24 August 2016

Dear Tim… an open letter to the new digital health boss

KnowCents Technology

 

Tim Kelsey, the newly appointed head of The Australian Digital Health Agency, has an opportunity to change the course of Australian healthcare significantly for the better. It’s not going to be easy, but it’s now or never

Dear Tim,

I can’t tell you how surprised and excited I was to hear you had left Telstra Health after seven months to head the Australian Digital Health Agency (ADHA). Of course I don’t know you personally, but your CV sings of a lateral thinker, leader and entrepreneur. Until your appointment, I thought the renaming of NEHTA a few times within a few months, and reasonably tame changes to the board, spoke of a government that hadn’t learnt much from a fairly spectacular fail on the electronic health record – and one which wasn’t likely to embrace the huge digital health opportunity we have before us.

I’m guessing you realise what you’ve got yourself into here, and haven’t just thought, “Gee, Telstra Health is a mess, I need to do something else.”

I have a few very specific concerns and questions about the whole My Health Record show so far and what the ADHA is going to do now.

In her media release about your appointment, Health Minister Sussan Ley says the agency was “responsible for all national digital health services and systems, with a focus on engagement, innovation and clinical quality and safety”.

Good start.

But then she goes on to say this: “Most importantly, the new agency is the system operator for the government’s recently launched My Health Record [MyHR] system which is …”  Blah blah blah.

Do you think MyHR is the most important thing here, really? After all, we just spent $1.2 billion on it without getting anywhere, and if you look at what a disaster chasing the electronic health record dream has become in the US, shouldn’t we perhaps stop for a bit and question how we got into this mess? I don’t think the reason we couldn’t get anywhere with $1.2 billion is just mismanagement by the previous administrators.

We all love to criticise failures like this one (me in particular) and generalise about the public service, but the reality is, most of those who oversaw this failure were far from stupid.

Could it be that the implementation and concept of an electronic health record is far more complex and difficult than any of us imagined? That potentially, at least for now, we should maybe think whether a dollar spent elsewhere on digital, might have a significantly greater return on investment in the longer term?

I realise this might not be an easy one to pitch at your first ADHA board meeting: “You know this electronic health record thing guys, maybe we should rethink it a bit…”

But it feels as if all the hype about what electronic health records might achieve in savings to the healthcare system has seduced us. We are still thinking about that magical end point and not the obvious degree of difficulty. Yet, all over the world is evidence of such attempts failing.

The problem with building big dams 

Long ago, as an engineering journalist, I interviewed the CEO of the Hydro Electric Commission of Tasmania about the building of a new dam. By then, the commission had built so many dams, and had an organisation geared so highly to do it, there was no longer any question of whether they should stop and think more carefully about what they should do next.

They had become a dam building organisation, not an organisation thinking carefully about the energy future of their state and people.

Any chance the electronic health record is the ADHA version of dams in the hydroelectric commission?

There are clearly some issues in building an electronic health record system that have been revealed by our billion dollar-plus spend so far. Some seem almost impossible to overcome.

The need to resort to opting people into their electronic health record should have rung alarm bells with someone. Most patients aren’t interested, and they potentially never will be interested, in their healthcare record. Why do we know this? Not just because no one opted in.

If your life depends on taking regular medication and you can’t even do that, why are you going to bother about keeping your electronic medical health record in good shape? More than 50% of patients don’t take medications according to instruction. This, arguably, is the number one issue for inefficiency in our healthcare system. Patients who are a few statins short of a massive heart attack still won’t take their statins.

They may end up dead or in emergency, and the cost is huge. Do we really think that going upstream from this key dilemma of patient engagement to something far more ethereal than taking a tablet each day is going to work that well?

You can’t make doctors drink the water either. Fortunately, they are particularly stubborn and freethinking individuals.

You can pay them, of course, to make their way to the water, and then pay some more to get them to do a bit of drinking, as you are now doing with MyHR health summaries and ePIP – but at what cost?

As a start, $50k per practice per year if they do ePIP. Not all of them will, but if only half of them did you’d be up for a cool $150 million. In the scheme of things, at least now you are getting doctors to upload case summaries of their patients to a central database.

But has anyone questioned yet what they are actually uploading? And to what purpose? Presently there are no standards on what a practice has to upload in their case summaries. You are going to assume they are loading good stuff, not the cricket scores. But they are going to be hugely varied no matter what, because they are not standardised.

Return on investment

So how useful are these records likely to be in the next five to 10 years? The patient summaries are being uploaded by doctors with no standards to work by and no requirement for quality. Patients are being opted-in now, but we know largely they don’t care and aren’t engaged. And those few who do care will do one of two things:  go in and change their record and make it even less standardised, which they are allowed to do, or, thanks to a group of scaremongers who are on the news saying all our health records will be stolen by the Chinese or Russians, just delete themselves to get off the grid. Why the Chinese or Russians would want someone’s medical record I’ve got no idea, but it does scare people. In any case, this is starting to look awfully messy again.

That makes it pretty hard to predict the likely return on investment in the years to come. The major argument for a comprehensive electronic health record system is that modelling suggests lack of information about a patient’s medical history leads to about 8% of all medical errors and additional costs to the system, depending on who you believe, of between $660 million and $2.6 billion.

Can we spend this money better?

Tim, I know you’re just starting and you’re facing a room full of engineers, dam builders (CTOs and CIOs in this case) and a bunch of politicians who’d love to see the digital equivalent of the Hoover Dam built in their likeness for their children to marvel at, but we’re talking about the most important thing a government can do for its population, next to education.

Despite all the harbingers of doom about cost and our healthcare system, we find ourselves blessed with a confluence of circumstances that put us in a unique position to change the future of Australia. As one analyst said to me recently: “Thank Christ we only wasted $1.2 billion… that’s actually not much and hopefully we’re learning that you can waste a lot more if you aren’t careful.”

Digital transformation is a once-in-a-century opportunity for us to laterally change how we deliver health, make it better, and perhaps even, cost less. Imagine running into the problem of having to close hospital beds because your system is so efficient you have too many. That’s actually occurred in a region in the US.

Following are just a couple of examples of some things where a little bit of smart spending on digital – far less than you probably intend to fork out in the near term on rebooting our electronic health records – is potentially a lot more likely to produce dramatic and effective change.

What if we put just a bit of money into providing all Australian doctors, especially GPs, with access to very high grade, up-to-date, treatment protocols and algorithms?

Dr Peter Edelstein, the chief medical officer of Elsevier, was in Australia recently to preach his views on this idea. Normally I’d counsel beware of  Americans from big corporates bearing gifts. But Dr Edelstein is on a mission to make healthcare better, not make Reed Elsevier more profitable. Lucky for Elsevier.

He says that while an electronic health record is a great idea, in practice it’s massively expensive to implement and still hasn’t made much  headway globally in terms of promised returns. He preaches using what resources we have: the internet, mobile technology, and tonnes of highly targeted, specialised and up-to-date treatment information and algorithms for doctors.

“Digitalisation is great,” he told The Medical Republic, “but if you focus solely on it, like we seem to with the electronic health record, then you almost unintentionally divert doctors and hospitals from their core function (which is) to provide the very best treatment and care.

“If I work in country Victoria, why do I have to wait until I get an electronic health record to treat a heart attack the same way they are treating it at Melbourne’s best teaching hospital? The information is available and accessible.”

The chocolate chip cookie paradigm

Dr Edelstein argues that if we put a bit of thought into providing doctors with the latest credible, up-to-date, evidence-based information, in a format that countenances the idea that “you don’t know what you don’t know” when you are searching for clinical answers, then we can vastly improve our health outcomes in a very short amount of time.

He recently presented the concept of “order sets” to a group of senior Australian health leaders, technologists and strategists in Melbourne.

Order sets are taking off in the US but are relatively new here.

“I’m not disputing that electronic records ultimately will be very powerful. But you don’t need one to get massive improvement in care today. Essentially, all you need now is access to the internet and a printer. You can’t tell me that just because I’m in country Victoria, or even rural India, where I have the internet and a printer, I can’t I can’t apply the same chemo protocols to treat someone with breast cancer that are used in Sydney, Baltimore, New York and Mumbai, electronic record or not.”

Order sets organise live, professionally reviewed treatment information in a manner which Edelstein says overcomes a key issue for doctors in using treatment information – searching for unknowns that may affect your treatment. He provides an example in warfarin treatment.

“Despite being the most common blood thinner in the world, not that many clinicians are aware yet that the reason they will sometimes have difficulty getting this treatment right is that there are 22 genetic variants in people which affect how they respond to the drug. Now you can test for them easily. An order set will push something like this to you when you’re asking about warfarin,” Edelstein says.

Order sets are also designed to overcome the inevitable variability in how doctors view treatment protocols across geographies and cultures. Edelstein explains this issue away with his ‘chocolate chip cookie paradigm’.

“There are probably about 10 absolutely great ways to make chocolate chip cookies. You can use any one you want. This is variability that clearly doesn’t harm people or waste money. Use more sugar or eggs. I don’t care. Just don’t add rat poison – that’s not acceptable variability in a choc chip cookie menu. In a similar way, there are usually about 10 different evidence-based ways to treat certain diseases. That’s fine. As a doctor, you do the reading and choose, based on your context.”

Asked if the provision of such an information service to all Australian GPs tomorrow would make a significant difference to the delivery of health in Australia, Edelstein almost falls off his chair. “Hell, yes… huge and within one year you’ll see a big change and massive savings.”

What would the return be of offering such a service to GPs? Elsevier and Wolters Kluwer proved reluctant to provide The Medical Republic with a quote, but having worked for Reed Elsevier myself for a few years I’ve made a well educated guess : something like $2 million to $3 million per year to provide enough GPs with licenses to this information to have a big impact.

Quick question Tim: How hard would it be to see if Edelstein might have a point? Three million dollars is 50 times less the cost of what ePIP incentives might end up costing us to get doctors to upload case summaries in one year. With this money, you might hit enough GPs in the country and shift the needle in a matter of weeks, not years.

And there’s an added bonus here. You’d be seen to be directly supporting and engaging the GP community with something efficient and positive. Embracing our doctors’ enthusiasm and talent and bringing them on this journey as drivers, not passengers, is a mental and cultural shift the government needs to make if we are going to succeed here.

Another potential higher return project might be to incentivise GPs to move to cloud based patient management systems with ePIP, like we got them to get computerised within a few years about 20 years ago. Currently they are stuck at their desks with antiquated and isolating desktop systems. If we help them set themselves free with cloud systems so they could easily connect to each other, their patients and other services, and be mobile, the efficiency gains would be massive. These systems exist today, but they need some financial help to make the jump as their data is stuck on their desktops and needs to move.

Too futuristic?

I run a small business which came out of a larger corporate with a lot of legacy and we put everything we did on the cloud, including our financial system (Xero). The efficiency gains were astronomical. It changed our business futures and our lives. We had to take a leap of faith and believe in new tech… that’s what you’ve got to help GPs do.

I’m sure I will have got stuff wrong here. It’s all very easy to sit on the side, out of context, and solve problems. Being the poor sod who has to actually get it done is not easy. I’ve been there in my working life. I’d be happy to hear your thoughts and even publish them if you like as you move into your role and work this stuff out. I wish you the best of luck.

This is big. Don’t screw it up.

Regards,

Jeremy Knibbs,

Publisher, The Medical Republic

 

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4 Comments on "Dear Tim… an open letter to the new digital health boss"

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John Alexander
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John Alexander
3 years 26 days ago

Jeremy, I liked the dambuilder analogy. With that in mind I think even more more lateral thinking is required. The answer is in front of out faces every day when we use eBay, Uber and Airbnb. See https://goo.gl/aZLz7J Healthcare is used as example

Glenn Rosendahl
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Glenn Rosendahl
3 years 26 days ago
Jeremy, There is both good and bad in what you say. If ” there are usually about 10 different evidence-based ways to treat certain diseases. That‚Äôs fine. As a doctor, you do the reading and choose, based on your context.‚Äù That is not fine. We simply do not have the time to read and evaluate 10 different ways to treat certain diseases. And if these ways of ‘evidence based’, then we must look at the evidence to order them as to efficacy and safety. At present we are not paid to do this. We are paid to make an intelligent… Read more »
David More
Guest
3 years 27 days ago

Jeremy,

The CIAP program from NSW Health does lots of literature and information provision for NSW Health Professionals – it should always, from the start, been made available to GPs and other health professionals. Has been going for at least a decade and is invaluable.

More broadly, until someone works out just what problem the myHR is to solve and if it is the best way to solve it – we are all doomed. The myHR is presently a very expensive hammer looking for a nail!

David

Linda Mann
Guest
3 years 26 days ago
There already are solutions in this space, but they are all limited by the origins of their funding: CIAP is not available to GPs unless they have access via NSW Health, not a likely scenario in urban practice. You say What if we put just a bit of money into providing all Australian doctors, especially GPs, with access to very high grade, up-to-date, treatment protocols and algorithms? Healthpathways ( eg https://sydney.healthpathways.org.au/) is indeed a solution to this, intentionally local , but with common guidelines and treatment plans, set up with common discussion between GPs and specialists. The development of this… Read more »
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