Keynote address to Healthcare Information and Management Systems Society (HIMSS) AsiaPac11 by Dr Mukesh Haikerwal AO Wednesday 21 September 2011
It is indeed an honour to stand here before this august body of the leaders of healthcare, of health innovation, health IT and indeed those that plan and direct health services across Australia and across the whole Asia Pacific Region.
I am in awe of the trust you have placed in me to start off this sentinel conference, here in my home town – well allegedly my home town – marvellous Melbourne. I hope I can start that thinking and sharing process that is inspiring from gatherings such as this.
I am particularly excited that this reunion (as it is said in French) brings together many peers and heroes from our region to share ideas and challenges, learning and aspirations.
The location, here in Australia, is a great tribute to planning and foresight - and of course very fortunate - noting where we are in our eHealth innovation, implementation and planning.
Australia is at a very exciting point in the evolution of healthcare and health IT usage.
I stand before you as a medical practitioner, as a patient, a parent and an advocate...an advocate for my patients, my profession and the industry which I am now proud to work with...the Health Informatics industry which I see as core for a successful sustainable health system.
This Government, like many before, has embarked on an ambitious change management process for health, noting that healthcare cannot be delivered in the same way tomorrow as it is today.
We know the equation:
o more people in the system
o more with chronic and complex diseases
o an ageing population
o more expectations
o more demands
o more technology to maintain, preserve and lengthen life
o increased costs and fewer healthcare practitioners to look after individuals.
The way we do healthcare across the world has to change.
In this country it is the notion of:
o patient empowerment
o the patient being at the centre of their care
o the patient being the integrator of their care
o the care moving to the home, community and near where people live
o from the hospital where they go when the levels of care required increases, is more intensive and requires more specialist and high cost high infra-structure cost interventions
o the care in the new paradigm revolves around patient need as the end-user and for whom the service is required, from the services set-up by the answering the system's needs.
In short, we cannot continue to work as we've always worked.
Something's gotta give!
To me, I'm sure you'll agree, working smarter, and using new tools to enhance the way we work has to be the answer. eHealth - using modern technologies in health.
eHealth is health's get out of jail card.
I would like to illustrate why we need to keep advocating for our goals and keep reminding those that take advice and make decisions that this process – embedding technology in health is a very valid, cost effective and valuable investment in health, healthcare, health outcomes and the improved care of individuals and an enhanced patient journey.
September is the month when Australian Football Leagues (AFL) finals come to Melbourne. The Grand Final takes place on a hallowed 'one day in September' – except this year: 1 October 2011.
My first story then is from Grand Final Day 2008.
On this day the Hawks from Hawthorn upset the Cats from Geelong.
The other upset for my family was that I ended up in hospital with a fractured skull and blood clots to the brain after a violent attack about one kilometre from my home.
The details of that are not important but the care I received was magnificent.
I was lucky that I was in my home town and that my two first attenders were my wife and brother: both medical practitioners.
My local hospital cared for me superbly, but my history from me on admission was not the clearest: in fact my brother signed my consent to operate for me.
There was the journey from the scene of the attack, to the Emergency Department, to the operating room to the Intensive Care Unit and onto the ward.
Then there was the transfer to another institution – the Epworth Hospital where my life, now saved, was restored with pain-staking rehabilitation with at least eight disciplines involved actively over three months.
My point here is that I stand before you as the result of my brilliant colleagues from across the health professional spectrum who worked intensively, long and hard and who did what they did despite the poorly connected hospital not because of it.
The systems do work today. They are excellent, but they are disjointed.
As an example, my arrival at the Epworth necessitated a rushed note of discharge, some photocopied notes and probably unhelpful commentary from the dreaded doctor/patient who lived up to the reputation as the world's worst patient!
Comfort aside, the process of at least eight interviews with the same questions being asked, at a very vulnerable time psychologically and physically was gruelling.
Of course the normal processes of good medical care is needed but if there was a synopsis to help both the patient and the clinician save time and the feeling of being interrogated to find fault is a very real benefit.
Remembering details of medication took a little time to recall.
Having a health record summary supports the process for both Clinician and more so the patient and their carer.
The rehabilitation team all used hand-written notes, usually in different files or different parts of the same file which on more than one occasion went missing in one of the many places visited.
What I later learned was the hand-written notes were supplemented by hand written billing by the clinicians so that much of their time was wasted in administration when IT could relieve their burden.
And recovery is not just a function of the hospital, the clinician and the system but the patient and their willingness and ability to be an active participant.
The other case is just an observation from my general medical practice that every day an enormous amount of time is taken up hunting down patient information as they seek continuation of their care for which they have no clue about their care, expect information will have been provided...and it is not!
As our state minister's greeting to the conference notes, 'the Victorian Government's Health Priorities Framework includes a commitment to obtain the best possible health outcomes'. This is welcome.
Victoria is not alone.
The governments of Australia – the state and territories and the federal government - in their wisdom – and I am being serious and not facetious here – established an organisation to tackle the disparate developments and lack of connectivity with IT in the health sector.
The formation of the National E-Health Transition Authority (NEHTA) in 2005 by the Council of Australian Governments (COAG) has brought a standard rail-gauge approach to the widespread deployment of modern electronic technologies in the healthcare system.
This allows leveraging of developments across the nation and avoids perpetuating the current situation of multiple technologies used across the system which can't talk to each other. Using technology is what Australians are very good at doing across sectors of the economy and now will be seen in health with multiple benefits.
The current federal government investment of $466.7 million will see the introduction of the personally controlled electronic health record (PCEHR) which all Australians can register for from 1 July 2012. It will be the catalyst for widespread use of eHealth in Australia with multiple dividends for Australia.
These investments and the way we are embarking along the journey to delivery have learnt much from international experience and home grown activities.
It is fair to say that this time is probably the most exciting time to be in health IT because, at last, the penny seems to have dropped and investment is flowing.
The other pennies that are dropping are:
This is about change management in health and not about the technology.
o eHealth is the key enabler of sustainability of healthcare in each state, territory and nationally. The technology is there, and will evolve
o technology will be the subject of innovation and itself can drive innovation but, fundamentally this change is about healthcare
o does the technology enhance current the excellent practice; the dividends are there for all to take advantage of.
o the pitch to the clinicians then is not a sales pitch of vapourware and shiny new toys and widgets, but a business proposition that works for them, supports their considerable breadth and depth of work and enhances it
o there must be a clear value proposition for any such investment over feel good and an expectation that it will just happen
o changes must not impede them nor increase the volume or complexity of their work processes but reduce it.
The other penny is that this cannot be done in isolation and the way in which we invoke the brilliance, advanced thinking and innovation of the IT sector – the vendor space – is key and core to success.
o the way this sector works though needs to be with a clear sight of the end user and their needs.
o to provide what the clinician requires in their daily work and not over-promise and under deliver, to grow incrementally the offerings and build on successes
o the way in which the vendor community works with the Clinical community then is another place for change
o providing what the vendor needs provides the other side of the equation
o working in isolation is folly and doomed.
NEHTA needs to act as a supplier of technology standards and products which are part of the build for eHealth in Australia and in particular what's needed to play in the PCEHR space.
o The new partners are on board for the PCEHR: this does not exclude and bar others from working in this space.
o It is imperative that those willing and able to participate have access to the standards and specifications in an orderly and professional manner with the needs of the end user: in this case the vendor supplying the clinician and being advised and supported by NEHTA to understand and comply with the build developed.
o This needs to be a concerted, collective effort.
We have heeded the lessons of great successes in Australia and across the world – and felt a little of the pain from our colleagues.
If there is no clinical input, there is no system- at least the system will have little use as it is of dubious benefit.
At NEHTA I have the honour to work with over 60 Clinical Leads from many disciplines who are our internal clinical check points within NEHTA. This means for each area where products are being developed there is a clinical gateway. This also includes clinical safety with a different part of the team.
This work is now seen to be of benefit so that when we do what we have to do and go to our stakeholders for an external check and ratification the build is well enough developed to require little change.
The other groups we work across the health system with are the consumers, the vendors and the policy makers.
My talented and committed Engagement Team and the NEHTA sector expert advisers are helping drive this new way of doing business.
There have been extensive consultations around the development of the final concept of operations of the PCEHR developed by the team.
This included two symposia of people from the health sector on eHealth - coined the 'Four cornered roundtable' (discussion across a round table with each of the four key parts of the healthcare community).
Such gatherings at an early stage with consumers and clinicians as well as the IT sector all working with policy makers is a critical path for success: active participation, meaningful discourse and a willingness to change.
The benefits and need for such a system were well agreed: the method and level of participation was the key outcome to develop.
There needs to more of this and the clinical inputs have to be meaningful, continuous and integral. It must and will continue to work through difficulties and concerns.
It can be well argued that investment in eHealth will satisfy many calls on the health dollar. This may include lessening the need for significantly more high-cost hospital beds.
IT also provides pertinent, accurate, timely good information about the system.
Allowing good service planning, service requirements and needs into the future based on good current healthcare information.
Information that is current, accurate and accessible can be used to monitor patterns of disease (epidemics and pandemics) and emerging trends.
Funding of eHealth is often accompanied by howls of protest and a barrage of negativity as the cry of 'What has eHealth ever done for us?' Well, we could say legible accurate prescriptions, electronic pathology results downloaded rapidly, radiology reports, Picture Archiving and Communications Systems and Radiology Information Systems (PACS & RIS), secure messaging. As they are implemented, we can also say Healthcare Identifiers, the personally controlled electronic health record. When we have things and they work and are part of normal usage, they are often ignored and forgotten.
Service delivery is enhanced with consistent transfer of clinical information between healthcare providers, following the patient's care journey. This is most important at the interfaces of healthcare (from a hospital back into community; from an aged care home to an emergency department). The ability to provide continuing care, based on up to date information including where and what has already been provided, allows an escalation path at the point of care so that patient care is responsive and mindful of past treatment.
In Australia GPs and pharmacists use computers for clinical management is almost 100%. This is a great achievement and a very sound base on which to build capacity and enable good clinical information transfer. There is a very poor uptake of this technology in other sectors outside the hospital.
The single gauge for the system is now in a position to pay dividends. The passing of the Healthcare Identifiers Act on 24 June 2010 in a bipartisan manner allows the assigning one number only for every Australian which can be attached to each piece of health information about them (not the 20-30 we may have today). Together with a robust system to identify health providers and the organisations they work the Healthcare Identifiers allow for access to information with security which attaches to the usage of the number and surety that the right information is available about the right patient at the right place at the right time written to and read by a known health provider.
Danger points for our system include:
o not enough people enrol
o if the information or their personally controlled electronic health record is of poor quality
o insufficient information making looking for the record a chore not an asset.
This has led for some to call for this to be provided to all with an opportunity to opt-out of the system rather than willingly and knowingly enlist to it.
If key expected information like pathology and radiology reports are not available its usefulness is diminished.
Complexity or increased risk to clinicians or increased workload will see it fail: its ability to benefit all is vital.
Worldwide, successful systems have meaningful clinical use, clinical governance and clinicians fully part of the decision making process. In Lombardia (Italy), Cleveland Clinic (USA), Denmark to name a few, clinical leadership and consumer support have seen great strides in better clinical information transfer and consequent patient care and timely access to services. Contrast the supportive implementations in Austria of a clinically competent and supported rollout of their eCard solution with the technologically competent German system which ran into deep water as nobody supported the roll out. Today they have a target for how many cards will be introduced but the utility is in question.
In our region the work in Hong Kong and Singapore are worthy of praise.
Our local heroes in Northern Territory and Barwon in Victoria took a pragmatic, clinically led and useful system that grew iteratively success upon success whilst working through failures.
The Australian system, with its national standards and embracing of all sectors of healthcare in developing the personally controlled electronic health record, is being watched with interest internationally as we are poised to deliver a secure, robust and useful system for all Australians. It has been seen a way to succeed where others have not, learning from them as we are. National standards and working at an early stage with consumers and clinicians as well as the IT sector continues to be critical. Better understanding between the four corners is essential to reach a solution that can work for all.
Thank you