Ahha issue9 web


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The Health Advocate is the AHHA's high quality, insightful and entertaining magazine filled with the thoughts and opinions of Australia's leading health managers, academics and clinicians. The magazine keeps you up to date on the latest developments and thinking in the Australian health system. To receive the printed magazine please contact the AHHA by email at admin@ahha.asn.au or on 02 6162 0780.

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Ahha issue9 web

  1. 1. The Health ISSUE 9 • JUNE 2011The official magazine of the Australian Your voice in public healthcareHealthcare & Hospitals AssociationThe e-health imperative Clinical informaticsWhy we need to improve our for dummiese-health capability Providing better health care by using technology E-health In Australia The development of e-health A history of pathology informatics ALSO in this • Governance • Who’s moving in • AHHA news issue training for health the health sector and events
  2. 2. More people in health and communityservices choose HESTA than any other fundYour super fund can make a lifetime of difference3 Run only to benefit members3 No commissions3 Low fees 7 hesta.com.au/superIssued by H.E.S.T. Australia Limited ABN 66 006 818 695 AFSL 235 249 regarding HESTA Super Fund ABN 64 971 749 321.Consider our Product Disclosure Statement before making a decision about HESTA - call 1800 813 327 or visit our website for a copy.
  3. 3. The HealthAHHA Counciland supporters Prue Power Executive Director Cydde Miller Policy and Networks Manager and Editor Terrie Paul Business and Membership ManagerThe AHHA Board has overall Luise Zakosteletzki Traineeresponsibility for governance Policy and Planning Manager Adjunct Professor Annetteincluding the strategic direction Schmiede ( NSW) AHHA Officeand operational efficiency of the Ms Joan Scott (ACT) Unit 2, 1 Napier Closeorganisation, the protection of its Deakin ACT 2600assets and the quality of its Mr John Smith (VIC) Postal addressservices. The 2010-2011 Board is: Mr Mark Sullivan (VIC) PO Box 78Dr David Panter (SA) Ms Sandy Thomson (WA) Deakin West ACT 2600National President T: 02 6162 0780 Dr Annette Turley (QLD)Dr Patrick Bolton (NSW) F: 02 6162 0779 Ms Anna Fletcher (Personal E: admin@ahha.asn.auNational Vice President Member representative) W: www.ahha.asn.auDr Paul Scown (VIC)National Vice President Dr Owen Curteis (Asian Hospital Editorial and general enquiriesMr Felix Pintado (VIC) Federation) Cydde MillerNational Treasurer Professor Helen Lapsley T: 02 6162 0780Ms Siobhan Harpur (TAS) E: cmiller@ahha.asn.au (International HospitalDirector Federation) Membership andDr Yvonne Luxford (AssociateMember Representative) subscription enquiriesDirector AHHA Sponsors Terrie Paul T: 02 6162 0780 The AHHA is grateful to the E: tpaul@ahha.asn.auThe AHHA National Council following companies who supportoversees our policy development Advertising enquiries our work:program. It includes the AHHA Frank RisvanisBoard above and the following Globe Publishingmembers for 2010-2011: Primary sponsor T: 03 9699 4279Mr Grant Carey Ide (ACT) HESTA Super Fund E: frank.risvanis@ globepublishing.com.auMs Helen Chalmers (SA)Dr Stephen Christley (SA) Event sponsorsMs Rosio Cordova (NSW) TressCox LawyersDr Martin Dooland (SA)Ms Jan Evans (NT)Ms Jane Holden (TAS) Other organisations support The Health ISSUE 9 • JUNE 2011Mr Graem Kelly (VIC) the AHHA with Institutional,Ms Shaune Noble (NSW) Corporate and Associate The official magazine of the Australian Healthcare & Hospitals Association Your voice in public healthcareMr Patrick O’Brien (QLD) The e-health imperative Clinical informatics for dummies membership. To find out about Why we need to improve our e-health capability Providing better healthDr Tony O’Connell (QLD) care by using technology joining the AHHA and havingAssociate Professor Alan your organisation listed,O’Connor (QLD)Mr Ross O’Donoghue (ACT) contact Terrie Paul. E-health In Australia The development of e-health A history of pathology informatics ALSO in this • Governance • Who’s moving in • AHHA news issue training for health the health sector and events The views expressed in The Health Advocate are those of the authors and do not necessarily reflect the views of the Australian Healthcare and Hospitals Association. The Health Advocate June 2011 3
  4. 4. 36 Contents 28 Every issue In depth 06 President’s view 8 Clinical informatics for 13 News dummies 16 Events By Tony Sara 39 Who’s moving 19 The development of 40 Become an AHHA Member e-health in Australia 42 Snippets By Michael Legg 25 Is the Personally Controlled Electronic Health Record Brie ng an evidence-based intervention? 34 Governance training for By David More the health sector 28 Computer says NO! 38 Book review – Improving The challenges of e-health Health Care Safety 8 implementation and Quality: Reluctant By Philip Darbyshire Regulators 30 The e-health imperative: By Christopher Baggoley the latest e-health news and developments By Peter Fleming 19 Opinion 36 What does health ICT actually achieve? By Patrick Bolton
  5. 5. President’s viewDr DaviD PanterPresident of theAustralian Healthcare andHospitals Association w e are almost half way through the year already and, while health has been fairly quiet in the media, those of us in the health system have been working harder than ever. Networks in all states and territories as well as the first group of medicare locals, which will begin operating from 1 July 2011. some of the issues being immediately felt are the uncertainties around the precise roles of In this issue of The Health Advocate our these organisations and how service integration focus is on e-health and health informatics, a will be achieved – an objective we have long been critical element of health service delivery that toiling to realise in the australian health system. has received recent attention with the Federal For instance, which of these bodies will take Government’s release of the draft Concept of prime responsibility at the local level for helping Operations for the personally controlled electronic consumers and patients navigate the system?This year has health record (PCeHr) due to start in July 2012. What are the practical mechanisms for local at the aHHa we have been spending a lot of our Hospital Networks and medicare locals to workalready been a time setting up two new arms of the organisation together to ensure the right care in the right place? – consulting and research – building on our the aHHa, along with a number of otherbusy one with the already strong foundation of policy development, organisations, has also raised serious issues with advocacy and information dissemination. the Federal Government’s legislation to establishAHHA establishing JustHealth Consultants is a new service offered the National Health Performance authority. ournew arms of the by the aHHa designed to easily connect health services with experts in a range of fields. our panel members expressed consternation that state and territory governments were not consultedorganisation in already includes Chartered secretaries australia (Csa) who will be providing nationally consistent in the drafting of the legislation and that, as tabled, there was little recognition of the states asconsulting and clinical and corporate governance training for new hospital ‘system managers’ in terms of reporting and existing bodies under the reforms. We also have and accountability. You can find a more detailedresearch leaders and experts in health law, strategic planning, summary of our concerns on page 13. health service planning, industrial relations, health of course, health performance data relies informatics and financial/audit support. heavily on information and communication the Australian Institute of Health Services and technology to ensure accuracy, consistency and Policy Research is the aHHa’s second major change timeliness. In this issue we hear from some key this year, being built on university membership figures in the e-health domain, including the Chief emanating from the australian Institute of Health executive of the National e-Health transition Policy studies. the new Institute provides a central authority, Peter Fleming. point through which research and evaluation is associate Professor tony sara gives us a simple linked directly with health services – to the benefit guide to clinical informatics – that is, the use of of services themselves, managers and practitioners, electronic systems and information to help guide as well as academics and the public as a whole. and improve clinical practice. We also have the the Institute is the first active endeavour to close first of a two-part article from Dr michael legg, the loop through implementation, evaluation and Past President of the Health Informatics society improvement of health service delivery. of australia, on his personal experience during the If you are interested in being involved in these evolution of ‘e-health’ in australia through the new activities or would like to know more about lens of pathology. what services the aHHa can offer you, please Dr David more, a well-known clinician, contact our Business Director, terrie Paul, on commentator and blogger on e-health, shares his 02 6162 0780. concerns about the e-health record and the need another reason for our increased fervour is the for australia to learn from implementation of such rapidly approaching ‘go-live’ date for a number systems in other countries. of bodies and organisations being established so please read on! the next time you hear from under the National Health reform agenda. among me we will be in the full swing of making the these entities are the local Hospital and Health health reforms work.6 The Health Advocate June 2011
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  7. 7. In depthCLINICALINFORMATICS for dummies8 The Health Advocate June 2011
  8. 8. TONY SARA Director of Clinical Information Systems South Eastern Sydney and Illawarra Local Health Network i HAVE BEEN doing ‘clinical informatics’ becoming more public (eg the Bristol RoyalTrying to make the for more than 10 years, but was forced to Infirmary1), the information explosion, and also re-evaluate just what it is that I do, and the need to provide more care in the contextmost of health the context in which I do so, following the of the greying of the population, higher costs, request from AHHA for this article. I used to increasing expectations and increasing cost ofinformation systems give lectures to Masters students five years ago technology, but a reducing workforce. on ‘Introductory Health Informatics’, so I went Essentially, this means the need to provide back to those slides to see how little, or how demonstrably better care to more patients much, the landscape has changed. with constrained resources and proportionally The principles are the same – health fewer staff. informatics is about providing better care to patients using technology. It sits How does health at the intersection of computer science, information science, health care and informatics expect to healthcare management. achieve these aims? The definitions all congregate around the notion of the art and science of providing Let’s follow the patient journey to analyse better health care using IT. But what are the where health informatics can assist. driving forces behind health informatics? The patient presents and is registered. Firstly, there has to be a ‘desire to take Have we uniquely identified the person to better care of patients’, deep and right at ensure we have the right person and the the core. Others include the increasing right information held against them? If we power of technology and the internet, an have a robust unique person identification increasingly stronger need to demonstrate public accountability in the context of errors system and process then we have made a good start. > The Health Advocate June 2011 9
  9. 9. In depth e focus of clinical informatics has narrowed onto the use of information in IT systems ” ” in health care by clinicians> Do we have relevant history available of the triggering of the rules engine noted enough about health and health care, andfrom past encounters with our practice and above, but more importantly as to outcomes its work processes, and have learnt enoughothers? Immunisation status? Medications? of care, by disease, by patient group, by about information and computer sciencesImportant lab and imaging results? Alerts ward, by operation and by clinician. that they can assist both their clinicaland allergies? Again, an encounter summary Lastly, the monitoring of the processes colleagues and the IT groups to achievewith unique person identification will help and outcomes of care should be able to be common aims.the process of care. applied to the population as a whole by the Bill Gates said it fairly succinctly in 1999 in Can we compare the images from the aggregation of de-identified patient data. his book Business at the Speed of Thought:past to those captured today? A Research An interesting example of the latter was the “It’s impossible to properly re-engineer aInformation System (RIS) or Picture analysis by Kaiser Permanente of its large data process using technology in an area withoutArchiving and Communication System store that identified that Vioxx contributed to oversight of someone who can bridge [the(PACS) program will do this, assuming it is an excess rate of myocardial ischaemia2. different] teams.”fed by the unique identity system already The various academic definitions have not The technologists just don’t understandin place. Perhaps the symptoms and signs changed in a real sense over the last decades. healthcare processes; and clinicians,are not diagnostic – decision support listing So what has changed? without further training or experience, don’tdifferential diagnoses will assist. The focus of clinical informatics has understand the technology. It has become The condition found is unusual – what narrowed during the last years onto the use the solid perceived wisdom that it is easieris the best care? Access to the internet will of information in IT systems in health care to train a doctor or a nurse to have enoughquickly determine what is evidence-based by clinicians. understanding of the broad brush strokesmedicine. The prescription process, one of the What has also changed has been the and some of the detail of technology so theyfour main sources of errors in health, should increasing pervasiveness of technology. can effectively bridge the teams.be monitored by clinical decision support Google, similarly, has made significant In fact, in the USA, there arose, insoftware that applies expert rules devised by changes to the way we work and study. 2009, the clinical sub-specialty of clinicalsenior clinicians along with graded drug/drug Some of this article was sourced from informatics3,4.interaction alerts. The process of clinical care Google, the depth and reach of which wason the ward should be monitored for unusual unthinkable when I started this job. So, what do Clinicalobservations, again by expert IT systems. Informaticians do and When the care pathway is over, the Who are Clinicaltransfer of care should be electronic and what do they use?seamless. The monitoring of the processes Informaticians?of care in the facility should be able to be Clinical Informaticians are doctors, or nurses, These professionals use their knowledgesupervised by the clinicians, by both analysis or health information managers who know of healthcare processes, of informatics10 The Health Advocate June 2011
  10. 10. principles and processes, and How does the clinical from before the inception of a clinical project health informatics tools5. Clinical informatician seek to or system, to well after the (nominal) project processes need no introduction – but do this? had finished – it is a truism that health what are the latter two? Informatics information systems projects are never principles are about IT technology, privacy In essence, they achieve these goals by finished until the data and information haveand health law, database concepts, project bridging the different teams. Specifically, been passed onto the next system and themanagement, change management, this means to develop, implement and original system has been turned off.statistics, health and IT standards, refine clinical decision support systems, The last of the queries is where and themessaging, person identification and so understanding both the clinical processes in answer is fairly intuitive – wherever clinicalon. Health informatics tools are things like depth and the technology in a broad way. As care is delivered and close to the point of care.clinical guidelines, pathways, order sets and well, it means to lead or participate in the The state of play for clinical informaticsstaff education processes, to name a few. procurement, customisation, development, in Australia is not optimum – there are a So, what does the clinical informatician implementation, management, evaluation handful of doctors who do it full-time and aseek to do? (S)he seeks to: and continuous improvement of clinical much larger number who do so part-time. • Assess and inform the information needs information systems, again understanding There are no training positions and some of clinicians, managers and patients both the clinical world and the IT world5. tertiary courses. • Characterise, evaluate and improve It would be understood that clinical What I find the most gratifying, as a doctor clinical processes. informaticians, then, would do this work in this field, is the capacity to improve the care that large numbers of patients receive, and interestingly, from a ‘life satisfaction’ perspective, problem-solve with my colleagues how we will practice medicine tomorrow. References 1. Treasure T, ‘Lessons from the Bristol case’, BMJ 1998; 316: 1685-1686 2. http://www.fda.gov/NewsEvents/Testimony/ ucm113235.htm, accessed 15 March 2011 3. Gardner RM, Overhage JM, Steen EB, et al. (2009), ‘Core content for the subspecialty of clinical informatics’, Journal of the American Medical Informatics Association 16 (2): 153–7. doi:10.1197/jamia.M3045 4. Safran C, Shabot MM, Munger BS, et al. (2009), ‘Program requirements for fellowship education in the subspecialty of clinical informatics’, Journal of the American Medical Informatics Association 16 (2): 158–66. doi:10.1197/jamia.M3046 5. http://en.wikipedia.org/wiki/Health_ informatics, accessed 14 March 2011 The Health Advocate June 2011 11
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  12. 12. In the Have your say… We’d like to hear your opinion on these or any other healthcare issues. Write to us at admin@aushealthcare.com.au or news PO Box 78, Deakin West, ACT, 2600 Dental probe welcome, but not the solution has been allowed to run for soCautious first steps long when it is clearly wasting valuable health resources whichin health reform could be used to help those in genuine need – particularly low income earners, Indigenous In March the ahha the states and territories. communities, others in rural➧ expressed serious concern about the lack of consultation bythe Federal Government on “as a result of the lack of consultation, the legislative framework for the nhPa has a number of critical flaws which and remote areas and older australians. the ahha urges the government to consider alegislation to establish the will reduce the body’s capacity new proposal we developednational health Performance to fulfil its role. hospital and in consultation with our Oralauthority and warned of the health service performance is and Dental health network, inrisk to future health reform if a complex area in which the conjunction with dental healthsimilar approaches continued states and territories have experts and peak groups, toto be used. considerable knowledge and the ahha WelcOMeD address the growing oral health “the Bill establishes theinfrastructure and legislativemechanisms for the nhPa.however, the legislation fails to expertise,” said Ms Power. the ahha therefore called on the commonwealth to make critical amendments to the ➧ the Federal Government’s intention to further investigate widespread misuse of the Medicare chronic crisis in the australian community. the proposal focuses on the provision of medically necessary oral health care for those withrecognise the role of state and Bill in consultation with state Disease Dental Program, but genuine chronic conditionsterritory governments as the and territory governments. We expressed disappointment and targeted assistance tomajority funders and system have also sought an ongoing that our earlier warnings went the 30 percent of australiansmanagers of our public health commitment to involving the unheeded, which has resulted who currently have difficultiesservices as agreed at cOaG,” states and territories, as system in massive over-spending on a affording private dental care.said ahha’s executive Director, managers of public healthcare, program with limited scope in It involves integrating thePrue Power. “this is despite in the following processes: the community. Medicare chronic Disease Dentalthe fact that health Ministers • nhPa strategic planning; We have for years been Program into a revised versionare accountable to their local • Developing performance highlighting the problems with of the commonwealth Dentalpopulations, along with their indicators to assess quality; the Medicare dental program health Program, which wassenior officials, to meet the and while lauding its focus on proposed by the governmentdemands of a dynamic and • Dealing with improving the oral and general before the 2007 election.complex system and for underperforming hospitals health of people with genuine the proposal focuses onmaking sure services are when necessary. chronic conditions. ensuring funding is directed toavailable at all times.” two years ago the ahha delivering cost-effective, essential the approach threatened as originally drafted, the proposed a solution to the and preventive oral health care forto undermine the national legislation prevents the problems inherent in the those who need it most. It wouldhealth reform agreement jurisdictions from participating program that would have also include universal dental careformulated at the cOaG in all these activities. We dramatically reduced spending for children aged 0-18.meeting in February as well as will keep you posted on the under this scheme and delivered You can read more about thethe commonwealth’s stated establishment of the nhPa and much better value for money. outcomes from our Oral andcommitment to a cooperative other new organisations over It is frustrating that this poorly Dental health network meetingapproach to health reform with coming issues. designed and targeted program in adelaide on page 16. The Health Advocate June 2011 13
  13. 13. In the newsIncreased ambulance useputting pressure on hospitals A study from emergency department➧ february’s Australian Health Review has found that the increased demandfor ambulance services over attendances. Pressures on hospital systems are well recognised, with congestion and overcrowding reportedthe past two decades is putting regularly in the media and peer-pressure on health care resources reviewed literature.potentially resulting in reduced this study involved a review ofaccess, safety and quality of care the literature concerning trendsfor patients. in utilisation of emergency “In Australia, as in other ambulances throughout thedeveloped countries, there is developed world and discussesan expectation that the health the major underlying driverssystem will fulfil our care needs, perceived to be contributingespecially those that are urgent to this increase. A betterand life-threatening. the role of understanding of causes ofambulance services has evolved increased demand is essential the authors recommendover the past 20 years into a vital to enable the development of further investigation of the majorcommunity resource embedded strategies to manage demand causes of rising demand. for thisin the health system,” said in the future. to be undertaken, there muststudy author, Judy Lowthian, the review found evidence be collection and recording ofan NHmrC post-graduate that patient transportation by standardised data with commonresearch scholar. emergency ambulances has definitions of demographic, Initially designed as an been increasing over the last socioeconomic and health-emergency transport service, 20 years. many contributing related factors. Effectiveambulance services now factors have been postulated, management of future demandprovide a range of healthcare related to changes in the needs will depend on a comprehensiveneeds, including pre-hospital of the community arising from analysis that goes beyondemergency and urgent primary ageing, declining health, social simple demographics of age andcare, emergency and non- structural change, and changes population growth. until we haveemergency patient transport in organisation of primary a better understanding of theand referrals to alternative healthcare. Limited price signals drivers of demand for ambulancehealthcare professionals. and improved accessibility of services we cannot ensure the In recent years escalating ambulances, alongside improved future sustainability of thisgrowth in demand for community health awareness and essential healthcare service.emergency patient services expectations possibly contribute you can access the Australianhas placed increasing strain on to a degree of avoidable use. Health Review by becomingboth ambulance and hospital the relative contribution of these a member of the AHHA. findresources. rising utilisation factors to the continuing rise in out more about the AHr andof ambulances is occurring transportations has not been our other publications on ourin common with increased well studied. website at www.ahha.asn.au.14 The Health Advocate June 2011
  14. 14. Private health insurance needs change The sTrucTure and regulation health status), that contributors were to take out PhI) has insulated the health ➧ of private health insurance needs to change radically in order to meet consumers’ need within our current health system. The new research treated fairly and that the organisations were prudentially managed. competition between funds on price and product innovation and funds from the conventional business imperatives to satisfy customers and contain costs in the industry, and inflated their significance in the funding of was reported in the February issue of the differentiation has been deliberately healthcare in australia. ahha’s peer-reviewed journal, Australian stifled in order to realise these objectives. If the commonwealth wishes to Health Review. This may have made good policy preserve a system of private hospital “Most australians are familiar with sense when the private health funds treatment employing user charges as an high profile private health insurance were the financial lynchpins of the alternative to its own hospital Medicare, it (PhI) companies, like Medibank Private commonwealth’s national health scheme, should consider redirecting its subsidies to and hcF, but few people understand prior to the introduction of a universal the hospitals themselves. PhI could then how this unique sector of the economy health insurance scheme. however, its be reconfigured as an option for accessing operates and the influence it exerts on rationale is questionable in the current private hospitals rather than the privileged the delivery of health care in australia,” environment given bipartisan support for mechanism for doing so. a deregulated said study author dr ardel shamsullah of Medicare as a universal public insurer. industry using insurance principles of risk- La Trobe university. The result of this system is that rating and allowing competition between The company structure of the PhI private health funds are now wedded firms would emerge, and it may attract a sector has always been markedly different to a highly regulated and subsidised more diverse contributor demographic, from typical commercial industries, in system that assures their existence which would consist of more demanding part due to the comprehensive framework while they deliver expensive insurance and price-sensitive customers. of commonwealth regulation within packages to a segment of the australian “This would result in a PhI industry that which they operate. This regulatory population covering a select set of supports, rather than hinders, innovation regime was designed to ensure that PhI, healthcare services. The commonwealth within the health sector and which is heavily subsidised from the public purse, guarantee of a certain level of income genuinely centred around consumers’ was accessible to all (irrespective of their (from subsidies and incentives for people needs,” dr shamsullah said.Safety and quality afocus for health ausTraLIans can over several years the➧ Look forward to safer health care in the future with a permanentorganisation dedicated to commission, and before it the council, has undertaken excellent work in raising the profile and evidence base for process of receiving health care. within individual hospitals.promoting safety and quality improved safety and quality in The ahha believes that every This is why it is crucial thatthroughout the health system – a range of health care settings. person has a right to receive safe we have a body dedicated tothe australian commission This has included major and high quality care and that identifying and addressing theon safety and Quality in campaigns to increase hand each avoidable adverse event is policies, structures, practiceshealth care. washing and hygiene, reduce one too many. and cultures that can make our While we were concerned hospital-acquired infections Most harm caused in health system safer.with parts of the legislation to and improve medication health care is not the result The permanent establishmentestablish the national health management. of individual errors but due to of the commission enshrinesPerformance authority, the other australia’s health system is underlying problems such as a the critical imperative for safecomponent of the Bill to make very safe by world standards lack of consistent information and high quality healthcare inthe commission a permanent but too many australians are systems across jurisdictions, all public, private and non-profitbody was most welcome. still harmed unnecessarily in the health services and sometimes health services. The Health Advocate June 2011 15
  15. 15. Events & meetingsOral health experts agreeon a way forward The AhhA convened oral health reform – including health foundation year that proposal formulated at the➧ its oral and dental health network in Adelaide on 11 March 2011. The meetingbrought together directors of stronger links to the evolving national health Reform agenda, such as through the national Preventive health Agency in the first instance will be an application-based (and therefore voluntary) program. For instance, 20 foundation year placements AhhA’s oral and dental health network meeting. You can find the nRhA’s priorities on their website at:state and territory public dental and possible inclusion in the may be offered in the first year, 11nrhc.ruralhealth.org.au.services (most of which are national health Agreement – expanding over time. Using this We look forward to workingmembers of the AhhA) as well and emphasises that the starting model, a focus can be placed with our partners, membersas representatives from the point must be a program to squarely on rural and remote and the government to ensurenational Rural health Alliance, address the oral health problems placements in the initial roll-out. that another year does not passthe Public health Association of those most in need. At the ensuing national without action on oral health.of Australia and the Australian We are seeking integration of conference of the national Rural If you would like moredental and oral health the existing Medicare chronic health Alliance held in Perth over information on the AhhA’s oralTherapists’ Association. disease dental Program into a 13-16 March, one of the priority and dental campaign, contact us The discussion centred on revised commonwealth dental recommendations agreed by on 02 6162 0780.building a campaign for the ‘poor health Program (with a new delegates was this combinedcousin’ of hospital and primary name) that will mean all carehealth care reform, oral health. provided is on the basis of highestAlong with mental health, oral need while ensuring best value forhealth has been put on the back the taxpayer dollar. As originallyburner to simmer away while intended for the cdhP, the newhundreds of thousands of needy combined program would ensureAustralians continue to struggle care for the 500,000 people onwith accessing affordable and public dental waiting lists as welltimely oral and dental care. as specific early intervention and The group worked from the treatment targets for those withbasis of the RePAIR proposal chronic conditions, Indigenousagreed during the 2010 election and rural/remote communities,campaign by the national the aged and children/youngoral health Alliance (of which people (aged 0-18).the AhhA is a member). This The group also agreed toproposal is available on the put forward more specificnohA website at: recommendations in relation towww.oralhealth.asn.au. the workforce plan of an intern The revised proposal reworks year for oral health professionals.some of the touchstones for We would prefer to see an oral16 The Health Advocate June 2011
  16. 16. Moving towards healthgovernance in regional areas ON 18 APRIL, a beautiful➧ autumn day in Canberra, the AHHA convened its first Policy Think Tank forthe year in partnership with theAustralasian College of HealthService Management (ACHSM).Our focus for the day was on thedistinct governance issues facingrural and remote health services,particularly under the nationalhealth reforms. The day was facilitated withgreat skill by Associate ProfessorPaul Dugdale from the AustralianNational University. We had afantastic range of speakers whoimpressed the delegates withtheir perspectives:• Prue Power and Daryl Sadgrove, Directors of the host organisations, gave tranche of Medicare Locals on strategies for community As a follow-up from the event, good overviews of the reform 1 July; engagement in health service the AHHA wrote to the Federal context on which discussions • Carole Bain travelled all the governance and planning. Minister for Health, Nicola focussed throughout the day; way from Silver Chain in Roxon, to outline some of the key• Jodi Hallas and Jenni Pilcher Western Australia to discuss Delegates commented on why issues and possible strategies for from Queensland Health the issues facing a community they liked the Policy Think Tank: making health reform work in detailed state-wide work care and nursing service that “The discussion and different the bush. We will be advancing on health service planning, needs to work across all parts perspectives in the presentations the outcomes from the day in particularly to support rural and of the reforming health system and linking back to on-the-ground a formal policy development remote health service districts; in metropolitan, rural and issues. [It was] well facilitated program that will contribute• Terry Findlay from the Transition remote towns; and with a great variance of people to our inputs to the National Team in the Australian General ark • Mark Ashcroft from Alpine with real commitment to rural Rural Health Alliance. For more Practice Network shared some health, a multi-purpose service and remote health.” information or a report from the substantial insights to the in the Victorian high country, “The practical and advocacy- day, please contact us. imminent roll-out of the first shared some very interesting It was well facilitated with a great variance of people with real committment to rural ” ” directed focus of the whole day.” Our next Policy Think Tank will be focussing on community health in the reforms. We would love to welcome you to Canberra in winter (it’s not as bad as you think!) on Friday 22 July. For more information or to register and remote health your interest in attending, please email the AHHA at admin@ ahha.asn.au. The Health Advocate June 2011 17
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  18. 18. In depth MICHAEL LEGG Principal of Michael Legg and Associates The development of e-health Michael Legg provides the first instalment of a personal history of health informatics in Australiaa  LTHOUGH CHATHAM HOUSE rules were invoked at the recent meeting of the CEOs of the Medical SoftwareIndustry Association, I hope Minister Roxonwont mind me picking up on a comment she The early years It began for me in 1977 when, in my third year at Sydney University, I was in a physiology course taught by Michael Taylor - what multi track FM recorder and then digitised over hours producing washing baskets full of punched paper tape. These were subsequently submitted to Fourier analysis to determine the frequency spectrum of pressure wavesmade recognising that many in the room turned out to be his last. Michael Taylor was using the University’s SILLIAC and KDF9had been working in the field for a long time a mathematician2¬ physician-physiologist computers. The point of this is that SILLIACand that a debt was owed. Her comment interested in optimisation. Fascinated by his was the replacement for the first computerand a recent article by Robert Flanagan1 on account of this field, I undertook to do an in the southern hemisphere the CSIR Mk 1!‘why IT is all so hard’ prompted me to record honours year with him. These were computers that took up the wholesomething of what I knew of the history of Taylor had a distinguished research career basement of a very big building!3 Of coursehealth informatics in Australia. Because the looking at the physical properties of arteries now this can now be done on your phone.space is small and since I have had the privilege and how well-designed they turn out to be. He What was to be my honours year however,of spanning most of it, this will be somewhatpersonal and focused around pathology. and his colleagues had built various pressure and displacement sensors that fed into a huge saw Taylor move to be Deputy Vice > Chancellor and so I joined his student, The Health Advocate June 2011 19
  19. 19. In depth>Barry Gow, who had inherited the laboratory.With Barry, I looked at the conundrum ofwhy aneurysms formed on the low pressureside of a constriction in arteries. Barry was adentist who made organs and harpsichords inhis spare time but in the lab we built our ownmicroprocessor-based computers including aDEC LSI-11 and used these to drive machinesto prod and scan arteries as well as for real-time Fourieranalysis of vibrations. Grant Carter4, a medicalstudent, helped with the programming ofthe Intel 8080 microprocessor5 following hissuccess at writing the BASIC compiler for theAustralian Microbee. Arthur Guyton, arguably the last personto have a complete understanding of knownhuman physiology, also visited during this timeand gave us his FORTRAN dynamic model ofthe human cardiovascular system; we wereable to run it on our home-grown machine. The laboratory next door was David Read’s,a respiratory physician who had formeda relationship with Ita Buttrose and the Programming then was in assembler (the bits and bytes level) because that was the only way to ” ”Australian Womens Weekly in support of hiscot-death research. Needless to say we werejealous of their funding. David, who was a make the computer work fast enoughgood scientist and great teacher, attracted anumber of bright young clinician-researcherskeen to be associated with this cutting edge GE in the US. After a spirited New Year’s party I and a couple of others ended up doing time.laboratory. Among them were those who are found myself being interviewed for the role of Interestingly, many remember these newswell recognised now in health informatics and Coordinator of Computing and Quality Control items but few could tell you that seven of thethe medical technology sector, including Vince in the largest NSW pathology laboratory 10 Australian Nobel prize winners were/areMcCauley6, David Rowed7 and Colin Sullivan8. (Macquarie). In many respects this was a role pathologists or physiologists.Vince and David were programming then in and job title well before its time. It showed a At Macquarie, I specified a laboratoryassembler (the bits and bytes level) because clear recognition of the link between quality information system and it was put out tothat was the only way to make the computer and informatics in pathology. tender. Relying on contractual promises andwork fast enough for the experiments. Macquarie Pathology was founded in a judgement that the ‘new’ language ‘C’ with the early 1970s by Tom Wenkart9. Tom was, an approach then called ‘parameter driven’Pathology and still is, a visionary in what has become (and now called archetypes) was the way to known as e-health. From the outset Tom had go, and following my forecast of the demiseYou may be wondering now how this has the vision for the digitally connected health of MUMPS, we embarked on implementationanything to do with pathology informatics. system. Indeed in the very early 1970s he had with a partner – the specification was okayWhere I had seen myself as an academic and printing computer terminals in surgeries for but the implementation a failure. For thewas set to go to UNSW in what was, and still pathology reports but these were removed record the successful non-winners, Alexis, an exciting area of research, Functional because they were seen as inducements. Anderson’s Détente10 and Sonic’s ApolloMRI, the project collapsed when at the last Times were interesting in Sydney and system, still use MUMPS (Cache) today veryminute the Australian research leader, who pathology then. It was the ‘underbelly period’, successfully.was returning to Sydney after working with during which a principal of a Sydney pathology At Macquarie we also tested the value ofthe Nobel Prize winning Nottingham Group, practice was shot outside his Concord computerisation to a pathology laboratorygot an order-of-magnitude better offer from laboratory over a ‘business related matter’ with a somewhat unnatural experiment.20 The Health Advocate June 2011
  20. 20. I arrived one day to find the place on fire – an was a CIO before George. In a twist of fate siders saw a working computer for the firstarsonist had broken into the secure data I came back some years later leading the time. A patient would sit in a perspex pod tocentre, opened the data safe and set it and the ‘occupation team’ after Mayne bought answer a computerised questionnaire in fullcomputer centre alight. The laboratory, which Macquarie laboratory. view of the computer with spinning tapes andwas downstairs, was saved and continued to flashing lights behind glass. This was highlyfunction but it took a week of 24-hour days to Medicheck controversial and on a number of occasionsrebuild a computer room and to get the system made front-page news. There was real concernrunning again. There was a disaster recovery After Macquarie I moved to be CEO at another from the less well-informed profession thatplan and no loss of patient data but we went highly innovative organisation, Medicheck. In computers were being pitched to replacemanual and it was absolute mayhem. 1970 after having sold his transformer business doctors. Of the many eminent people No pathology practice would think to GE, Sir William Tyree13 established a trust. associated with this organisation, Brankoof starting (even 25 years ago) without With Sir Eric Willis14 and Sir George Halliday15 Celler17, who was Director of Research, andelectronic health records and no laboratory the funds were used to build a preventative Bruce Barraclough18, who was a leading breastcan operate now for more than a few minutes health facility which had the dual aims of surgeon at the associated Sydney Squarewithout its information systems. On the systematising medicine and moving the Diagnostic Breast Clinic, have important rolessubject of records, another well-known emphasis toward prevention. Medicheck16 in health informatics now.health informatician George Margelis11 broke new ground in many areas. It introduced I arrived at Medicheck in the mid-1980slater joined Tom at Macquarie as CIO and mammography to Australia, created the first and led the third generation replacementtogether they worked on an early versionof the Personal Health Record. Klaus Veil12 mental health atlas of Sydney and, relevant here, it was the place that many Sydney- of the information systems in this organisation that had always had > The Health Advocate June 2011 21
  21. 21. In depth>fully electronic records (replacing one from of Medical Services with the Red CrossBUPA). Having learned from my previous 5 Intel’s second-generation 8 bitexperience and with a talented computer microprocessorscientist19 we used prototyping directly 6 Emergency doctor; developer of awith the doctors, nurses and scientists who laboratory information system; Pastwere working in the organisation to build President of the Medical Softwarean information system from the ground up Industry Association and currentincluding a laboratory information system Chairman of IHE;(LIS). From the technology point of view and standards developerthis was a time when relational databases 7 Electrical Engineer; GP; one of thewere just becoming commercialised. We OpenEHR founders and standardspurchased Oracle before they had established developeran office in Sydney, ran it on one of the first 8 Respiratory physician and ResMed the Board without a knighthood for some timeMicroVAX’s and had networked PCs attached. co-founder 16 Medicheck and its sister organisation inMedicheck became a technology showcase 9 Entrepreneur, GP, private hospital operator, Melbourne, the Shepherd Foundation, werewith weekly visits from people mostly outside PHR developer and now with an interest closed down when medical benefits werehealth. Because of my role at Medicheck in Pen Computing - he was also a one-time withdrawn by DoHA because the valueI became a director of the International large-scale computer bureau operator for couldn’t be demonstrated to their satisfactionHealth Evaluation Association with Morris local government and provided microfilming – the protocols and testing have since beenCollen after whom the highest honour of the and microficheing for the NSW police among well-proven but no organisation exists whereAmerican College of Medical Informatics is others it can all be done in a single visit includingnamed. That also meant I got the privilege 10 Now Integrated Software Solutions counselling in 90 minutesof visiting with him at Kaiser and using those 11 Optometrist; medical practitioner; 17 Electrical engineer, computer scientist,learnings in the Medicheck system. informatician and now lead of the Intel GE founder of Telmedcare and now Executive In the next issue I will complete this personal Healthcare Alliance in Australia Dean of the College of Health and Science athistory of informatics in pathology and how 12 Informatician; standards developer; past the University of Western Sydneythese developments influenced the broader Chairman of HL7 Australia and Board member 18 AO, past President The International Societyapplication of ICT in healthcare. of HL7; current President of the Australian for Quality in Health Care, past Chair of the College of Health Informatics Clinical Excellence Commission and currentReferences 13 Electrical Engineer; Entrepreneur Chair of the CSIRO Australian E-Health 14 Former Premier of NSW Research Centre1 http://www.pulseitmagazine. 15 ENT surgeon and former President of the 19 Mark Abel - still an Oracle contractorcom.au/index.php?option=com_ BMA in Australia. I was the only member ofcontent&view=article&id=511: why-is-it-all-so-hard-in-pathology2 Mathematics is a branch of informatics.Taylor would play chess with the head of the Take home messageselectronics workshop by making moves as Here are some morals to the story so far: science development;they passed in the corridor – without a board! • There are more than 40 years of history • Australia has been keeping pace3 The Basser Department of Computer Science in health informatics in Australia; intellectually and has led at times but(so named because Harry Messel was able to • Health is not a laggard as some argue does not always realise its potentialprocure part-funding for the computers from when it comes to the application of when it comes to recognising the value ofthe Melbourne cup winnings of jeweller Adolf information technology; what it has and commercialising that;Basser) was located in the basement of the • Some pretty smart and dynamic people • One of the reasons there hasn’t beenPhysics building have and continue to contribute to the more progress is because it is hard; and4 A fellow called Bill Gates had done a similar development of e-health; • It would be inefficient not to learn fromthing, but for the IBM microcomputer. Grant • There is more to health informatics (and the history so we must provide specificwent on to do biomedical engineering. He e-health) than shared records; education in what is a knowledgedeveloped CRS, was IT Director for Western • Pathology has been at the vanguard of domain in its own right – healthSydney, headed GE’s Medical IT group and was health informatics and computer informatics.a VP at ResMed, and is now Qld State Manager22 The Health Advocate June 2011
  22. 22. Operating e ciencies up Carbon footprint downCustom-Pak™ procedure pack - Australia’s leading ophthalmic surgical pack. It’s not just twenty-first century living that leaves a measurable carbon footprint – it’s our nursing practices too. But how can we increase operating room efficiencies while limiting their carbon impact? Simple things, like choosing a surgical procedure pack that is fully customised for one ophthalmic surgical procedure can help to optimise your time and the quality ofyour patient care. While the reduction in waste generation, when compared to generic packs, can helpto reduce the negative environmental effects of our nursing activities.1 This is why Alcon®, Australia’sleading ophthalmic surgical supplier, is willing to dedicate resources to protecting the world’s resources.A greener world starts with greener practice. A greener practice starts with Custom-Pak™ procedure pack. Reference: 1. Lausten G. Reduce-Recycle-Reuse: guidelines for promoting perioperative waste management. AORN Journal, April 2007. For further information please contact Alcon Laboratories (Aust) Pty. Ltd. 10/25 Frenchs Forest Rd East, Frenchs Forest NSW 2086. ABN: 88 000 740 830. Phone: (02) 9452 9200. Customer Service Freecall: 1800 025 032. Juicy Advertising ALC088. PSUR 0899.
  23. 23. In depth DAVID MORE Clinician and Health Informatician Where’s the evidence? David More asks is the Personally Controlled Electronic Health Record an evidence based intervention?a  S A CONSEQUENCE of a series of recommendations in the National Health and Hospitals ReformCommissions A healthier future for allAustralians – Final Report June 2009, the basic individual demographic details and the information that is normally held, either electronically or on paper, in the General Practitioners Summary Record. This would include allergies, regular medications, key Commonwealth Government, that will be accessible via a web portal for the clinician, with permission, to review. At a later date, the patient will also be able to contribute their personal information and commentssubsequent Commonwealth Budget allocated elements of history and current diagnoses. should they choose. The system is apparentlyalmost half a billion dollars over two years to The Event Summaries are envisaged to be intended to be a lifelong record that will bemake a Personally Controlled Electronic Health such things as a set of pathology results, accumulated over time.Record (PCEHR) available to all citizens who referral letters and so on. At present the system is intended to bewanted one by July 2012. The idea is that the patient will be in control available to patients who choose to have a As the PCEHR has evolved – largely away of this information and will, if they agree and PCEHR and register for access by July 2012, nowfrom the public gaze and in secret – it has consent, make the information held in this just 14 months away. The system is presentlymorphed into a conceptual Health Summary record available to clinicians caring for them. planned to operate in an ‘opt-in’ fashion whereand a series of Event Summaries. The Health The patient PCEHR record is to be held an individual takes a positive decision >Summary contents are intended to be the by a PCEHR system, presumably run by the to register for and establish a PCEHR. The Health Advocate June 2011 25
  24. 24. In depth>Concerns regarding is designed as the minimum necessary for the evidence for the value of provider emergency care, not as an information rich Electronic Medical Records (EMRs),the concept long-term longitudinal record. especially with embedded clinical decisionIn mid-April the Department of Health and Second, the evidence from the UK suggests support, is very strong indeed.Ageing released the draft PCEHR Concept that even when such summary information is Sixth, adoption of and the value of patientof Operations for public review and this made available, actual use of the information access to their clinical records is best seeninformation has been considered in the is quite low and the clinical impact, if any, is in situations where the PHR is a linkedfollowing comments. hard to determine. extension of the provider EMR (as in Kaiser On the basis of what is presently known, just Third, designing systems to be ‘opt-in’, while Permanente in the US) and where otherhow based in evidence of real positive clinical politically easier, means adoption is slow – over functions are possible.impact are the present proposals? years – and for this reason few will bother to Seventh, it is clear that the so-called ‘digital I would suggest they are not and that the look up such systems. divide’ is alive and well with patient portals,claimed rationale for this very substantial Fourth, the present plans for seeking where often those who need them most areprogram is based on a combination of consent for both access and for information the least likely to be able to obtain access.wishful thinking and ignorance. My reading provision into the PCEHR will have very Eighth, it was obvious from a recentof the global literature leads me to the significant clinician workflow impacts, i.e. slow workshop conducted by NEHTA on thefollowing conclusions. clinicians down, which will ensure that without PCEHR that there was considerable concern First, there is no working example anywhere major financial incentives to compensate for and disquiet from clinicians regarding justin the world of a parallel longitudinal patient- the time costs, clinician usage will be minimal. how well the available funds were planned tocontrolled electronic health record. There Fifth, while there has been much research be deployed given other perceived prioritiesare successful examples in small countries on the topic, it has not been possible to in e-health, such as improved standards,(Wales and Scotland) of emergency health consistently demonstrate positive clinical better clinical systems and improvedsummaries derived from GP systems being outcomes through the use of Personal Health information flows between clinicians, areimplemented, but the information content Records (PHRs). On the other hand, very high on the list. Key points of the PCEHR Key points to be noted about the presently proposed model of the PCEHR include: • The PCEHR is an additional and clearly parallel health record to that held by the health care provider. The PCEHR is conceived of being a secondary record in some senses – as far as clinician contributed information is concerned – and a primary storage of some consumer generated content. • The PCEHR will contain a summary of the full patient record, with a variety of other information (lab results, discharge summaries and so on). • There is no clarity just what arrangements are intended to ensure the copy of the clinical information held in the PCEHR is properly synchronised and consistent with the current practitioner record. • All the documentation made available to date has been silent on just how the situation of a patient attending multiple practitioners is handled. • The PCEHR is not linked / attached to the practitioner record in any direct way. This means that functionality such as secure direct communication between clinician and patient, appointment and repeat prescription requests, and access to current information in the provider system is not available.26 The Health Advocate June 2011