Published by Computachem Services

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“Health electronically long-standing promises”, HELP, is a corny acronym to introduce a serious and somewhat good-news summary of where-we-is and where-we- aren’t, in the landscape of the journey to embrace the Internet, in a practical, affordable and acceptable manner for the Australian healthcare sector.

It is now widely recognised that there is a need for better communication between today’s healthcare providers.
It has been more than a decade since community pharmacy embraced “computing’ – and today, ask any pharmacist, in any context, about “computing” and the answer will be; “how did we ever get by without it?"

Pharmacy has achieved the level of acceptance where the technology becomes the daily “guardian angel”. And like most angels, is pretty much taken for granted.
Is this the case elsewhere?
No way.
Far from it.
The rest of the gang has a lot of ground to make up and it is not going to be a simple, easy task.

The emerging issues include admission forms, discharge summaries, patient monitoring to e-commerce and supply chain opportunities.
Pharmacy is looking to PBS-online and maybe BMMS as the coming holy grail.
For some others it is the promise of HealthConnect.
Yet the view from the top down and the view from the bottom-up, have many missing pages in the “e-health song book”.

If we were in the vision business we could use this quote as a reasonable guideline:

“To enable medication related data capture and reticulation, including clinical, supply financial and reference information, to be electronically shared using open global standards. This will deliver the community accurate, timely and useful information with full consideration of participant consent and adoption of appropriate measures to ensure security and privacy”. (unquote).

Pretty good, if I do say so myself.
How is this to happen?
What has to be done?
What are the impediments?
Who is going to pay?
What is in it for me?

Well, lets have a look at the present situation.

There is a lot of activity going on out there.
Most of it will fail.
Which is not really bad or a surprising thing.
Things have to be done and lessons learnt before we eventually get things right.
No better way to consider this than to look back over the journey pharmacy has travelled since the mid-1980s in making a computer tool a guardian angel.

Some of these programs, ones that will work include; BMMS, PBS-online, HealthConnect, MCCA, decision in support systems, ICT interoperability, the use of IT14 standards, broad band infrastructure investments, claims processing and other accounts payable/receivable improvements.

One particular issue that comes up more in the more corporate/government world of top down health ICT systems is that of scalability.
Arrgh!
You just get your mind around “interoperablity”, remember - that is the ability for systems to “talk” to other systems, without re-keying, and now here is another IT buzzword word, “scalability”.

It is becoming clear that a fair number of large ICT systems are designed for the size of their large home (foreign) markets where all partners are, in comparison to Australia.
Big organisations dealing with one another.
Small business in the USA, or medium sized hospitals in Europe are actually quite big, compared to Australia.
It is becoming apparent that the cost of these imported systems is not only difficult to justify, they are also difficult to implement when they do not totally meet the local conditions.

Take the comparisons with HR software systems.
There would be very few, if any, foreign software/payroll systems that would work in Australia, without modification to meet the unique mix of sophistication and egalitarianism of the Australian HR culture.
It is this set of parallel circumstances that is suddenly ringing bells here in the corridors of health sector policy and power.
Interoperability and scalability are real and present issues.

Why has this not affected the installed pharmacy dispensing systems and the GP prescribing and reference systems?
Because they have all been developed in Australia.
What the SME level of “computing”, doctors and pharmacist are using, is true blue, dinky-di stuff.
And it works well.

Meanwhile up at the top-end applications of financial, database, catalogue, e-commerce, patient history and so forth is generally not locally developed software.
It is designed to be affordable and workable for somewhere else.

This situation is not going to be a seamless plug-in guardian angel tool for GPs, our hospital care delivery professionals and other clinicians.
There is a fair amount of work to do before we can mix and marry top-end aspirations with workplace reality, without a lot of local ICT developments.

And, that is a good thing too, as it will strengthen the local ICT industry.

What sort of “things” and opportunities are we talking about?
The BMMS papers sum it up nicely by giving one of the many, good old three-dimensional answers.
They say there are problems that have to be overcome by goals that will be delivered by certain means.
It is however not that simple.
There is no one policy, one group, one priority – no one size fits all scenarios.
Take a look at this jigsaw of interlocking 3x3 dimensional pieces.

Which, Is all summed up by asking the ultimate 3-dimensional set of what is:

* the scale of affordability
* the scale of interoperablity
* the scale of workability?

An explanation in bullet form of the 3s in the box above is:

Focus
Nothing will happen without the compromises necessary for people to mould the policy goal within the process of power plays.
Which, as mentioned above will wrestle with the problems, what we then agree we wish to accomplish, and how to get there.
Summed up by moving and managing healthcare information in a accurate, timely and useful way

Scope
None of which can be made to happen without agreed standards that move information in an interoperable manner, with technology that suits the scale of the local scene.
Or, what is available, how does it all plug together, and does it have the grunt to do the job.

Outcome
Illustrates what it is we want to achieve.
To improve basic functions of patient care, by sensible data capture disciplines that result in safe, private and prompt claims processing and patient history systems.

All of a bit of a doddle really.
As long as we keep in mind a serious matter.
One big mistake people make is to imagine that it is one big, complex problem.
It is nothing of the sort.
We have a situation of many 3x3s, say, 133 little problems.
All of them individually simple, that collectively appear to be complex until they are separated to be solved, one at a time.
A tedious, boring, unwelcome but totally necessary task.

Happily it is now clear however, that the Australian situation compared to any comparable overseas location or system, is in pretty good shape.

Firstly we have the lucky country effect – we have small population that is intelligent, adaptable and well served with resources.
However, we have almost exactly the same problems as any Western HealthCare system - but on a scale and impact far less that the worse examples and generally better, or equal to the best.
Finally, we have the required macro plans in place, mostly government driven, to achieve success.

I am talking about the programs mentioned above: BMMS, Healthconnect, MCCA, IT14 and so on. Most of which came directly and indirectly from government investment in programs like PeCC and notably the publishing “Health Online” and “Setting the Standards” as well as establishing and conducting the work of AHMAC, NHISAC and NHIMAC.

However, even here we still have the problem of the lofty and the intelligent policy makers grappling with the simple and obvious.
And no more commonly apparent, is the classic mistake to confuse the “what”, with the “how” with the “why”.

Essentially we are about implementing technology-based solutions to make things better.
What “things”.
Usually the moving of the document we wish to exchange, with the information it contains, by the method it is transported.

Is this saying that technology will change the document?
No!
Will it change the information?
It should not.
Will it change the method?
Of course it will.
We moved from walking the document/information, to the horse, to the coach, to sail, to steam, to rail, to plane, to jet and now to the Internet.
We are not going to change the prescription, the order, the payment, the admission form, the record; we are just going to move it faster.
Hopefully with minimum human intervention and error inducing re-keying function.

The other matter that gets knickers knotted, without often-rational thought, is the sacred issue of privacy and security.
Pshaw, I say.
Lets look at the normal patient security and privacy issues today with a GP and a hospital.

Who sends the faxes the patient related information to and from the hospital and surgery?
The doctor?
Not on your nelly.
The office staff do it.
Is this as private as electronic, machine-to-machine transactions with full encryption and firewalls?
Hardly, it has to be said.
We are not changing documents or information accessibility as much as the manner by which the information is transported.

Any and all information can be corrupted and access to information can corrupt people.
Is data more secure in an envelope, in a jet or courier?
Is it secure on a fax?
Of course not, we just imagine it to be the case, because the Internet means change.
Change can be better as long as every factor is kept on balance.

We should not be concerned so just much by these matters as we should be by policy, leadership and culture of adapting to the inevitable evolution, that started back with the horse drawn coach and now is reaching the stage where the Internet will becomes as ubiquitous as posting a letter was 20 years ago.

And then there is the 3-dimensional matter of money.
Existing evidence shows clearly that the broad SME industry sectors are not engaged in the cliche bingo and promises of corporate Australia, regarding the wonders of the Internet.
This includes the health SMEs.
Which include not only small suppliers, but doctors and pharmacists as well.

Although pharmacy is PC literate, and a growing number of doctors are well up there with PC technology, it is not for the whole jigsaw.
The problem is not so much, “what is the weakest link” as much as what is the missing links?
One of the answers is money, money and money.

The money to firstly fund capital purchases for systems.
Secondly the remuneration for using these systems and finally the ability for the banks to electronically pay claimants for the use of these systems.

In the broader industry based commerce world the SME is not rushing in to throw away the fax machine in favour of the PC, to send and receive documents because you can not bank a faxed cheque!
Think about it.

They will not do so until the three answers above is closed off and the guardian angel effect emerges.
The contention being that health SMEs will be no different in seeking answers to the “what’s in it for me” question.

One professional association sums up the other non-money issues of e-health applications in something along these lines:

* It should deliver clinical benefits and reduce instances of error induced patient events.

* By sharing the information freely and inclusively while maintaining clinical independence and convenience.

* With strong standards and security, privacy and confidentiality protection.

* And solving the telecommunications infrastructure business model that is fair, and that the costs and benefits are appropriate and proportionally divided.

Recently a Melbourne newspaper ran a series of hyped-up stories on medical misadventure, with headlines:

“2000 fatal slips”
Saying that 2000 Victorians are killed each year by prescription related errors and that 400 000 Australians visit a GP for similar reasons. Closing with the radical journalist observation that bar codes are the answer.

“140 000 hit by drug mix-ups”
A follow up article saying 140 000-hospital admissions come down to medicine errors

“Report blasts hospital care”
Somewhat sensational story quoting deaths, thefts, misuse of unused drugs, all calling for 73 reforms.
Ah you see – not one big problem, but 73 little ones!

None of this is news overseas.
A USA report endorsed by 40 000-hospital pharmacists’ calls for mandatory bar-coding.
The “Err Is To Be Human Report” claims 90 000 Americans perish each year due to misadventures. Meanwhile the UK published “Sugar Coated Pills Report” says the same sort of things, quoting 30 000 deaths in the UK as a result largely of medicines interactions.

Which all to goes to highlight that money is not everything.

Leading to a natural introduction for the Medicine Coding Council Australia – a world first.
At the time of writing the MCCA Committee and senior Commonwealth officers are completing a review of a consultants report before proceeding with a recommendation to the Minister.
Abridged extracts from the Executive Summary include:

* Key findings show widespread agreement on the need for the establishment of a central medicine data repository, as an essential building block to support BMMS, Healthconnect and an upgraded PBS, as well as supporting the supply and clinical chain processes, while improving the usability of prescribing, dispensing and decision support software and systems.

* Shows unanimous agreement that it is essential for the Commonwealth to take a lead role in the establishment and funding of the MCC as a key piece of public health infrastructure

* Also offers several far-reaching recommendations regarding the TGA and relevant legislation into the future use of a central repository of healthcare products.

Even though this is good stuff there still remains the interoperablity problem.
The ICTeHealth Mapping Project is studying that.
A consortium of AEEMA, AAIIA and the NSW Department of IT Management who are conducting a study of the “pipes and plumbing” connectivity inside ten NSW hospitals.
Once completed the study will give a snapshot of what has to happen to move the information, inside a hospital, without re-keying.
Not change the document; not change the information, just the way it is exchanged.

In a similar vein the NSW Auditor-General recently published a report titled “e-government, e-procurement for the hospital supply chain”.
An excellent paper.
In part it says a number of good things by way of these quotes:

“the Internet will transom the world we live in”

“achieving value is a huge challenge”

“structures and attitudes will have to change”

With a strong series of accompanying recommendations.
It mirrors or supports the awareness of the issue that is placing Australia in a good position to meet, cope and deliver electronic influenced healthcare change.

All of our favourites get a gig, one way or another; BMMS, broadband, collaboration, EAN unique product identifiers, financial systems, HealthConnect, ICTeHealth, IT14, MCCA, PeCC, standards, supply chain reform-with clinical relationship.
And a universal acceptance that there is a patchwork of pieces to join-up.
Not one big bang, one-size-fits-all superdoopa solution.
No one has one answer, the report says.
But the overall puzzle is the same of many pieces fitting together.

Then there is the interconnectivity of the platforms to move the information outside the hospital.
For that matter to move all health information across the vast ether of the Internet.
This comes down to one word, broadband.

Help is at hand here too.
A new acronym, “BAG”, which stands for broadband Advisory Group.
A welcomed initiative from NOIE with a mission to provide high level advice to government and to foster cooperative communication between stakeholders.
The focus of BAG is on health, education and research.
The aim is to deliver connectivity to metropolitan and regional sites on a shared basis.

Even closer to home is the Health Grid Access Centre idea.
Here the ANZCIO group is exploring the European example of a concept of significant collaboration with State governments to facilitate involvement for all health jurisdictions to deliver patient care, built on broadband performance, regardless of location.

Which frankly is pretty much the minimal requirement.
Recently a survey was conducted on the number of phone lines in some typical pharmacies.
The average was 7 lines being used for voice, fax and e-mail.
Without broad band that will jump to 17 phone lines to cope with the theoretical demands that BMMS, PBS, HealthConnect and other Internet related services and systems will demand, whether the pharmacy or surgery is in Willoughby, Wollongong or Warialda.

What is on a list of desirable benefits?
We have already considered that it should not be just about money, cash, direct funding, subsidies or merely using cost-cutting savings to be measured in money, money terms alone.

A rough, unofficial guesstimate could reasonably be 10 percent.
Ten percent of everything and anything, that becomes e-enabled.
We have just passed the $60 billion mark on health spend, and that's is a lot of money!
However, accepting again that this is not just about “me-money-me” – we can also look to convenience, speed, safety, lives, resources, taxes, performance, accessibility, reliability, availability and a bundled outcome for patients that is better than is the case today.

A schematic of this can look something like this:

Problem		Introduction	-------->	Information	------>	Governance
Goal		Conditional	-------->	Financial	------>	Delivery
Means		Embrace	-------->	Performance	------>	Patient

Problem
What are the weaknesses in terms of performance, finance, quality, productivity and convenience do we have in the local health sector outcomes?

Goal
What can be reasonably achieved in milestone parameters that balance the benefits to and for all concerned, not just one or a few privileged participants?

Means
How are we to accomplish these goals? What costs, resources and education tools are needed to successfully implement the staged re-engineering of many overlapping regimes and practices? And, once completed, how to maintain the impetus?

Connects to the timeframe stage

Introduction
The first block of time for planning and demonstrating changes – using real practitioners and patients to illustrate and measure the means to achieve the goal that solves the problems

Conditional
Expanding the time to engage a wider community and begin to remedy the missing and weak links in the plan and implementation

Embrace
The point in time when everyone accepts that there is a guardian angel factor in place – a “how did we ever get by without this” stage

Which need to measured

Information
The ability to move and mange information with all participants in a shared and open manner, across all platforms with a minimum of human intervention

Financial
The debits and the credits of the money and funding factors

Performance
Delivery better care, without over spending the nation’s ability to pay for it and to make it happen

The payback stage

Governance
The governing community exercising policy for the well being and fair operation of e-enabling the health sector

Delivery
The clinicians, mangers, administrators, enablers and others who make it happen and maintain it happening

Patients
The end result of improved, not less, patient care

Whew! Can we list some of these things in a simple form? Here are some examples:

* funds from supply chain waste diverted to ward functionality
* better claims processing, better cash flow
* overall job growth with higher morale
* more convenient ways to do things – the guardian angels
* minimise human intervention as the way to move data between systems
* create the funds to fix interoperablity
* which builds wealth for the local ICT industry sector
* minimise medical misadventures
* to achieve these things for all Australians, not just those with broadband access

What about the tribes – who is who in the zoo of Healthcare communities?
Who are the different people, who have to collaborate and make the brave new world function in 3x3 relationships?

Governing community

Enablers

Delivery community

Patient community

Just recently there was a striking NHS/Health related article in the UK Economist Magazine (19 October edition) which had a powerful benchmarking value for us here in Australia. A selected snapshot of the story includes these observations and statements:

* large government IT projects have a history of going spectacularly wrong
* people not technology is the issue
* consultants are good at reports but not at making things happen
* the vision is for the Internet as part of the NHS system for the next 20 years and failure is not an option
* they are paying the new NHS chief more than Prime Minister Blair is – $A800 000 pa.
* he will control a spend on IT of a $A30 billion over 5 years – that’s right billion not mere millions
* says – “doing away with paper work, forms, brown envelopes and carbon paper, which is the way most data is exchanged”
* has three goals – admissions, e-scripts and patient records – which in our terms is MCCA, IT14, BMMS and Healthconnect
* will set national standards but let regional bodies have some autonomy
*notes that the NHS is not a one-size-fits-all organisation – but is loose confederation of thousands of pharmacists and doctors (SMEs) – so the government needs to become more humble in its grand plans and implementation models (hear, hear)

The comparison with our situation and attitudes is compelling reading.

So there it is. A lot happening and a lot still to happen. A journey that stated long ago and has a long way to go. Aside from the probable need to add-in a glossary for the extensive number of acronyms as a closing statement it can also be summed up by saying:

Wishing all you IT readers a Happy Christmas and a New Year full of good IT Problems From Pat Gallagher