Presentations by:
Professor Michael Georgeff, Monash University
Dr Mark Parrish, IBM Australia
Discussion and debate

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Professor Michael Georgeff
Professor of Health & Information Technology, Monash University

It is better sharing and utilisation of information and knowledge that is going to make a difference to our healthcare system, not just better drugs and treatments etc. Information is becoming a more critical factor with challenges such as the ageing of the population and focus on chronic disease management.

The vision is clear but it is proving difficult to realise. We are seeing the problem in the wrong way! We have a highly complex, heterogeneous system made up of fiercely independent groups. To date we have tried to bring these together under a uniform approach, apply standards, get the information right, minimise variation, link up information in a shared health record. This is the approach the banks have used. But such a way is costly to implement and a long time to seeing value. Sharing knowledge does not imply that it will be utiliised in a way that delivers the outcomes or value. There are not strong user or market drivers to invest in this strategy.

Another way of looking at this is that we are trying to move the cottage industry into the age of the industrial enterprise, focused on resource management, economies of scale using big players, standardisation, planning and getting it right at the outset resulting in systems that operate well together.

Another approach is the knowledge enterprise built on a knowledge economy for example the way Google, Amazon or others operate. The knowledge enterprise is about networks of knowledge, economies of innovation, autonomy, customised and highly adaptable systems. The fundamental component is connectivity. The more people connect the better and accepting heterogeneity. We don't have to get all the data right - the internet has showed us how to do it. Individuals and the market drove it forward.

This is not to say that getting the industrial enterprise right is important, as shown by the video in the last session. We have to also focus on the knowledge enterprise.

The first step is just get connected - this will drive towards standards. Then plug into the network the key objective eg referrals. It may be that just sharing limited data eg who treated who may be enough. Focus on high value objectives, which will lead to progression to the EHR. Also start with regions and expand.

Progress is occurring as seen in the Goldfields. Melbourne Health is connecting researchers and clinicians. At Monash we have established the Health Web Alliance - open consortium prepared to invest in getting regions connected.

Dr Mark Parrish
IBM Australia

IBM wants to improve outcomes in health care: both clinical outcomes and business outcomes though the use of technology. It's all about glue: glue sticks data together and turns it in to information. "Glue" will have benefits in:

1. Connectivity in information based medicine and improving health outcomes
2. Connectivity in wellness and improving outcomes
3. Connectivity in the back office

We currently practice medicine in an episodic manner. An example: Think of Mrs Jones visiting her doctor for a review of her type 2 diabetes. What happens now?
Her doctor may have some record of her previous blood sugar results if he has seen her before; if he is lucky he will have some results from other doctors;
He will probably have some laboratory results; if he is lucky he will have a number of lab results and if he is really lucky he may be able to graph them;
He will probably have some record of Mrs Jones' treatment regime.
Mrs Jones may have brought results from her home blood sugar testing; if he is really lucky he will be able to interpret these, and they will be a truthful account, with an accurate recording of dietary intake
He may have recently read an article about the best practice management of type 2 diabetics like Mrs Jones; if he is lucky he will remember this and apply some of its principles in the consultation.

So his care of Mrs Jones is episodic. And his ability to link the data he records at this consultation to other health care providers is limited. What will happen in the future? In the future all this information, and more, will be linked and will contribute to improving Mrs Jones' healthcare. Information will be sourced and interpreted even before the consultation commences. We call this Information Based Medicine. When Mrs Jones comes in, the machine on the doctor's desk, or his PDA, will start to look at all the other information about Mrs Jones, in all the other clinical systems around the State, the country, the world. It will link this to research information, best practice medicine information, pharmacy information. So before Mrs Jones has started talking to the doctor the system will:

Have found all Mrs Jones' blood results from GPs, hospitals, laboratories and her home monitoring system, which will have recorded the results in a consistent manner. It will present this as a graph or graphs in the format the doctor wants;
Have compared Mrs Jones' prescribing information with her pharmacy dispensing information, will apply some clever algorithms, and will realise that they don't match. It will suggest to the doctor that Mrs Jones may not be complying with her medications;
Knowing Mrs Jones' genetic information it will match this to research information and pharmaceutical information and suggest that, given Mrs Jones' genetic pattern and some research from somewhere in the world, she is likely to have the best outcomes from changing her medication from A to B;
And it will do this automatically. It requires glue to stick the silos of data together. IBM makes a lot of glue. And this reality isn't as far away as you might think.

Examples:
Denmark example and diabetes care
Alberta example and medication management
Melbourne Health and linking research information

We can do this now, without replacing current systems. Clever glue stuff can stick together what we've got now and turn data into information. (Recent Gartner report: There will be a 50 percent growth in healthcare software investment that could enable clinicians to cut the level of preventable deaths in half by 2013. Healthcare has historically under invested in IT; however, this is changing.)

Now move outside just clinical health care. Look at wellness. How do we manage disease outbreaks like Avian flu, SARS? They affect all aspects of a country, not just the health system. They affect the economy, society, culture, the environment. Go back in history. John Snow and the Broad Street pump. The father of epidemiology, he tracked cholera outbreaks to one pump in Soho in London. He drew a map of where the deaths were and based on a link with one water source, took the handle off the pump and stopped the epidemic.

We need equivalents today. We need to know when outbreaks occur before they present to the health system. By linking information on school absenteeism and over the counter sales of medicines we can potentially get an early warning on disease outbreaks. Another two examples:
Canada: link 6 hospitals, Canada's only Level 4 Microbiology Lab, Provincial health and Defense Agencies and a PBM for event detection, usage reporting, trending, alerting;
IBM research showing pharmacy over the counter sales linked with school non attendance, picks up disease outbreaks well before they present to healthcare providers.

CONNECTIVITY IN THE BACK OFFICE
We tend to see back office stuff (financial management, supply chain, procurement, HR systems) as separate to the provision of clinical healthcare. In some ways however, it is not possible to do a procedure without the right consumables and linking clinical systems with order systems might allow a better tracking of what is needed and preventing materials going out of date. Such systems exist today in pharmacies and hospitals. If we start sticking this stuff together we get lots of benefits.

By putting some standard systems in place, there are significant savings to be made, both in the costs of clinical care and the costs of running the systems that support the health system (financial, HR, supply chain, procurement).
A recent editorial in the Medical Journal of Australia stated that every day 25 patients die in Australian hospitals from preventable errors, and another 22 suffer preventable permanent disability. The costs of this are significant. But the potential savings are significant as well: up to 15% of the annual costs of healthcare could be saved by decreasing unnecessary and duplicate medical tests, shortening hospital stays and cutting administrative costs. Some studies suggest this figure could be higher. If we just look at back office systems that support healthcare and consider only one of those: supply chain and procurement, there are significant savings to be made. The IBM company is a good example: by standardising our supply chain we have saved US$20billion over the last 3 years. That's about $7bn a year in a company with costs of about $55bn: about 12%. Doing this in health would both improve healthcare (you can be sure you have the widget that you need for the patient on the shelf, when you need it, always) and cuts costs (no widgets going out of date while they sit on shelves, just in time delivery).
I hope I have described how linking information can improve health outcomes - the glue can help in:
1. Connectivity in information based medicine and improving health outcomes
2. Connectivity in wellness and improving outcomes
3. Connectivity in the back office

Discussion and debate

What is the glue that does all of what has been described? The glue analogy basically means we don't have to throw away all our systems, and can build on existing technology. Start incrementally (Mark Parrish). Our children are using the basic infrastructure to share music images etc. We have to work out how to layer our systems on top of this but the basic infrastructure is there (Michael Georgeff). From an international networking perspective the standard surfacing is the Internet Protocol (IP) (Jeffery Tobias).

Is the UK NHS network the type of answer for us? The Internet was not considered secure enough (Margaret Chirgwin).

The difficulty with the glue model is that in many parts of our health system there is nothing to glue together. The development of enterprise level systems has happened in some areas: pathology, hospitals. To make connections in the private practice world we need an infrastructure like the Internet. To make this work the medical profession must lead, models of third party fee for message type services will not work, it has to build on trust and ethics, must be secure and reliable. Current private practice systems do not have 24/7/365 connectivity or reliability. Need to move past the vision like that proposed by Mike Georgeff. (John Rimmer).

The Internet isn't by itself connectivity - it may provide access or link into connected networks. Need service agreements for quality, security - medical grade networks. (Jeffery Tobias)

Perhaps Mike Georgeff has given us a vision. Interoperability for reading is different to interoperability for data processing. (Tony Firth)

Outline a vision of connectivity between patients, doctors and hospitals. Even if this can only be achieved in a small percentage of patients is a good place to start. (Peter Thursby)

Not intended that the responsibility of managing the ongoing record should fall to patients, just as in the banking sector we expect the banks to provide the infrastructure for us to access our accounts. (Mike Georgeff)

The Healthweb could have a search engine to locate key documents for patients and this could apply to MRI, specialist reports etc. This could be a good place to start (Marissa Lassere). (Editorial note: this is the basis of Integrating the Health Enterprise)

Banks are trying to move from the industrial enterprise to the knowledge enterprise. The interconnectedness between banks is the result of some serious collaborative standards work - Australian Payments Clearing Association, originally convened by the regulator but now involves consumers and banks. The market might move this faster than structured approaches. (Leslie Martin)

The glue could be the patient (Tom Weinkhardt).

We can't risk having different systems in public and private (community and hospitals). (John Aloizos)

The idea of connectivity was put by the professions years ago, and services to support quality, and understanding of impact of Government decisions. Need to better understand the roles of players, it is not the job of doctors to pay rebates, this year has been a bad year for consultation; serious workforce problems are in the offing. Need the right mix of education, regulation and incentives. Think about the incremental and layered approach. What GPs need is appropriate support not admonishments. (Ron Tomlins)

To use glue the surfaces must be clean and carefully prepared. Much work has been done to prepare the way with the GPCG and key project work is ready to be rolled out. One project was about helping vendors get data into a form that could be exchanged. A key next step is to get vendors and users together to decide what needs to be shared, how structured it needs to be and what clinical events will trigger this sharing - this is a piece of work which can go forward now. (David Rowed)