Presentations from:
Dr John Youngman
Professor Johanna Westbrook, University of NSW
Discussion and debate

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Dr John Youngman
Professor Public Health, Bond University

It is not possible to look at any implementation of health IT systems without looking at human behaviour and change management. Overall I feel that the current position with e-health is negative, a lot of rhetoric, but at the coal face what are computers doing to help patients? The assumption that the younger generation will use computers may not be a reality. They will use computers for their own purposes.

There are many "fear issues" which continue to surface - these and other logistic issues have to be overcome. Doctors can't type! Surely this may compromise looking after patient needs. With data being potentially collected all the time, the volume and data management issues will be very difficult. `

Many of our lessons learned about IT have come from the USA, which is a very different environment. Many of the metrics for benefit come from there and may not be relevant to Australia.

Data sharing is a two way street. If GPs want discharge summaries then they need to send good referrals. Technology is changing work practices, we work from home, how is that impacting on our quality of life? New communication models can be intrusive e.g. email. There is now an expectation of instant response; you should be watching your email constantly!

Technology performance and problems have to be factored in. Systems such as pap registers need backups. We need failsafe systems. Be this as it may technology is becoming pretty reliable and those risk averse should not rely on this as a grounds for not proceeding.

Who benefits, who pays? The Government subsidies to GPs is a matter of recognition. It is actually the consumer and system that primarily benefit and this has to be recognised in the funding models. Ideally there needs to be benefit for the clinicians themselves.

Risk management - we are still duplicating electronic and paper systems. There has to be a focus on security and disaster recovery. Security needs support. Most security fails for human reasons e.g. failure to update virus protection programs and leaving passwords around. With regard to consent we could look to how issues have been dealt with previously and apply that to the new e-systems. Real issues are people issues, involvement, listening, not process. When will we stop focusing on projects and get on with some implementation.

Summary: change creates fear, technology may fail, and we must take some risks, change in technology intimidates, heightened expectations are induced, impatience abounds, performance may be inadequate and solutions need to be people focused.

Professor Johanna Westbrook
Centre for Health Informatics, University of NSW

The presentation will examine from local and overseas research how behaviour change can be an obstacle in the introduction of e-health systems.

Looking at implementation of online evidence resources, there was considerable variation in the use of the systems with no pattern in the top 10 users. Case studies found that high use hospitals had a culture of use and value of the system - there were expectations. Low use hospitals had the rhetoric but not the effective practice. They still had the old paradigm of looking up unusual cases only and using resources retrospectively.

"Why would you bother looking it up as a junior? You're very much a sheep to your consultant's quirks" - this explains the low use somewhat!

People use systems when they have some benefit. However often the benefits accrue to someone else. Computer pathology gets results out 20% faster but the clinicians have to spend much more time entering their test requests.

RAND study showed the motivation to use EHR yet the uptake of clinical systems is low and probably less than 10% for full on clinical care systems. The reason for this is that implementing clinical systems is really very hard.

E-Health challenges how care should be organized, changes clinician roles and tasks eg. entering data is time consuming and may be seen as demeaning. It leads to increased accountability with anxiety, anger and concern. In clinical environments changes in the behaviour of one group impact on others - a computer order system may lead to chaos initially in the laboratory as was shown on a video vignette of such an implementation in a major Sydney Hospital. Hence computerisation can lead to increased internal and organisational conflict. What happened was that the label printers could keep up with the demand and slowed the doctors down. They threatened to boycott the system so a pragmatic solution was made to revert to printed requests. However in the video we saw that these did not always get attached to the sample.

We underestimate the amount of change that introduction of new systems involves. Some recent research on how the paper chart is used found that in a ward round several bits of the chart are looked at by different groups simultaneously, data is being entered and questions asked by others. Moving to an electronic record will certainly change the way this work is done. Holding the ward round around a terminal removed from the patient bedside may have some negative consequences for the involvement of patients and their ability to participate.

We need to better understand the work processes so that explicit decisions can be made about what processes need to be changed, rather than having changes unknowingly dictated by the introduction of technology.

Success is not final, failure is not fatal, it is the courage to continue than counts.

Discussion and Debate

Why is it so hard to have a discharge summary on time? This failure and notification of patient death are examples of systematic communication failure and discontinuity of the healthcare system. (Graeme Miller).

Very few hospitals can send a standard structured summary. Lack of standards is the problem (Andrew Magennis). Standards need governance and driven from top down. Yet there is evidence that where standards exist they are not being implemented (Helena Britt)

The Department of Human Services believe that open systems accessible to all people depend heavily on standards and the Department will do all it can to support them (James Kelaher, Department of Human Services).

The problem with discharge summaries is a systemic issue in hospitals (Tony Firth)

Discharge referrals may happen if work practices were changed to ensure that a referral back to the GP was required before the patient could be discharged (Carmel Simpson)

Are we achieving efficiencies by getting clinicians to put data into computers, some law firms don't allow their partners to do so. From a research perspective we can look at sample data and don't collect the whole amount (Graeme Miller).

Experience from early implementation in clinical software - first of all looked for the major problem - repeat scripts. There are major efforts in learning all the bits of a complex system. Suggest you do a little bit really well and then progress (Andrew Magennis).

Experience from hospitals is that users have to see the benefit. In their medication management system pharmacists adapt quickly due to their 20 plus years of experience with IT. Nurses less so until training and familiarity with system show them the benefits. Doctors are the show stoppers - what is wrong with the medication chart on the end of the bed? How does it benefit them? What is the problem being fixed and it just slows them down (Tony Firth).

The rollout of a national standard medication chart is being backed by strong evidence that it improves patient safety. (John Youngman).

Looking at use of smart card technology and internet for government services and learning from previous problematic implementations of technology in the HIC it seems important to look at the whole problem, not just bits of it. Compared with major international comparators, they also have regional government and funding models based on public and private mix. We shouldn't use these as excuses for failure. Starting to see change models based on collaboration followed by mandating and incentivisation. Recognising that there will be losers and need for incentives. Our failures are due to the "Australian way" where legacy systems are allowed to continue being fully funded while the new more effective systems are partly financed, over the short term and with insufficient investment in change management and incentives - we end up with half a dozen partially complete systems all soaking up money but not producing the outcomes. We need to change the Australian way to put more effort into what should be mandated and what should be incentivised. (James Kelleher - Dept. Human Services)

The problem with mandating and requiring behavioural change is that this will create opposition. Change must be based on benefits. Change should happen by getting it right with NEHTA, consultation and pushing money out to those who need to change. If the process is right and the product is right people will accept the change (Mukesh Haikerwal).

The view was challenged that we can move forward only if it is good for doctors and there are incentives. Surely if a system will benefit consumers then that should be an incentive for doctors - isn't that what healthcare is all about? All the benefits of a change have to be articulated and communicated to all involved. (Helen Hopkins).

These points have highlighted the need for careful use of language. When discussion turns to benefits to GPs this should recognise that better outcomes and benefits for consumers is also a benefit for GPs. (Jill Maxwell- facilitator)

There seems to be a misunderstanding about the different between Standards eg the communication format and codes and the systems themselves as used by clinicians. Mandating a particular standard in the background is different to saying you will use this particular system whether you like it or not or the computer says you cannot prescribe drug x for condition y. Consider the flow Standards for Infrastructure - Clinical Systems - Benefits for Consumers - all are necessary (Peter Garcia-Webb )

It is not possible to dictate standards top down - they must be developed by the users and accepted by the users. There are lots of examples where standards developed without industry involvement have failed. There are many success stories eg the internet where industry is involved and has got behind them and implemented the standards. Lots of the projects undertaken around e-health have made the mistake of focusing on the needs of one group eg. HealthConnect or State Health Departments rather than looking at the needs of all the players. Have to understand the needs and benefits of all the players. An example is the "reason for prescribing field in prescription software". The software can record this data and the State Health Department may say this is a mandatory field if you want to send us a record - but that wont make GPs do it unless they can see some benefits for themselves or other stakeholders or better clinical practice. They have to be included. (John Frost - HCN)

Having been involved in health IT standards in several organisations over many years you can have standards quickly and with consultation - it just needs organisation and resources to bring the players together and fast track the work (Michael Legg - President, Health Informatics Society Australia)

There are many examples of new information technology which did not need to be introduced with a formal change management process e.g. email, Google. People wanted to use these products and did so. Is it possible that the vendor community has got it wrong with the products it is delivering? (George Margelis) It is hard to predict what we need down the track, how can we move to the next step.

Following on from the example of the staff who did not use e-resources as the direction was set by the consultant and no one would listen so why bother. Evaluation of Victorian equivalent resource found the same. Perhaps we need to talk about organisational change not just behavioural change (Teng Liaw). This emphasises the need for leaders and champions to drive change upwards into the organisation as well as outwards among end users (Joanna Westbrook).

It is important to keep the systems simple and focused. Concentrate on key data. Our local experience is that GPs are using their systems for prescribing only and that busy doctors do not have the time to learn all the complex and useful features (Marrisa Lassere).