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Timeless Quotes - Sadly The Late Paul Shetler - "Its not Your Health Record it's a Government Record Of Your Health Information"


H. L. Mencken - "For every complex problem there is an answer that is clear, simple, and wrong."

Monday, April 05, 2010

Last Chance to Comment on E-Health and the NHHN Article.

First thanks to all who commented. New version addresses those comments and adds material on the recently announced diabetic treatment approach.

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The Australian National Health and Hospitals Network - Where Does E-Health Fit?

(Version 2.0)

In the report published in early March on the Commonwealth Government’s National Health Reform Plan there were a major set of structural reforms announced.

In brief these are (taken from page 9) of the report the Commonwealth Government:

  • becomes the majority funder of public hospitals;
  • takes over all funding and policy responsibility for GP and primary health care services;
  • dedicates around one third of annual Goods and Services Tax (GST) allocations currently directed to state and territory governments (referred to throughout this document as ‘states’) to fund this change in responsibilities for the health system;
  • changes the way hospitals are run, taking control from central bureaucracies and handing it to Local Hospital Networks; and
  • changes the way hospitals are funded, by paying Local Hospital Networks directly for each hospital service they provide, rather than by a block grant from the Commonwealth to the states.

As with many such large scale reform proposals the more detailed revelations as to what is actually planned seem not to come in the initial document release and in the case of e-Health the report specifically notes that there are more detailed announcements in this specific area to come.

That Information Technology is an area to be addressed is seen on page 19 where “improved integration of information technology across our health system” was a key element of feedback received from the consultations held following the release of the NHHRC Final Report. This is confirmed in the press release associated with the report’s release where we find the following.

“On the basis of these reforms, over the coming weeks and months, the Government will announce critical additional investments to:

  • train more doctors and nurses;
  • increase the availability of hospital beds;
  • improve GP services; and
  • introduce personally-controlled electronic health records.”

As I write this, in early April, 2010, we have also seen the additional clinical training announcement, part of the preventive care announcement – on Diabetic Care - but are still waiting for the others to fill in details in areas like e-Health and primary care.

It seems a major part of the final e-Health plan is to introduce “personally-controlled electronic health records” and that this is a key thrust of a relatively imminent announcement. Just what these actually are and the implications of this plan are totally unclear at this point.

Before commenting specifically on this specific proposal we need to flesh out the other aspects of the plan a little. The reform plan talks of small networks of public hospitals of 3-5 or so hospitals. (It is mute on how these will relate to primary care and the private service sector (hospitals, radiology, pathology etc). According to the AIHW there are 736 public hospitals so we can assume that there will be around 170 Local Networks formed.

On the basis that we do not as yet have an e-Health plan announced what needs to be included?

First, any new plan needs to closely review the directions which have been agreed by the States and Territories to date in the form of the National E-Health Strategy which was released late in 2008.

Second any new plan needs to recognise that there are significant ‘facts on the ground’ already in place and in process and these, where appropriate, need to continue on uninterrupted.

Third the plan needs to properly address coordination of care and information flows between all the various elements of the health sector. It needs to be genuinely inclusive of the public, private and community health sectors.

Forth there is a major issue in e-Health regarding just what should be addressed at a national level and what is appropriate for local decision making and governance. My preference here is for a high degree of local autonomy within a pragmatic, flexible and responsive national e-Health standards and governance framework. If this is not addressed the risks of all sorts of failures is very high. Careful decision making will be required to determine the correct scope of national versus local provisioning and infrastructure etc. It will be important to avoid both inefficiency if the scale of e-Health service delivery is too small, while at the same time ensuring any larger service delivery agencies that are developed are both responsive and genuinely efficient.

Fifth any concept of shared personal health records needs to be deferred until the automation of all public and public care providers, and clinical messaging is well advanced and consistently standardised. Once this is achieved is the time to take the next steps of clinical information sharing with very high levels of consumer consultation around areas such as security and privacy. This is very much a walk before you run, essentially bottom / middle up approach rather than top down in most aspects.

Even with this limited ambition there are a range of problems that will need to be addressed.

An obvious one is that even if the number of local networks is only half of what seems to be planned there are a range of infrastructural elements which will be too small to be efficient and practical. E-Health is very likely in that basket.

A possible solution to address what is needed may be to adapt the Health Information Exchange (HIE) Model which is seemingly being quite successful in the US. In this model primary care computing and care co-ordination is central – empowered by secure information flows, with patient consent, between health care providers.

Appropriate aspects of the information flows can also made available to consumers via clinical portals and a Personal Health Records (PHRs). Everyone needs to realise PHRs are still a very unproven technology and may not actually prove to be all that useful or valuable in the longer term.

Appropriately sized Health Information Exchanges – maybe covering four or five local networks are both feasible and demonstrably effective. Of course the governance, leadership, funding and resourcing in terms of implementation, project and change management skills would be critical if success is to be assured.

If we do not see a proposal similar to this emerge from the Government in response to the NHHRC report and the National E-Health Strategy I will be very disappointed.

It also should be noted that the plan for diabetic care announced late March has some quite direct e-Health implications.

This announcement has to be seen as signalling a move to a disease based capitation approach from the from the fee for service model we have seen for the last 40 or so years under Medicare and its predecessors.

The IT implications for GPs choosing to enrol such patients are interesting as they will need to keep track of the various activities being undertaken for the apparently fixed fee of some $1200 per annum for a total package of diabetic care.

It is not clear present systems are set-up to optimally handle what is essentially a ‘managed care’ model for these patients. As enrolment is voluntary there will need to be the capacity to manage that process as well as ensure all the relevant preventive and treatment interventions have been delivered. Additionally there will presumably be an increased record keeping role to ensure that the outcomes sought by the overall $10,000 practice incentive payment are being achieved. Again a good deal more detail will be needed to see what precisely will be needed.

As the plans already announced have a considerable care coordination aspect it seems likely there will also be implications for inter-provider messaging and communication which will also need to be addressed electronically.

It seems highly likely that the planned announcements in the primary health space will have further e-Health implications separate from any particular strategic direction, and bringing all this together is a considerable task which is going to be important to get right if the still somewhat vague overall vision is to be successfully delivered.


National E-Health Strategy – September, 2008


National Health And Hospitals Network Report – March, 2010


Ministerial Press Release – March 03, 2010

A National Health and Hospitals Network for Australia’s Future


Primary Care Based Health Information Exchange (see for example).


Ministerial Press Release – March 31, 2010

$436 Million To Take Pressure Off Our Hospitals By Delivering Personalised Care For Diabetics



Dr David More is a Health IT consultant with over twenty years experience in the e-Health area who blogs on all matters e-Health at www.aushealthit.blogspot.com. He may be contacted via the links provided on the blog.

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Comments welcome for a few days.


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