to reach this goal in our final report.

And:

4.6 T o improve quality, data on quality and safety should be collated, compared and provided back to hospitals, clinical units and clinicians in a timely fashion to expedite quality and quality improvement cycles. Hospitals should also be required to report on their strategies to improve safety and quality of care and actions taken in response to identified safety issues. (Pages 31 and 33)

And:

5.6 We recognise the vital role of equipment, aids and other devices, in helping people to improve health functioning and to live as independently as possible in the community. Ensuring affordable access to such equipment will be considered under reform direction 13.4 that foreshadows further work on the development of integrated safety nets. (Page 34)

Finally we see right at the end of the introductory papers:

“This is an Interim Report and remains a work in progress. We recognise that we are further advanced in some areas of focus than others. Our work in the key areas of e-health and workforce, for example, will be further developed in our final report. We are also yet to fully explore the opportunities and challenges that new technologies may present, and their influence on health care and our world in the future. In some instances, we have presented options and our work to date will benefit from further discussion.” (Page 45)

The ideas summarised above are further developed in Pages 99-100.

On Page 350 we also find:

“The call for better data linkages would of course be unnecessary if all patients had an electronic information record which could be readily ‘mined’ for information on diagnoses, care pathways, treatment and health outcomes. The plea to ‘get going’ with electronic, patient-centred information records, as a rich source of research information and as a pivot for better coordination of safe and high quality care, was heard loud and long:

And my completely earth shattering idea is not very surprisingly the speedy and effective deployment of electronic health records into the community. So that we can start reaping the benefits of the measurement of health outcomes and the efficiencies the workforce would enjoy from being able to message each other instead of having to send pieces of paper round and download x-rays instead of having patients sitting around and all that sort of stuff.40

Our health system really is centred not on patients or individuals, it’s centred around the practitioners and the providers, and that’s just the way it’s evolved historically. So we really don’t have a patient-centred system. So it’s a huge change to get a system to turn around to be focused on the consumer. I think that means that, for instance, a patient-centred system would mean that we should have a patient-centred information record, so that each person can know that there is a record that contains all of the things that are related to their health, and they’re all brought together electronically in the one place, so every person with an interest in their health can access it. So a GP’s interventions, a speech therapist’s work, a medical specialist of one kind or another, a home care worker, could all see the whole story of what’s going on in the person’s life. And we just don’t have that. At the moment, every practitioner keeps their own records in their own filing cabinet, and no-one else can see them. No collaboration can take place – hopeless.41

The complex and controversial subject of e-health, personal health records and information management is one which we have chosen to defer for further exploration in our final report. The vast number of options suggested to expedite a patient-centred electronic record, and leverage the investment required to roll-out and sustain it in practice, require further deliberation.“

So what do we have here? A few general reactions are as follows.

First there is no mention or citation I can find of the Deloittes National E-Health Strategy. This has the left and right hand being clueless about the other feel to it. And why no comment on their implementation roadmap?

Second e-Health seems to have been just too hard – and so consideration has been largely deferred until the final report – due in about six months. One really wonders what they hope to learn in that period having already being operating for 12 months or so.

Third there is just no clarity at all about what a ‘Personal Health Record’ is and absolutely no pathway described as to how we might get there if we think it is a good idea. It is odd they talk about the need for information flows and linkages but then fail to say we get this happening so the PHR can be then evolved a little later.

Fourth one wonders what is behind use of the phrase “The complex and controversial subject of e-health, personal health records and information management”. Is this reflecting a bureaucratic mindset that does quite ‘get it’ or is afraid of it given the stuff ups to date? Complex I agree – controversial – well not really in the rest of the world.

Fifth it is not clear that the Commission recognises how many of its ambitions will be frustrated without an improved e-health infrastructure. “Connected health” is just a phrase without a real e-health upgrade.

Sixth there is a worrying feel that the NHHRC is going to have a go at developing another e-Health Strategy and set of recommendations. That will mean we will potentially have NEHTA, Deloittes and the NHHRC all heading in non-coordinated directions. A prescription for policy paralysis if ever there was one.

Seventh one wonders if deferring consideration of e-health reflects a view as to the importance of the area – and its key role in Health Reform. Hardly what national leaders in the rest of the world believe as far as I can tell.

There is some useful work in this report. However as far as e-Health is concerned it is really pretty hopeless. In summary the NHHRC is saying “we think this might be important but we can’t get out head around it!” Pretty sad really.

David.