Professor Enrico Coiera is Director of the Centre for HealthInformatics at the University of NSW. This is the text of his address in the UNSW Medicine Dean's lecture series last night. Used with permission.
The E-health revolution
E. Coiera
2010 Dean’s Lecture
Today I can download a new episode of my favourite TV show on the night it shows in the US, I can email a home movie of my son to his grandparent overseas, and use Skype so they can watch him grow. I can log onto my bank account and manage my finances, I can find a long lost friend using Google or Facebook in less time than it takes to make a cup of coffee. With my Kindle or my iPad I can download any number of books or magazines, and within a decade, pretty much any book ever published.
What I can’t do today in Australia is download my medical record and see my medical history or latest test results. What I can’t do today is search online to see which health professionals can see me, and book myself in. I can’t find out who is best qualified to treat me, or who even has an interest in my condition. And even if I did, and sent them an email, how many clinicians today use email as a major part of their health practices? Imagine asking to use Skype!
For such a high technology industry, healthcare seems strangely decoupled from much of the information revolution. Which is surprising given that the first research papers on the use of computers in health date back to the 1950s.
Well, the revolution, as they say, is coming.
In the US, the Obama administration is spending over US$21 billion for e-health, as part of the national stimulus funding to recover from the GFC, but also because Obama campaigned on this in his bid for presidency. He is committed to modernization and reforming the US health system, and he can’t conceive of doing that without the use of information technology.
In England the NHS has been at its modernization program for over a decade, investing over £12 billion just in health IT. The news from the UK is that there are mixed results, and if there is a single headline, it is that large scale IT programs should never be managed by government. Government is good at policy, not systems implementation.
If we want to look for shining beacons, we can look to countries like Denmark, which seem to have gotten this right. Virtually all Danish primary care physicians and specialists use computers to electronically send and receive clinical messages such as prescriptions, lab results, lab requests, discharge summaries, referrals, etc. Their national health network is used by over 3⁄4 of the healthcare sector, comprising over 5,000 organizations. The Danish national health portal created in 2005 permits providers and patients to access laboratory results via the Internet. Danish patients can also see who has accessed their data. They can access waiting list information, online appointments with primary care physician, e-mail contact to primary care physicians, and renew their prescriptions online.
In Australia, we have been slow to the mark. If there is a shining success story it is in primary care, where the vast majority of GPs use computer systems at least to write prescriptions, and most have some for of electronic record. The situation in our hospitals is not so good. States are slowly investing in e-health systems for our hospitals, but the pace is painfully slow and patchy. And up until now, the likelihood that some of the data stored in your GPs computer can be transmitted to the hospital or a specialist, or vice versa, is close to zero.
There is however some hope – in the most recent budget we have been promised just under a half billion dollars to allow our medical records to be shared between different providers. We are promised that in 2 years time, each of us can log onto the web, access our medical data, and allow our carers to see that information. What is not being proposed is some large centralized national database of medical records. Rather, learning from recent US experience, we are most likely to see our electronic medical records stay where they were created, and a national network that allows patients to log on to see their records, and share them with other members of their care team. This is a plan that makes much sense, and seems to have broad support from consumers, industry and the professions. But just as I started to get excited that Australia would belatedly catch up with the rest of the developed world, the coalition has announced in their budget reply that they will not proceed with this e-health investment if elected.
So, why do we need to spend money on e-health? There are so many competing demands on the health budget, that spending it on computers and networks and software seems so disconnected from the clinical front line. Don’t we need more beds, and more doctors?
Our biggest challenge is keeping healthcare sustainable. We are stuck on the twin horns or increasing demands on the system, and decreasing resources, creating a classic sustainability gap. The costs of health as a % of GDP are projected to double in the next 30 years. Some of the increasing demand comes from the increased health burden of the aging population, but 75% comes from the costs of new drugs and new technologies, keeping us alive longer and in better shape than before. Better health is not free.
But our health resources are decreasing, as we all know. An aging population means relatively fewer tax payers, more dependents, and relatively smaller workforce.
This is where E-health can help. Automation allows healthcare workers to be more efficient, and make fewer mistakes. And as a consumer, it permits you to engage actively in your own self management, which is essentially a cost shift from the health system to the individual – a shift which I think most would actually welcome.
There is now good evidence to support this. Through repeated studies we have shown that e-health can:
–Improve patient safety (eg by reducing prescription or medication errors, and avoid adverse drug events)
–Improve clinical efficiency (eg by reducing duplicate tests, or reducing admissions by home monitoring, which allows the chronically ill to be better managed and avoid exacerbations needing hospitalisation)
–Help clinicians care for more patients (e.g. having an electronic medical record, and computer systems to handle medications and tests in a hospital is associated with reduce length of stay – in other words frees up beds)
–Helps the burden of care shift to the consumer (e.g. electronic messaging reduces GP visits by 10%)
What will it feel like to live in an e-health world as a patient? Well, we already have many instructive examples from around the world.
You will be able to access web sites where people share their experiences, positive and negative, about hospitals or doctors, and provide stories, comments, and yes .. ratings. Whether or not government chooses to publish rankings, or the professions try to stop it, the public will do it anyway.
You will have your own ‘healthbook’ which is a bit like facebook meeting internet banking, where you will handle all your health ‘accounts’ – juggling bookings, managing your care according to agreed plans, and keeping records of what you and others have done. And using the new social computing world to ‘invite’ others in your care team to see your data.
If that all sounds too far fetched, or you are worried about privacy, why not log on to pateintslikeme.com. Started a few years ago by some MIT engineers, you can not only join and create your own personal health record, but you can read other people’s records. While people are a careful about not reveal their names, you will see communities of patients share detailed information about their treatments, and experiences. It is refreshing to see what patients want, and what they are willing to share.
We have been hard at work trying to understand what this new world looks like and are trialling our own system, called healthy.me.
In healthy.me, you can do standard things like create your own medication records in your pill box, and keep a record of what you take. You can keep records of important test results to share with others. You have a schedule that tells you when your next appointment is due, or remind you to make an appointment. You can create your own ‘team’ of healthcare professionals, and manage what parts of your personal record they can see. And we stitch the whole thing together using treatment plans, which we call patient journeys. These journeys don’t just tell you what to expect, but help you manage your medications, your appointments, your record. The journeys can be written by a local GP, a national standards body like the heart foundation or NHMRC, a hospital, or by groups of consumers. Parents of children with autism, or cerebral palsy already work hard to share information on self-management online, and these tools allow them an even more powerful way of sharing information. It’s a very simple and powerful unifying idea.
Not only are systems like healthy.me going to make each of us more engaged and more effective in managing our healthcare. They will create new sources of data to support medical research.
Today we can already predict flu outbreaks just by mining google. Google engineers have shown that if you look for spikes in search keywords related to flu like illnesses, you can accurately predict or track flu outbreaks.
And as we start build detailed personal health records for populations, researchers will have a powerful new data source to study diseases at a population level.
I want to now finish with a little blue sky and tell you what I am secretly most excited about. For the last two hundred years the model for medical research has been the diligent scientist hard at work on the lab bench, carrying out experiment after experiment to gather data. The inspiration for the experiments is always human intuition, looking for previously unseen connections.
If any of you have ever seen the movie Lorenzo’s Oil, you’ll be familiar with the idea that for many problems, all the data is already there – it just has not been joined up. And that is where e-health, and specifically, the computer, comes in.
The computer is a perfect machine to join up the dots. As we put more and more of human knowledge online, as more and more of our medical record gets digitized, as more and more of the genome revolution enters routine practice, we are creating a giant sandpit for the computer to play in. Computers are well suited to trawling through billions of data points, looking for hidden connections or associations. Indeed, many of us think that the 21st Century will be one where many, and perhaps the majority, of science will happen through the used of computer-aided discovery.
I will end by showing you some recent computer discovery work at our own Centre.
We have downloaded the entirety of pubmed abstracts, which represents most of the English language medical research for the last 50 years, onto one of our computers.
We were interested to see if we could find out previously unknown associations between disease and infections. We have built what turns out to me a giant map of the entire literature of research into infectious diseases, showing which infections are most predisposed to which diseases.
We can ask questions about what genes are common between different organisms to allow them to cause the same disease. We can track the changes in the importance of diseases over time using what we call our Doppler graph, showing red for increasing publications relating diseases and organisms, and blue when the topics decrease.
And using publication heatmaps, we have already found many new genes, which are promising candidates for bench researchers to investigate. The computer model thus not only allow a scientist to visualize what is already known in new and challenging ways, it also suggest new hypotheses.
Medical research has been described to me as searching for the truth in a large dark room with a bright narrow flashlight. If you are lucky enough to point the flashlight in the right direction, you will see what you are looking for. What the computer allows us to do now is to dimly illuminate the whole room, so that the human flashlight knows where to look.
The e-health revolution is coming. It is going to be transformational. And it will touch us all – as patients, as clinicians, and as scientists. These are very exciting times indeed.
----- End Address
The speech was also covered here.
The net can be good for your health
ENRICO COIERA
May 25, 2010
I can download a new episode of my favourite TV show on the night it shows in the US. I can email a movie of my son to his grandparent overseas. I can find a long-lost friend on Facebook in less time than it takes to make a cup of coffee.
But in Australia I can't download my medical record and see my test results. I can't search to find health professionals who can see me, and book myself in. I can't find out who is best qualified to treat me. Even if I did, and sent them an email, how many clinicians use it as part of their practices?
For such a high-technology industry, healthcare seems strangely decoupled from much of the information revolution. Which is surprising, given that the first research papers on the use of computers in health date back to the 1950s. But the revolution is coming.
The US administration is spending over $US21 billion ($25 billion) for e-health. Barack Obama is committed to reforming the health system, and he can't conceive of doing that without information technology.
In Denmark virtually all primary care physicians and specialists use computers to send and receive clinical messages such as prescriptions, lab results, requests, discharge summaries and referrals. Patients can access laboratory results and see who has accessed their data. They can access waiting list information, make appointments or renew their prescriptions online.
In Australia we have been slow off the mark. Most GPs use computer systems to at least write prescriptions, and most have some form of electronic record. The situation in our hospitals is not so good. The likelihood that some of the data stored in your GP's computer can be transmitted to the hospital or a specialist, or vice versa, is close to zero.
Full Article here:
http://www.smh.com.au/opinion/society-and-culture/the-net-can-be-good-for-your-health-20100524-w7w0.html
Good to see such contributions and publicity.
David.
