Presentations from:
Ms Vivien Rowland, Optus
Dr Peter Garcia-Webb, AMA
Discussion and debate

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Industry Perspective
Ms Vivien Rowland, Optus

Partnerships across the Health Sector - Government to Primary Care

The concept of partnerships has a general meaning of sharing, inclusion, success and friendly relationships. In reality, genuine and successful partnerships are tough work. The objectives need to be clear and shared. Each partner needs to understand the roles, risks and rewards and this needs to be agreed and managed. Processes to work together and manage the relationship have to be clear and functional in day-to-day operation. Health is based on collaborative care between multiple players - some is built on formal contractual relationships, but much is done on an informal basis. Partnership and teamwork is intrinsic to care.

From an outside industry perspective healthcare is a confusing morass of players, interests and complexity. Knowing where to begin is a challenge. The processes to influence are now known and it is no wonder people in industry talk about trying to herd cats. We can target one geographic or market area if we want to provide services in health, however the problem for us is how to engage the industry at a strategic level to genuinely consider partnership opportunities. For example to engage in the primary care area there are the professional colleges, AMA, medical registration boards, allied health, divisions of general practice, state health system, pharmacy, private hospitals and insurers and so on; for many in industry it is all too complicated and difficult.

The complexity is not an excuse to complain, it is just that complexity increases costs and the first requirement of industry is to turn a profit. Given the choice, industry will look to sectors which are less complex to develop, market and maintain product.

In health even mico-businesses expect customised solutions and individual service. There is already a mismatch between expectations and the types of products and services industry can deliver. At the higher levels there is more potential for industry wide solutions that can improve care and reduce backend costs for all. This has potential for greater rewards and it is no wonder there is interest in solutions such as HIC online, Eclipse, HealthConnect and so on. We struggle to remember the days of banking before electronic transactions or accountancy without e-lodgement, flying without e-tickets. Of course we don't talk so much of e-ticketing now it is just tickets and the "e" component has become part of the landscape.

Industry level solutions have some common features: standardisation and agreement about business processes, information flows and serious industry partnerships. Business partners had clear revenue drivers. This is proving more difficult in health with State and Federal funding arrangements but not impossible. Sector wide initiatives require partnership, lots of stakeholders, consultation, cultural change and difficult issues. The telecommunications industry has a lot to offer, is used to working on big projects, delivering real time industrial strength solutions and we understand the issues about support. Solutions are available for the small business or enterprise level, however cross sectoral solutions require significant investment. This investment can be encouraged by:
Minimising unnecessary variety, gain agreement on work practices and information flows and implement standards. Without this agreement it is difficult to build, deploy and support systems and will cost more and reduce future flexibility. The Internet has gone a long way with standards all the way down to the IP address on each computer without restricting choice or ability to provide services.
Facilitate the engagement between industry and health and reduce fragmentation. Industry can now not afford to invest in loss leaders or speculative solutions as in the dotcom era. We are happy to work with professional bodies and to invest in health systems but the level of effort will be proportional to future revenue. Solutions will come faster if partnerships address the issue of investment and development risks.
Doctors know that profit is essential and so the health sector must be prepared to pay a fair price for solutions and realign unrealistic expectations about the costs and services.

The health sector is competing with other sectors for capital and attention. Complacency and self-importance do not impress the IT industry. Some have found working with trades people more profitable and observed that they are more professional in their approach. At the strategic level it is even worse. Where would one take a serious proposal for a health sector wide solution involving EHR?

Industry partnerships are essential for large projects and cross sectoral reform. The health sector is fragmented and difficult to engage. Industry needs serious commitment, investment and risk sharing. We know how to do IT and big projects and are happy to work with you on getting IT to work for clinical care. Many of the solutions needed in health build on those arising out of telecommunications, business and other government programs. The IT and telecommunications industry has a lot to bring to the table, and is keen to come to the table. We just need help to find the table.

Medical Profession Perspective
Dr Peter Garcia-Webb
AMA Expert Committee on Information Technology

Doctors want information management systems that do really useful things. However they also know that that want them to be simple, quick, reliable, useable and of course inexpensive. The systems already do prescribing pretty well, allowing for some functional issues and some less than ideal features and outcomes. Smarts, alerts and information are all the same thing. Doctors want systems to provide key alerts, perhaps guide care or remind of things that need to be done. Doctors would like to not see advertising, however with a caveat. Advertising may not be wanted all the time, but there are times when we seek it out as a source of information and it does defray the costs of newspapers and the like and that goes back to the preference for the less expensive. GPs are caught between the annoyance of advertising interfering with their work and the reality of more expensive software.

Doctors, like us all, do not always know what they don't know. What many don't know is that they need systems that can interoperate and connect with each other. They don't know that to move patient information around requires a unique identifier or that for their system to do smart things the data must be coded and structured. They may not think too much about having a viable software industry, which can achieve cost-effective solutions and many don't know that they actually need an electronic health record.

What types of partnerships are needed to work with the medical profession? Firstly unless the rules or standards are defined that underpin their systems we, the doctors, can't have those things we know we need and the things we don't know about. I have had a look at the NEHTA website and despite the assurances given earlier, it does not tell me much about timeframe or what will be delivered. When will a pathology result about a uniquely identified patient come securely back to me on an interoperable communication system, with the result coded in LOINC, placed in a standard HL7 message, and be integrated with my OpenEHR structured electronic record and linked with the diagnosis that I have written in my own words but which will be coded in SNOMED? Without this type of effort it is hard for any partnership with industry to progress.

We have now heard about the issue of resources. Payment for introduction of e-health in Australia will come through the means of medical fees and patient rebates. Perhaps we should be getting Access Economics on the job as the Department of Health seems incapable by their own admission of working out the sums. However it is done; we know from overseas experience that this is going to be a significant sum of money. If we know that this is the way then the way is clear to proceed, whether this funding model will result in advancing e-health remains to be seen.

For an industry health partnership to work there needs to be joint understanding of what are the coalface requirements. Also a joint understanding of the costs and benefits. This may not be known by the partners. Will there be more or less GP visits and workload? E-Health may help with the coming workforce shortage if one third of visits and processes are not needed, as has been suggested in some US studies.

We do need to go forward from here. There is partnership potential and the real beneficiaries are likely to be the people of Australia.

Discussion and debate

The MSIA is pleased to work with the AMA and others, however there is a problem with the funding model. It disadvantages those who move early or are the first cabs off the rank. (Vince McCauley)

We don't want to penalise those who are first off the rank, but we do want to see everyone on the road eventually. That's the idea of a deadline. (Philip Davies)

We have to be careful about our back of envelope calculations and assumptions, the costs of the IT system will not be carried by GPs and not in one year - there would be some amortisaton. (Philip Davies)

Some reality checks from the software industry: Less than 5% of public hospitals are even partial computerised for clinical are and an e-discharge summary is called a fax. I can send an e-referral for a whole host of reasons. We can't uniquely identify the patient, the drugs, the allergies etc. We have been talking about this for 6 years. Even where progress has been made uptake is slow, why would industry want to change without some good reason? It is high time that someone somewhere said we have 6 months to get our act together or else. We need the order from the top, some financial incentive or penalties, but the work actually came from the bottom-up and we are prepared to accept it. This is not the type of compulsion that the meeting has been so concerned about. We have been waiting and waiting and waiting to have some leadership on this issue of being able to send a structured medical record from one system to another and all that goes with it- that's what the AMA needs to address. These standards should have been here before anyone in Government did anything about encouraging people to connect. (Andrew Magennis)

NEHTA have been remiss in consultation, and the website is not ideal, however they are progressing the 12 project areas. Yes we all know it should have happened 6 years ago but at least now there is a focus on this. There is also criticism that NEHTA is only working on the interests of the States (jurisdictions). Even if this is so when did the jurisdictions ever work effectively together? It has to be a good thing. They need to make it clear that the game is bigger than the States; I think they understand this but have not communicated it. (Peter Schloeffel)

Progress is happening on the terminology and coding front with NEHTA. We just can see any action or movement, however announcements have been made about the strategic direction and discussions are underway. (Heather Grain)

I support the AMA pushing on the standards. NEHTA has yet to consider standards for classification systems. Reinforce Louise Jorm's point that if we are going to set up systems please think about the researcher, evaluator and public health at the start. (Helena Britt)

A key lesson from banking is that to get connectivity and partnerships the banks had to put aside some parts of their competing for advantage. This may apply to medical software companies. We need to consider if this is a good idea. (Peter Garcia-Webb)

Demand side stimulation has worked well in New Zealand, where standards and infrastructure were set, the business model was established and government let the industry get on with software development by creating a market for their business. (Tom Bowden)

There has been some criticism of industry for charging for accessing to data and transactions. We are besieged by requests to modify our systems to do this or that. No matter how worthy or useful it requires work to achieve and we have to handle the change management and support costs and help desk when things go wrong. There are real costs involved. It has to be a commercial proposition. (John Frost)

It is clear that the health sector has to take this forward. Note the banking industry set the standards and then brought in the IT industry. We need to get the health industry together and be inclusive - it won't work if people are left out. The AMA could facilitate but must not be seen to dominant. (Graeme Miller)

In the past when the profession has become frustrated with the pace of progress we took it forward through groups such as GPCG and AMA specialist forum. Government did then get involved and brought on some policies that facilitated further uptake and now they are pulling back. We are stalled for lots of reasons. We have to understand that while GP sector is ahead in adoption, other craft groups have specific needs and are different to GPs. The AMA is well suited to follow the model of what was done in the early days of GPCG. Show some leadership and coordinate with industry and commercial sectors. We have to focus on what we want, if Government wants to play the better. (Ron Tomlins)

We need more specialist representation in standards processes. (Vince McCauley)

If we accept the government model proposed today then practice costs and fees will rise. The Government may say well that ok today but we know that they are concerned about costs rising as the result as a secondary consequence of other proposals the AMA has put forward. They can't have it both ways. (Julia Nesbit)

There is an assumption that costs will go up and fees will rise. The jury is still out on this; it could go either way. (Philip Davies) There is no doubt from the discussions of the past few days that there will be heavy set up costs and ongoing infrastructural costs. What happens in the longer run to efficiency has to be determined. (Jill Maxwell)

It appears that progress is starting on provider and consumer focused EHR repositories but this is happening in an unlinked way in the States. If we put the consumer at the centre of what we do with e-health the ethical issues will fall out from that. (Simon d'Orsogna)