Quote Of The Year

Quote Of The Year - Paul Shetler - "Its not Your Health Record it's a Government Record Of Your Health Information"

Thursday, June 18, 2009

The National Health and Hospitals Reform Commission Totally Fails to Understand E-Health!

The NHHRC released a new discussion paper earlier this month. It was entitled:

The Australian Health Care System: The Potential for Efficiency Gains (A Review of the Literature).

This links to a download page:


The direct link to the document is:


On page 23 we are told there are 3 possible solutions that can deliver improved ‘Operational Efficiency’

These are:

1. activity-based funding;

2. e-health and patient electronic health records; and

3. greater use of data through measurement and surveillance of health system performance.

The E-Health Section reads as follows:

“Solution: E-health and patient electronic health records

It is expected that the introduction of health information technology, in particular individual patient electronic health records (IEHR), would enhance labour productivity and technical efficiency within the health system. Uptake has been low because of problems associated with implementation (delays and the lack of a coherent national strategy) and the high costs associated with start-up. Currently no country can claim to have a fully implemented and operational IEHR network. Germany is arguably the most advanced, and is aiming for implementation in 2010 (at the earliest) (Bartlett and Boehncke, 2008).

Efficiencies are expected to be delivered across in-patient and out-patient services by minimising the need to transcribe medical records, wait for paper records to be delivered, and re-order tests and diagnostic imaging because the results and x-rays/scans could be attached to the IEHR. Adverse events are expected to be reduced as it will be easier to manage medicines (and their interactions) and medical histories (including, for example, allergies).

Girosi (2005) estimates that full adoption of health information technology in the US could save approximately four per cent (US$81 billion) of total yearly health spending (approximately US$1.7 trillion). Although the initial investment in information technology is high, estimated to be US$7.6 billion, the annual benefits far exceed the costs. It is anticipated that IT-enabled improvements in prevention and disease management in the US could more than double these savings while also lowering age-adjusted mortality by 18 per cent and reducing annual employee sick days by forty million. It should be noted, however, that the US is starting from a low base of IEHR usage and has particularly high health service costs and high levels of operational inefficiency. Figure 9 shows an international comparison of primary health care physicians’ use of electronic medical records, although this does not show the usage of decision support tools or the capacity for records to be shared or accessed at different sites of care.

In Australia, few studies have been undertaken on the economic impact of an IEHR. One study (ACG, 2008) commissioned by the National E-Health Transitional Authority (NEHTA) found that the economic benefit to Australia from the implementation of an IEHR network would be between $6.7 billion and $7.9 billion over 10 years (in 2008-09 dollars). This may be an overstatement as the modelling assumes significant benefits to the economy through increased workplace productivity, as IEHR would lead to improvements in chronic disease management.

There is limited evidence for this (ACG, 2008). Interestingly, the modelling found that economic benefits would be enhanced if the slower paced implementation option was followed as there would be significantly less net foreign liabilities (that is, less dependence on overseas lenders).

A more precise estimate of the benefits of an IEHR system may be possible if confined to hospital and medical services. The ACG model assumes efficiency gains because of reductions in the number of adverse events (including medical errors) and duplication of services - for example, the number of repeated tests and images. There may also be further efficiency and effectiveness gains down the track if IEHR leads to the development of better decision making tools, and more accurate and rapid diagnosis. The ACG model assumes that there will be an increase in throughput (for example, a reduction in hospital queues), rather than savings (that could, for example, be handed back to government) due to excess demand for health care. Real output in the hospital and medical services sector is expected to increase by between 4.8 and six per cent by 2019 following the implementation of an IEHR network from 2010 (ACG, 2008).

The computerised physician order entry (CPOE) system is an essential element of IEHR in hospitals, and a key to delivering anticipated efficiency gains. However, the uptake of CPOE in many countries, including Australia, is limited. CPOE allows doctors and other authorised staff to enter orders electronically - for example, medication and diagnostic tests. This removes the need for paperwork and associated transport or delivery systems, and is likely to lead to substantial savings in terms of efficiencies (and patient safety). However, there continues to be difficulties with implementation including significant disruptions to work organisation and physician resistance to the CPOE systems (Georgiou and Westbrook, 2006).

Stroetmann et al. (2006) argue that a successful e-health strategy should include achievable, shorter term goals that provide incentives for change rather than ‘big-bang’ reforms over a short period of time. While there are many expected short and long term benefits from e-health, progress is slow, and change continues to occur in a fragmented fashion. Reform will only occur over time, but the right incentives for a range of players, along with national leadership, is clearly needed (Bartlett and Boehncke, 2008).”

Where to start. It is utterly clear the writers of this section are utterly clueless about e-health. (Sorry I can’t reproduce the figures)

First they totally ignore the transaction and communication efficiency provided by modern Information Technology (the same stuff that has transformed the way banks, airlines etc operate)

Second they devote almost ½ the section to discussion of a benefits paper developed for NEHTA which is not publicly available:

“ACG (Allen Consulting Group) (2008) Economic impacts of a national Individual

Electronic Health Records system, July”

As it happens I have seen this paper – and it is a Macro Economic Model of the benefits of a totally undefined Electronic Health Record systems that is assumed to provide benefits that are based on experience in the most advanced Health IT installation in existence. All these systems are hand crafted 2 decade long efforts which are essentially not replicable in Australia.

Third they clearly have bothered to read very little of the large volume of literature available regarding the benefits of deployment of health IT. The one major benefits reference they cite is 4+ years old!

There is a vast amount of much better quality material available here:


Fourth the paper also totally ignores the place of CPOE in ambulatory practice where it is fully deployed in health systems like Kaiser Permanente supporting 8 million + insured lives.

Fifth the document totally ignores the huge amount of work done in the Deloittes National E-Health Strategy – finalised late last year – because, incredibly, they don’t seem to have a copy. Ms Roxon should fix that urgently – for the NHHRC and the rest of us!

Sixth, there are many countries way in advance of Germany in all this. Try Denmark, Sweden and the Netherlands.

Seventh, the issues about definitional distortion as identified in my blogs over the last few weeks are still not addressed.

Eighth, there is no recognition of the scope of e-Health capability and how it fits as a total system enabler. If not done right this will be a fiasco. E-Health can enable a safer and better health system and the NHHRC does not get it!. Really, really sad.

I won’t go on. This is just another opportunity missed to do a proper job of work to define the place of e-Health in overall health reform.

I despair!



Anonymous said...

Yes many of us inside the bureaucracy also despair. We avidly read your blogs and your readers comments. We often bring your messages to our bosses notice and whenever we do we are told to get on with our work or get out. In a recent meeting with Deloitte we heard that they were as troubled as us but quite unable to do anything to improve the situation. Our bosses tell us we must all be patient and to wait for NEHTA to fix it. Yes, with you we too despair, but we can do nothing more to help because in this climate we have to keep our heads down and hold on to our jobs.

Anonymous said...

I suggest a simple exercise.

In one circle write the names of those Australians who are nationally or internationally recognised for their expertise in eHealth and informatics.

In the other circle write the names of folks working for NEHTA and NHHRC.

At the intersection, we find ....what ? an empty set?