By Dr David G. More MB, PhD, FANZCA, FACHI
(Note: This is a short article which may be published – comments welcome)
It seems many have difficulty coming to grips with just what impact it is that a broader use of Information Technology might have on our health system. This difficulty is also often combined with the problem of working out just how it might be possible to get from where our Health System presently is to a new Health IT enabled health system.
One way of approaching answering this question is to consider what diagnoses have been made as to what presently ails our system and then to consider how each of these ailments may be improved or even cured by an appropriate investment in an improved Health IT infrastructure and relevant applications. In approaching the question in this way I am very clearly indicating that extra investment in Health IT is a necessary but not sufficient step to create the safe, high-quality and efficient health system we all sense is possible but which seems to be very difficult to get to.
In a recent article in the Medical Journal of Australia Lewis and Leader provided the following rationale as to why Health Reform was needed.
“Abstract
- Traditional health care is fragmented, marred by quality and safety defects, with a failure to provide evidence-based care, and huge and unjustifiable variations in practice.
- There is abundant evidence that traditional means of delivering health care are obsolete.
- Concerns are deepening about persistent and widening gaps in health status that health care cannot overcome.
- Increased spending on health care has never definitively solved the problems of access, quality, or equity.
- Non-medical determinants of health indicate that the solutions to health problems lie mainly outside health care.
- The current financial crisis may create the urgency and courage to both eliminate the fundamental problems in health care delivery and reduce health disparities.”
See: Why health reform? Steven J Lewis and Stephen R Leeder MJA 2009; 191 (5): 270-272
This abstract is available on line here:
http://www.mja.com.au/public/issues/191_05_070909/lew10514_fm.html
What is being said here is quite fundamental and very important I believe.
Essentially the authors are saying that there are a range of things that can be done to address and correct the internal ills of the present health system (points 1 and 2) but that there are some critical externalities (points 3-5) that will need to be addressed by changes in public expectations and by more fundamental changes in our society to address disadvantage and inequity.
I must say in passing I agree totally with points 3-5 and believe their solution – where there is one -lies in there being a more sophisticated discussion of the limits to health reform than there has been to date.
In terms of what should be done, a key issue to address the addressable. In this context, I think it is worthwhile to consider a key conclusion from a recent book from Canada which examined how to develop high performance health systems and specifically what might be done in Canada. One of the key conclusions of the afterword in some senses says it all. To really make a difference, among other things, the following is recommended.
“Embrace the information revolution
When it comes to comprehensive, real-time health information, Canada exhibits all of the characteristics of a country that doesn't want to know and doesn't want to tell. Those responsible for the health information and information technology (IT) agenda have said over and over that it may take 10 times as much money as we have thus far been prepared to invest to produce real-time performance information accessible to providers, the public, managers and policy-makers. Every high-performing health system story has electronic, standardized, widely used information at its centre. The next frontier is the office-based electronic medical record, which has to be standardized, interoperable, linkable and useful at multiple levels. Otherwise, we will end up with less analytical power than we had a decade ago.”
This paragraph is quoted from the following.
Lewis, S. 2008. "Afterword." High Performing Healthcare Systems: Delivering Quality by Design. 267-272. Toronto: Longwoods Publishing. For the full chapter here:
http://www.longwoods.com/product.php?productid=20153&cat=571&page=1
The full book can be browsed from here:
http://www.longwoods.com/home.php?cat=571
I think it can be fairly said that there is not much difference between ours and the Canadian system in this regard.
Going back to the MJA abstract there are four areas of systemic inefficiency which are raised in first point above. These are laid out as follows and I will consider each in turn.
“Traditional health care is fragmented, marred by quality and safety defects, with a failure to provide evidence-based care, and huge and unjustifiable variations in practice.”
1. Fragmentation.
We are all made well aware of the lack for co-ordination and information flows within the health system every time we receive even the simplest health service. Each service provider asks the same 20 questions, each one seems quite unaware of what had happened previously and each finds it near to impossible to easily access previous investigations, x-rays and so on ordered by others so they just go ahead and do it again.
Clearly once we put in place a secure managed messaging systems that link all health care providers and, with patient consent, allow the information that is increasingly held in electronic form to flow both waste and inaccuracy will drop and efficiency will rise.
Of course, before this can happen we need to have providers enabled with local systems that capture and manage patient information safely and reliably. Building this infrastructure is already underway but still has a very considerable way to go.
Only with Electronic Medical Records (EMR) and a robust Secure Clinical Messaging environment will so see major improvement in the co-ordination, effectiveness and efficiency, and importantly patient centeredness of the overall system.
2. Marred by quality and safety defects.
I think most are aware that virtually all clinical care carries risk and that if treatment is poorly judged or just wrong the outcome can range from trivial inconvenience to death. The US Institute of Medicine estimated in 1995 that in the USA there were 98,000 excess fatalities a year. That is the equivalent of a fully fatal jumbo jet crash each day of the year. We would fix the airline system in a week if that was happening but for some reason it is OK for the health system to be that dangerous!
The way these errors can be reduced is via the use of an EMR which provides electronic prescribing and electronic ordering of investigations which provides advice at the point of clinical decision making, where the evidence is clearest that quality improvement is most likely and most effective. Such clinical decision support systems are now well evolved and are improving as experience with large scale implementation is gained. They work, they make a very positive difference, and in 2009 there is no excuse for not using them!
3. Failure to provide evidence-based care.
At a slightly less point of care level, it is also well recognised that ease of access to professional clinical resources via the internet can assist the practitioner to provide care that is current and has been shown to actually make a difference to a patient’s outcome.
Two examples that provide models are the Clinical Information Access Program provided by NSW Health (see http://www.clininfo.health.nsw.gov.au/) and Isabel (see http://www.isabelhealthcare.com/home/default). Both these should be funded by Government for all clinicians. It would cost very little and make and appreciable difference to the quality of care and the consistency of care received by the Australian public.
4. Huge and unjustifiable variations in practice.
The evidence is utterly compelling that major errors of commission and omission in the health system are very frequent and that these errors, while not as dramatic and the errors in prescribing where a patient is poisoned or worse, the impact on quality of life and longevity can be just as profound. Examples include the failure to ensure asthmatics have a treatment plan, diabetics have regular eye checks and those with coronary artery disease do receive appropriate statin medication. Each failure to not follow the well established guidelines can be pretty much as fatal as the acute poisoning!
There is also strong evidence that the rate at which clinical practice changes to reflect ‘best clinical practice’ is unacceptably slow with diffusion of the best practice into usual practice sadly often taking decades.
Also important in this area is the concept of ‘rapid learning’ where the contents of many EMR’s can be used to greatly assist in clinical research and the tracking of unexpected reactions to prescribed medications. Use of such approaches, once the EMR infrastructure is in place, can make a major contribution to medical knowledge and post-marketing surveillance of newly introduced medicines.
This ‘rapid learning’ approach can also be used very effectively to exploit the information captured by EMRs and using aggregate information to provide feedback to the practitioner, in the form of a personalised and private audit, to see just how they are doing compared with the agreed standards. This can be quite effective and can indeed be made more effective by a regime of financial reward and penalties. Some may complain this is a bit like ‘big brother’ but I must say that with well designed and peer reviewed and agreed guidelines the excuses for not providing optimal care most of the time are hard to fathom.
As is clear from the above, understanding making a difference to the quality, safety and efficiency of Health Care in Australia through the use of information technology really only needs to recognise the truth of these defects and to appreciate that, with investment in Health IT, very significant improvement is possible in each.
For more detailed information on many aspects of Health IT the following link provides access to a comprehensive range of discussion and evidence based on fully peer-reviewed literature from all over the world.
That we see major investments in Health IT being undertaken in Canada, the US, the UK, New Zealand only emphasises the importance of Australia beginning a seriously planned and co-ordinated effort of its own. Certainly such investments have been firmly recommend both by the National Health and Hospitals Reform Commission and the earlier Nation E-Health Strategy developed for the Council of Australian Governments by Deloittes here in Australia. Many are becoming frustrated by the lack of apparent commitment from the present Government. The time for action has well and truly arrived in my view – a position which is well supported by the material offered here.