Wednesday, April 26, 2017

The ADHA Puts A Case For Digital Health. Pity The Evidence Is So Old And Inconclusive.

This blog from the ADHA appeared a few days ago.

Health in an age of information

Thursday, 20 April 2017
"Cause we are living in a material world
And I am a material girl
You know that we are living in a material world
And I am a material girl"[1]
You know these lyrics. Madonna's single "Material Girl" and its accompanying video were huge hits in 1985, and went on to define much of her career. But was she right? Is she really a material girl? And are we living in a material world? More than 30 years after she sang this song, we find that the world we live in is becoming less and less about material things, and more and more about information.
From the perspective of the national and global economy, information technology is a vast and growing sector that is displacing manufacturing in value and influence. A similar trend is apparent in the economy of our daily lives: financial transactions are routinely conducted electronically, and reliance on the physical tokens of notes and coins starts to seem quaint.
The rising influence of information even shows in our understanding of reality itself. We’ve known for some time that the apparently solid objects of our experience are composed of atoms that consist mostly of space. And as physicists probe ever more deeply, even subatomic particles seem less and less substantial. Some theorists go so far as to propose that this gossamer-thin materiality rests on a bedrock of – you guessed it – information. As the science writer James Gleick puts it:
"The bit is a fundamental particle of a different sort: not just tiny but abstract – a binary digit, a flip-flop, a yes-or-no. It is insubstantial, yet as scientists finally come to understand information, they wonder whether it may be primary: more fundamental than matter itself. They suggest that the bit is the irreducible kernel and that information forms the very core of existence."[2]
Healthcare is no exception to these trends. As treatment methods become more sophisticated, we find that the quality of healthcare is increasingly dependent upon the quality of the information available to practitioners and patients.
It may seem like a truism to say that better health information leads to better healthcare, but in some respects the healthcare profession has been remarkably slow in embracing information technologies. Facsimile machines, for instance, are still in regular use to convey messages between medical practitioners, despite having been phased out in most other sectors. And handwritten notes are still commonplace in both large and small clinical practices.
There are good reasons for this conservatism, starting with the Hippocratic injunction to first, do no harm. Obvious as it is that reliance on facsimile messages and handwritten notes is somewhat old-fashioned, it is not so obvious that they are actively harmful. Newer systems for storing and communicating information may be more efficient and promise greater safety, but that promise ultimately needs to be tested in the crucible of daily practice. In such circumstances, a "devil you know" approach has clear attractions.
Network effects are another inhibiting factor. A single telephone is of no use whatsoever – it becomes useful when there is another telephone that it can call. And it becomes more useful still when there are hundreds or thousands of other telephones. Similar issues arise for other communications and storage technologies: they only become useful when both sender and receiver have similar equipment and apply compatible protocols.
The complexity of healthcare information is yet another factor. The financial sector has readily adopted modern information technologies in part because the key data in that sector is numeric information, which is easily represented and thoroughly standardised. In contrast, the underlying information in healthcare is exceedingly complex: it is often difficult to represent and only loosely standardised.
Despite all this, it has been estimated that adopting modern information technologies to Australia’s healthcare sector will save hundreds of lives and millions of dollars each year[3]. Let’s repeat that: hundreds of lives and millions of dollars could be saved each year by adopting modern information technologies to healthcare.
This represents the challenge, the mission, and the promise of the Australian Digital Health Agency’s work. Improving healthcare information may sound abstract, but this is work with very real, practical outcomes in the material world we live in.
Dr Andrew Westcombe is a technical editor at the Australian Digital Health Agency, with a PhD in Philosophy. 
[1] Songwriters: Rans, Robert; Brown, Peter. Material Girl lyrics © Sony/ATV Music Publishing LLC.
[2] Gleick, James, The Information: A History, A Theory, a Flood. Pantheon Books, NY, 2011, pp. 9-10.
[3] See http://www.strategyand.pwc.com/au/home/press/press-releases/displays/48757598
Here is the link:
I have provided the whole blog so as not to mis-state any of the arguments.
First it is really good to see some sensible points being made on the issues and complexity surrounding digital health.
Second it is really sad to see that the best that can be said on the benefits front is so old.

Booz and Company report identifies possible $7.6 billion in annual savings from Government investment in e-health

Sydney, 6 May 2010 — A report released today by leading global management consultancy, Booz and Company, has revealed Government investment in a comprehensive e-health system may generate more than $7.6 billion in annual healthcare savings by 2020.
The Booz and Company report, Optimising E-Health Value, outlines a comprehensive case for national investment in e-health to better connect GPs, hospitals and other points of care, so as to improve sharing of patient information.
The report points to reduced errors in medication as offering the greatest potential for savings ($2.6 billion), followed by improved care programs and prevention measures ($2.3 billion). Adverse drug events from errors in medication are estimated to affect 10.4% of patients currently treated by GPs in Australia each year, of which half are classified as moderate to severe, 138,000 require hospitalisation, and as many as 18,000 may result in death according
to some sources.
Booz and Company says a comprehensive commitment to e-health could help Australia avoid an estimated 5,000 deaths, two million primary care and outpatient visits, 500,000 emergency department visits and 310,000 hospital admissions each year.
Report co-author and Sydney-based Booz and Company Principal, Klaus Boehncke, said the analysis demonstrated clearly the benefits from significant investment in e-health, and the need to build such investment in the health reform agenda.
“E-health is the crucial missing piece of the health reform jigsaw presently, and it must not be allowed to slip from view,” Mr Boehncke said.
“Indeed, the success of some of the Government’s reforms, particularly the local hospital networks and primary care networks, and reduced Emergency Department waiting times, depends largely on the connectivity that a robust e-health system provides,” he said.
The report was based on Booz and Company’s global experience advising Governments and health authorities in countries overseas including the United States, Canada, Germany, Italy, Singapore, Hong Kong and the UAE. The e-health model outlined in the report draws on Australian health data and has been adjusted to reflect the characteristics of Australia’s health system.
The report says existing e-health investment in Australia has been patchwork, limited and often focused on acute care. It calls for a shift in e-health focus from hospitals to networking primary care settings – GP clinics - where the volume of patient interaction is high and the potential for flow-on benefits are greatest.
“GPs are increasingly at the sharp end of providing integrated and chronic care, and their role becomes more important under the Government’s reforms, with their initial focus on diabetes. There is a real opportunity to reap powerful gains by putting them at the centre of the e-health push,” Mr Boehncke said.
“Australia’s GPs – 95% of whom use computers - are among the most highly computerised in the world. However, they are not well connected with each other, or with other points of care such as hospitals, so the valuable patient information they hold is not shared with other care providers or indeed among their own community,” he said.
“With a national e-health infrastructure in place, we estimate an investment in information networking of $3,000 per annum per GP clinic could deliver up to $668,000 in annual savings per clinic, mainly through prevention and avoidable hospitalisation. Up to $5 billion of the total savings from e-health investment in our model would come from improving connectivity and dissemination of information to and from GPs.”
Booz and Company’s analysis argues the case for Federal and State Governments to fund the information networking of GPs, as they would be the beneficiaries of the resulting savings. The firm estimates Governments would share in 68% ($5.2 billion) of annual savings accruing from a national e-health investment.
Other e-health benefits identified within the Booz & Company report include:
  • Better use of healthcare infrastructure
  • Less duplication of diagnostics such as lab tests and X-rays
  • Savings from optimised use of pharmaceuticals
  • Enhanced productivity among healthcare workers
  • Early warning from disease outbreaks
Based on current trends, the estimated total annual savings of $7.6 billion from e-health may represent 3% of total health expenditure. This figure does not include flow-on economic benefits to Australia, such as improved workforce productivity, which are estimated to be considerable.
Mr Boehncke said the health community was watching closely for signs from the Federal Government that it would commit to a significant investment in e-health.
“It did seem obvious that e-health would figure prominently in the reform agenda but there are now concerns it may have slipped off the table. That would be disappointing – there are good reasons why comparable countries overseas are investing heavily in this area, and the arguments for doing so here are irresistible,” he said.
Here is the link:
Even if these benefits were real, and I don’t believe the quantum cited for a moment, with the strides in hospital computing, GP computing and secure messaging in the last 6-7 years surely most of them have been captured. Of course the myHR was not even a twinkle in anyone’s eye in 2010, so who knows what impact it may, or may not, have. Of course its costs of the myHR are also not included.
Before more is spent we need current estimates of costs and benefits. I wonder when they might be produced or is the May Budget just to have more evidence free expenditure, or worse, expenditure based on evidence like this. Really if this is the best evidence the ADHA can put forward frankly we are all doomed!
I hope not!
David.

25 comments:

Anonymous said...

The Booz and Company 2010 Report is a sad and painful reminder of how much excellent advice has been ignored resulting in 7 years being completely wasted.

By comparison Andrew Wescombe’s material girl puff piece does nothing at all to enlighten us about ADHA's understanding of whats involved in 'Digital Health'.

john scott said...

David, the ADHA article has left me wondering IF the focus on e-health as opposed to the MyHR might be a signal of some sort for re-opening the conversation about how to achieve the reported benefits.

And, in saying this, I suggest also that the metrics for benefits are too narrow in conception. It is very difficult to attribute the saving of a life to general IT investments as opposed to specific new technologies.

Equally, the use of cost savings fails to recognize the potential for improved allocation, improved safety, increased quality and increasingly important, improved adaptability. These are intrinsically local and networked.

Absent the reform narrative and solution framework we are without a basis for contribution as to the best way forward. Only when we have said narrative and solution framework will we be in a position to estimate the quantum of the various sources of costs and gains hopefully using a wider palette of measures.

Anonymous said...

David when you say “with the strides in hospital computing, GP computing and secure messaging in the last 6-7 years surely most of them have been captured” surely you don’t mean most of them have been captured IN Australia! – do you?

Re 8.12 AM Andrew Wescombe has given a PhD (Philosophy) view. I seem to recall Ian Reinecke filled NEHTA up with PhD's to solve Australia's eHealth problems. He thought they would know far more about the health system than health professionals!

Dr David More MB PhD FACHI said...

"David when you say “with the strides in hospital computing, GP computing and secure messaging in the last 6-7 years surely most of them have been captured” surely you don’t mean most of them have been captured IN Australia! – do you?"

Yes - think how much has been done in NSW and elsewhere with Hospitals in the last 7 years - Not perfect - but quite a bit. Equally GP systems are much more advanced as is the use of messaging I believe.

Royal North Shore in Sydney has been transformed compared with 7 years ago..

David.

Anonymous said...

Re 10.55 AM that's a fair observation. How much (what percentage) of these 'advances' to which you refer can be attributed to the Federal Health Department ??%, to NEHTA ??%, to ADHA ??%.

Trevor3130 said...

Here's an odd coincidence. When Health care homes: principles and enablers for their implementation in Australia popped up from Deeble Institute, I went looking for any mention of 'digital' in

"3.6 Principle 6: coordinated care across the care system"

and found nothing. Odd.

Dr David More MB PhD FACHI said...

"Re 10.55 AM that's a fair observation. How much (what percentage) of these 'advances' to which you refer can be attributed to the Federal Health Department ??%, to NEHTA ??%, to ADHA ??%."

My feeling would be nil. Any better offers??

David.

Dr Ian Colclough said...

I gleaned 4 ‘core’ messages in Andrew’s piece reflecting ADHA’s view of Digital Health.

1. Better health information leads to better health care.

2. The quality of healthcare is increasingly dependent upon the quality of information available to practitioners and patients.

3. Underlying information in healthcare is exceedingly complex it is often difficult to represent and only loosely standardised.

4. The challenges, the mission and the promise of the Australian Digital Health Agency is encapsulated by the statement that “hundreds of lives and millions of dollars could be saved each year by adopting modern information technologies to healthcare.

I think it fair to conclude that the ADHA desperately needs a better way of conveying it has a firm grasp of the Digital Health issues it is being funded to address.

Anonymous said...

11:18 AM David said "My feeling would be nil." Not many would disagree with you David. In other words while the States play the political game by paying lip service to the Department, ADHA and the MyHR, in reality they go their own way doing their own thing thereby making some progress.

Bernard Robertson-Dunn said...

Re Ian Colclough's 4 points.

Has anyone defined exactly what is meant by, and how we can recognise:
a) Health information?
b) The quality of information?
c) The nature of the complexity of information?

And, has anyone actually explained how "“hundreds of lives and millions of dollars could be saved each year by adopting modern information technologies to healthcare."

Andrew's piece is just a re-hash of the same tired old conventional mantra that computers are good.

IMHO, innovation will not come from those who believe in the old wisdom. Especially when the old wisdom cannot be backed up by evidence and/or logic.

This government's e-health policy is still sounding like cargo cult thinking. That or insanity - keep doing the same old stuff and hope to get a different result.

john scott said...

Bernard, the short answer to your three questions is Yes.
They can all be addressed. However, they can only be addressed by means of putting people, specifically clinicians, at the centre of the system. For it is only they who understand the differences, what constitutes quality of information as well as the complexity of health information. And when we speak to the quality of information we are really speaking to the right information at the right place and right time so that care decisions and treatment decisions are appropriate and actionable.

To address these challenges the ICT brigade has to stay well clear until asked to contribute.

The above implies and indeed obligates a fundamental shift in the way we see and understand how to go forward.

I have seen nothing over the past 5- 10 years that suggests the Commonwealth or its advisers fundamentally understands why this is so.

Andrew McIntyre said...

One thing for sure is that replacing fax machines with pdfs sent in a message is not going to result in major savings. We need good data to get real benefits. We need to track outcomes of interventions, drugs and diets and pdfs are not going to enable decision support, although may result in a slight efficiency gain, but not that much over fax.

Desperate for some sort of outcome people seem to have settled for pdf as the holy grail. Its a dead end and sells eHealth short. We need a push for high quality messages with atomic data. Then we will have something to message that actually works reliably. The promise of good data to evaluate outcomes is what I am after. Every patient is then a clinical trial that can be reviewed and collated. Sadly no one has actually tried to achieve that, I don't think they understand enough about the technical underpinnings required. Its all so high level and hopeless.

Bernard Robertson-Dunn said...

John,
I was asking if they have been or could be defined, not addressed. If you don't know exactly what they are, it's hard to do anything about/with them.

As they say, if you don't know where you are going, anywhere will do. A bit like MyHR.

john scott said...

Bernard, I fully agree with your statement that if you don't know where you are going...
I suggest that anywhere different from where we are now probably feels like progress--if you don't understand what getting to the destination is actually predicate on from a healthcare delivery perspective.

My answer stands in regard to both ability to define and to be addressed.

I fully appreciate that we are talking about pervasive semantics. That is, the medical / clinical terms mean the same thing at both the receiver and sender ends of a communications. And, that includes implicit communications with medical / clinical record repositories. This is no small ask and requires very targeted activity and patience.

The patient specific details provide the values for the various clinical terms at the time of the communication. Everything is what you might call 'academic' until you add the patient-specific details to any communication. This appreciation provides the next layer of the communications onion. For it is, as you fully appreciate, at this point that all manner of Duty of Care, medico-legal and privacy and security issues come into sharp relief.


Anonymous said...

John Scott: To address these challenges the ICT brigade has to stay well clear until asked to contribute.

With the greatest respect it is this 'go it alone' approach that is holding us back, dividing the community and allowing us all to be ignored and picked off. We need to be working together, not just ICT and Clinical, but all viewpoints, from this a better and emergent property of interactions over time will reforge a strong and focused community and I believe, create a more mature state of understanding and appreciation of each viewpoint, the respective constraints and value adds of each.

From what I have seen and heard from the ADHA goes against this, there seems a drive to deplete knowledge with miss-management, this seems a pattern across all levels of government, out with the brains in with the BS.

David, your reference to what value was gained, I would argue that NEHTA ( previous to the DOHA shutting down community and communications), played a key role in sorting out the less exciting aspects, such as common languages, architectures, standards etc.. bits commercial companies cannot do on their own.

Yes they are not flashy and you don't cut ribbons but extremely important IMHO. Sadly we have lost this national capability and Government is now an owner operator of a uncompetitive platform. SMD and others seem more about protectionism and market gain than anything else.

As for the originating article, this I believe underpins why everyone has a perspective and can be and are valuable contributors. Sometimes you need to see the problem through others eyes.

Bernard Robertson-Dunn said...

OK, let's start with the problem.

How can we achieve more effective and efficient healthcare?

First observation - the Federal Government doesn't provide healthcare, the states do.

So who is best placed to improve health care? Who has more experience of health care? Who has small environments in which they can test various solutions? Who would get the most benefit out of better health care?

Not the Federal Government.

So why are they even playing in this space?

Answer - politics and power. In Australia it's nearly always about State/Federal infighting.

Result - The states are happy to let the Federal Government throw money at some vague problem as long as their (the states') funding is not reduced.

Result - At the Federal government level - zero benefits. At the State level (not the Territories. NT does what the Feds tell them. ACT is too small), they are quietly getting on with it at a variety of speeds and success.

However, for the most part they are clinically driven systems as needed by hospitals and health care professionals. No mass invasion of privacy, no central, internet attached honeypot of health data.

The May budget and the ADHA strategy will tell us a lot more, but my advice is - don't hold your breath. Not if you are waiting for a brave new world.

Bernard Robertson-Dunn said...

... and one other thing. Maybe the reason why the Federal Government has failed dismally so many times to improve the delivery of health care is because they do not have the perspective, the people, the knowledge or the skills needed to solve such a complex and wicked problem. And still don't.

Anonymous said...

AnonymousApril 28, 2017 8:14 AM. Completely agree. Bernard, the strategy is or will be simply the myHR. The Government is hell bent on opt-out. Now wether they then address the serious concerns and design flaws so that myHR becomes more than an expense dumb library of high risk target of the personal details of every citizen is yet to be seen. Ignorance is bliss and I fear they do not know what they are playing with.

Anonymous said...

Looking forward to opt-out, we have had access to a large number of feeder systems for many years slowly injecting the tools of our trade. I am looking forward to demonstrating our capability.

Anonymous said...

6:01 PM I don't doubt you and your friends, however, the Government will do the job for you, they seem quite willing to illegally use meta -data, and all we get is - the good thing is the commissioner owned up to it quickly? These people are beyond words

Anonymous said...

Here is a fine consumer introduction to the MyHR, one that should get the airtime it deserves - https://youtube.com/watch?v=K4XcGlrXDtI

MY Health Record - advice to patients

Something the ADOHA and Madden should publish on their website for a balanced view

Anonymous said...

Interesting video Anon May 01 8:58 PM. This seems contradictory in some parts as to what the Department is saying and what Tim Kelsey is telling consumers? Are we sure those on the ground who deal with this in reality on a day to day basis know what they are talking about?

Sadly this video will be lost/squashed in amongst the volume of alternative information and carefully staged events coming from Government. In the same way as various legal focused reviews and medical practitioner views.

Bernard Robertson-Dunn said...

This might cheer everyone up; NOT.

There’s no good way to kill a bad idea
https://qz.com/966006/theres-no-good-way-to-kill-a-bad-idea/

"...it’s far easier to put forward ill-informed and nonsensical views than it is to systematically refute them, meaning that even the most logical rebuttal can fail to puncture a bad idea."

Bernard Robertson-Dunn said...

What Pharmacists are recommending re MyHR:
https://twitter.com/isbshep/status/857772467720306688/photo/1

* A deadline/timely rollout for national uptake of the out-out system

* Prioritise software adaption for health professionals\

* Digital assistance for hospitals

* Give pharmacists and other allied professionals ability to contribute to records

* Allow Interns and Technicians access to MrHR (sic)

My reading is that pharmacists want to open up MYHR so lots of people can just throw data at a patient's record without anybody having the responsibility for making sure it is consistent, accurate or relevant.

And they want non-health professionals (Interns and Technicians) to be able to see a patient's record.

IMHO, the more ADHA/Pharmacists want to do to MyHR the less useful and more dangerous it will become.

Anonymous said...

My issue with Pharmacies (not pharmacist) is they will want to push specific brands, products and snake oil treatments with little regard to patient outcomes or the practitioners wishes. Government is happy to let this happens as balance sheets make life simple.

Great article Bernard