Presentations from:
Mr Jeff Parker, Independent Consultant
Dr Carmel Simpson, General Practitioner
Mr Francis Sullivan, CEO, Catholic Health
Discussion and debate

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Industry Perspective
Mr Jeff Parker
Independent Consultant

Perhaps we are talking about patients falling into CHASMS rather than gaps!

The health space is big and complex and disorganised and this is the territory across which the patient has to travel. Along the way there are a lot of complex clinical and funding interactions.

In the associated presentation we build up a progressive model. Starting with key places on the journey: GPs, Specialists, Hospitals, Allied Health, Pharmacists, Diagnostic Imaging, Private Health Insurance. We have looked at issues of content quality and efficiency and scored each of the transactions. E-Health may be able to provide some advantage in these two areas of quality and efficiency.

Much of the initial clinical transactions with GPs, pharmacists etc. are relying on verbal transfer of information, memory and paper - not much is sharable. As we develop the model the slides show the increasing level of complexity as the journey continues.

The other dimension is the claims and payments, equally of importance to consumers. Many transfers happen between players directly.

I have also had a look at this issue of healthcare teams. Different teams come together to provide care at different times of life, or for specific conditions, or care groups. So for high need consumers the webs of service are multilayered and potential for falling between the gaps increases.
(Editorial note: there is significant evidence that complex care delivered by one provider or service also has the potential for major gaps)

Looking from the outside it is hard to see why we have the large gap between clinical and administrative systems. There must be some potential for efficiencies and to detect and reduce fraud where it exists

In the current world the patient is the "carrier pigeon" of their health data - surely there must be a more modern and effective way of moving information. Patients' memories are fallible and business processes must be supported by standards. Of course those that are at risk of problems are the 'frequent flyers".

Medical Profession Perspective
Dr Carmel Simpson
General Practitioner

My sense of the gaps is based on my experience as a GP in a practice that wanted to computerise to support patient care and practice efficiency.

'Our expectations were: aid memoire, patient flow, continuity, better communication with health sector, quality improvement and access to resources. Computers save neither time, money nor paper.

If the use of the computer extends my 15 minute consultation by one minute and I don't work longer than my 40 hours, then I will see 8 less patients per week and nationally this would be 13,600 less appointments per week, or another 757 full time GPs would be needed.

Many things are being done well in GP practice with computers, but what is done badly is the patient record. To me records are like a garden; labour intensive to establish and difficult to maintain. The reality is that to keep an organised electronic record I need to spend up to 1.5 hours per day consulting hours updating drug lists, referral information, discharge summaries, investigation reports. This work perpetuates the patient perception that the computer is a magic box, fully up-to-date with their information. Typing in the consultation lacks elegance and may impact on patient-doctor interaction. When I try to connect to doctors outside I end up cleaning up their "aid memoirs" - I have to weed their garden too.

Many specialists have become wary of the template-generated letter as it often contains out of date and irrelevant information! Mix of on line reports and scanning.

Improving chronic illness demands the establishment of many new templates, how do we follow-up on them. All this takes more time and effort. Systems are needed to follow-up on these templates of care - more time, more staff needed. Does not accommodate the names of many ethnicity. Room for improvement in aged and mental health. Lack the ability to move information across to other systems - the "essence of practice" the understanding about how patients react, important social or life events. The key bits of "essence data" get lost in the patient summary.

There is still some way to go for the computer to cover the patient journey.

Perspective from the Aged Care Sector
Mr Francis Sullivan
CEO, Catholic Health

This address will discuss those who we are to serve rather than the sector in general. A story from my home life reinforces that that there is only so far that our community is prepared to support those with entitlements and this is tight!

90% of people in aged care homes are on a pension and they pay 30% of their way. This is not a lucrative cash flow. Focus groups have identified:

70% express dissatisfaction about the number of drugs they take
Many are concerned that the drugs may not be necessary or may never have been
60% constantly confused around what to take and when
80% have poor discharge processes and confusion about medications. One lady was given two bags of medicines - up all night wondering which bag to open first.
70% felt exhausted by taking medications - helped if you swallow all in one go.
50% distrust the staff managing the medications - staff are too busy
40% impatient about continual questioning and recording of their history
65% anxious about having correct copies of their documentation or having to chase their own records around the hospital.

All want a single bill. Australians pay more out of pocket expenses than many countries - and not keeping up with average weekly earnings since 1993 (110% vs 34%).

Biggest political issue - lack of resources means nurses work too hard and don't have time to care for people. Nurses are exhausted yet hold the show together.

Aged persons want information, security, comfort, companionship, touch, human interaction of their current and future life and with their past, talk, treatment with dignity, sense of self worth, time to decide and people to be patient with them - where does e-health fit in with this? Aged care is about caring - there is a major danger in shifting responsibility to technology rather than human interactions. Aged people in many cases have already seen a shift in responsibility in their care and responsibility.

Discussion and debate

Problems with data entry - time and loss of interaction with patient. Would the benefits outweigh the costs and effort? Should we be offering patients a choice about whether the records should be kept - offering the record as an optional extra for more payment? (Jeff Tobias)

We need to look for new models and work processes, doctors are not good at data entry, have tried getting patients to critique their records and helping with update.

As a specialist working in hospital system. Need better user interfaces. The investment in new systems has concentrated on backend not the sharp end. Unless doctors and nurses have easy to use systems and those that have some benefit, there will be a lot of garbage put in just to fulfill data requirements - this issue is a priority. (Choon-Siew Yong)

The general health public needs education and a learning curve. Need to have some system for education. Doesn't believe that care delivered with paper and pen is less adequate than that delivered with computer records. (Charles Howse)

What can we change and where to start? (Tom Bowden) Start where you can eg prescribing, people need to want to learn, need some value to them, need training ancillary staff to be data enters (eg patient had colonoscopy two weeks ago), need to relax access and privacy to let this happen. Perhaps we can make a start with the non-electronic communication across sectors.

A key gap is lack of commitment by Government before telling us to fix the problem. Government use of standards is very poor - NSW Health has published a 600-page duplication of an existing pathology messaging standard. No requirements in Commonwealth tenders to use standards. Loss of opportunity to drive the market. Different rules in different States so each system is customised for the State. It seem the Government has some of the building blocks eg. Medicare number but won't let us use them. IP on software projects developed with public money is locked up. A complete provider directory is available but locked up due to "privacy considerations". (Vince McCauley)

In aged care e-health can help with safety and security. Keeping people out of care facilities with e-health may help. What is the vision for aged care, and issues, what are benefits and investments for short term and long term wins. (Michael Gill) Regardless of the benefits we must not use technology to further isolate eg do you look at the monitor or go into the room? (Francis Sullivan) We should not be afraid that properly used e-health will detract from patient care, put it to work where it is needed eg coordination. (Prue Power)

The reasons why Governments are slow to shift is the concerns in the polls and financially are about immediate need not communication! (Francis Sullivan)

Comments made about the template letter - some doctors seem unaware that they can customise it to meet their needs and style and that the data printed out is what they have in their own systems.