Human interoperability

Health professionals often complain about software and IT. It doesn’t always do what we want it to do. It slows us down, makes us do extra work.

A common problem is lack of interoperability. Computer systems are not talking to each other, a bit like Microsoft and Apple many years ago. Patients have also noticed that important information is not always available, which leads to inconvenience, delays and sometimes more tests.

At the same time GPs are unhappy that the hospital doesn’t provide essential info, for example when a patient has passed away, and hospital staff complain that referral letters don’t contain important triage information. Etc etc.

This raises the question, how ‘interoperable’ are health professionals? Do we know how we can best facilitate transfers and improve clinical handovers? What information do our colleagues need and when? How often do we meet to sort out issues in a collegial way?

It’s good to see there are passionate people working on these issues – but they need help. Computer systems are a reflection of the silos we work in. First fix human interoperability and our IT systems will follow.

Who is serving whom?

What are we going to do with the data once we have collected it? Often, when I ask this question, the answer is vague.

In the race for big data the purpose has sometimes been forgotten. It’s like doing research without formulating a question first.

I wonder who is serving whom: Are IT systems supporting health providers or are we increasingly following rigid templates and blindly harvesting information for reasons we often don’t even understand?

It is time to pause and gain a better understanding of where we want to go. How can data and IT best support patient care and public health into the future?

What can stakeholders agree on with regards to secondary use of data? Where are the trap doors?

The outcome should always be a win-win, or mutual benefit.

My Health Record: what’s next?

The end of the My Health Record opt-out period is in sight. Unless the government decides otherwise, next month the vast majority of Australians will have a digital national shared health record. What’s next?

A while ago I saw a patient who was passing through my town, on her way home from Cairns to Sydney. She had been seen at the emergency department in Cairns and was told to visit a GP for follow-up. She had no hospital letter or medical records but with a few clicks I was able to get access to the hospital discharge summary through the My Health Record, which included results of blood tests, ECG and chest x-ray, and I could see what medications were prescribed.

This is a rare example of the benefits of the MyHR; once the system will be used at a larger scale this could become an everyday reality.

The Australian Digital Health Agency (ADHA) says that about 1.14M Australians have opted out and apparently the opt-out rate is slowing down. At the same time others are signing up and there is an expectation, based on the opt-out trials, that many of those who opted out will eventually opt back in.

The Australian My Health Record is a compromise between a consumer record and a clinical record. This means that there will always be people in both camps who are not completely satisfied. Despite everything we’ve come a long way.

Work in progress

The My Health Record, currently in version 9.4.2, continues to evolve. Looking back over the years progress has been slow but significant.

For example, the software is far less clunky these days; accessing a record or preparing and uploading a shared health summary can now be done within seconds; we got rid of the dreadful participation contracts; there is a secondary use of data framework and users can choose to opt-out of secondary use of their data.

It is expected that more pathology and imaging providers will come on board next year and the legal framework will be further adjusted to improve privacy of Australians, including complete deletion of data if people decide they don’t want a record anymore.

Awareness?

According to ADHA over 87% of Australians know about the record and more than 85% of general practice is registered.

It is likely though that this awareness is rudimentary despite hundreds of engagement activities by the agency and Primary Health Networks (PHNs). Most Australians will not be aware that they have control over who-can-access-what in their records and how to change the privacy settings.

The RACGP has held many PHN-based peer-to-peer workshops across the country as well as webinars for general practitioners and staff, and around 2000 people attended – which is a lot but probably not enough. Most non-GP specialists are not yet on board.

Then there are still the concerns about for example privacy, workflow and accuracy, many of which are summarised in this year’s senate inquiry report. It appears there is still work to do.

The next stage

The agency has started preparing for the ‘post opt-out period’. As it stands around mid December empty shell records will be created, and activated once accessed by providers or consumers.

ADHA says the aims of the next stage of the consumer campaign will be maintaining awareness, taking control of the My Health Record and encouraging consumers to discuss the MyHR with providers.

The provider campaign will focus on the expected benefits including improved efficiency, such as less search-time, and better health outcomes – although skeptics will question the latter claim by the agency.

There will also be a focus on getting specialists on board, aged care access, improved family safety and child protection and education for vulnerable consumer groups.

International review

Meanwhile ADHA has released an international review of digital health record systems. The findings show that the Australian MyHR empowers consumers to access and personally control their information, including what’s in it and who can see it.

ADHA emphasised that, although many countries have laws that allow users to view their health information, only Australia and a limited number of other countries allow citizens to control who sees their information and request corrections to their own health data.

The MyHR PR machine is in full swing. It will be interesting to see what the response to the senate inquiry will be and what happens next year. I hope the momentum of recent times will continue.

What needs to change?

From a usability point of view the wow-factor is still missing and although that’s nothing new in healthcare, some work in this area would go down well.

For example, it would improve workflow and safety if doctors could download MyHR information not just as PDF but import new medications straight into a local medication list.

The secondary use of data framework is fairly broad, and could be tightened up a bit further. Many have commented that the messaging around the MyHR should be less promotional and more about benefits versus limitations – but I’m not holding my breath here.

What change do you want to see?

Details have been changed in the case above to ensure patient confidentiality.

Has Australian general practice moved one step closer to the British NHS?

In 2019, the Department of Health, via its practice incentive scheme, will not only start setting the key performance indicators of general practice but also further tighten its grip on practice data. It is not unlikely that the Department’s strategy will create the same issues the National Health Service is currently encountering: loss of patient-centeredness of care, unreasonable KPIs and low doctor morale.

The redesign of the Practice Incentive Program (PIP) has been in the cards for a while. The introduction of a new quality improvement (QI) payment system was deferred for 12 months in May 2018 because of concerns that it was not fit for purpose.

Central role of PHNs

If it goes ahead in May 2019, the impact of the new scheme will be significant. The big change will likely be that Primary Health Networks (PHNs) become exclusive “QI providers” for general practice. This means that they will extract, analyse and store practice data and present GPs with benchmark reports. Many PHNs have already started collecting data in anticipation of the changes.

To be eligible for quality improvement incentive payments, practices will have to demonstrate to PHNs that their performance is on par with the Department’s KPIs. Although analysis and benchmarking of clinical data are becoming increasingly important to improve patient care, there are many issues with the proposed PIP overhaul.

Initially, there was talk about more organisations becoming QI providers, such as the Royal Australian College of General Practitioners (RACGP) and the Improvement Foundation, but, according to Medical Observer, it looks like there will be no profession-led alternative to the PHN model and, as a result, practices will not be given a choice of QI providers.

General practice is at risk of gradually losing control over its quality improvement processes, which will no doubt leave many grassroots GPs dismayed.

Professional buy-in?

The main issue with the scheme is related to professional buy-in. The Department of Health has gone through the usual process of consulting the profession, but it has always been clear that the PIP redesign was going to occur regardless of the opinion of GP groups.

The Department may claim in its communications that the KPIs are supported by the various professional bodies, but the level of engagement, trust and satisfaction with the new QI system will be low for various reasons.

First, this is an example of a top-down government solution, largely designed by the Department of Health. As we have seen with the My Health Record and Health Care Homes, this approach usually creates just as many problems as it is trying to fix.

Similarly, there has been a lack of engagement with the e-health PIP (ePIP) scheme, which requires practices to upload shared health summaries to the My Health Record to remain eligible for incentive payments or ePIP. This may have given the Department a countable number of uploads, but there is no evidence to suggest that it has improved meaningful use of the My Health Record or quality of care in general practice.

Weak evidence

In the PIP redesign process, only payments to practices have survived. For example, the aged care incentive payment to GPs providing care to patients in residential aged care facilities will be scrapped. This incentive is worth $3000–$5000 per doctor. Many have argued that it is incomprehensible that funding benefitting aged care is removed at a time when residential aged care facilities need more support to provide the medical care required.

By stopping these service payments to individual doctors, the incentives will be one step further removed from those who are responsible for the actual quality improvement activities. Again, this does not inspire confidence in the Department’s new QI system.

Measuring performance against KPIs in combination with performance payments will almost certainly create new problems. Quality indicators used by governments around the world are often easy to measure isolated parameters that have limited valuefor complex systems such as general practice.

The evidence to support financial incentives is weak, and the British Quality and Outcomes Framework (QOF) pay-for-performance system has illustrated what can go wrong: QOF has not improved care but did result in the loss of the patient-centredness of care and has created a significant decrease in doctor morale.

No funding priority

The new QI PIP will be subsidised by a shift of funding from other PIP and SIP incentives — which has been labeled as “robbing Peter to pay Paul” by the Australian Medical Association. In 2016, $21 million were removed from the PIP budget to partially fund the Health Care Home trials. The last budget announcements made it clear that there will be no increase in PIP funding in the near future. The PIP scheme, introduced in the 1990s, has never been indexed.

The Department of Health has not yet provided clarity on what the PIP scheme will look like beyond May 2019. This lack of transparency about long term planning creates uncertainty for practices. Although the expectations will start off low, it is to be expected that the Department will adjust the KPIs upwards over time, wanting more for less.

One of the PIP eligibility criteria for practices is accreditation against the RACGP’s Standards for general practices, and it will be interesting to see if upcoming changes to the PIP scheme will affect the percentage of practices that take the effort to go through the accreditation process.

Data extraction

Finally, general practice is not only facing loss of control of quality improvement but is also about to miss out on an opportunity to become custodians of its clinical data. Although the QI PIP data will be extracted from GP practices, it will likely be managed and controlled by PHNs and other government agencies, such as the Australian Institute of Health and Welfare.

When the government defunded the Bettering the Evaluation and Care of Health (BEACH) study in 2016, general practice lost its most important longitudinal source of data. It doesn’t take much imagination to figure out what will happen with the QI PIP data when, in a future reform cycle, PHNs or other government agencies involved are subject to funding cuts or cease to exist altogether.

The Department of Health’s underlying thinking seems to be that the responsibility for quality and data should be taken away from the profession, even though the government’s own data governance practices don’t always inspire confidence.

Professional response

The department should have given professional organisations the responsibility to execute a mutually agreed strategy, acceptable to all parties, including custodianship of data for quality improvement purposes.

Our peak bodies are working hard behind the scenes to negotiate the best possible outcome. It is more important than ever for the profession to work through any differences and present a united front. The question remains, can we stem the tide of increasing departmental control or has general practice definitely moved one step closer to the NHS?

This article was originally published in MJA Insight.

It’s not just the My Health Record we should be concerned about

It’s often been said, the Australian My Health Record is not a finished project. It is evolving and has, indeed, lots of potential to improve and streamline patient care. Sadly, the privacy issues that have haunted the project for years still seem to be unresolved. And when it comes to secondary use of patient data, there’s more to come from a different direction.

Back in 2013 I wrote this in a blog post about the My Health Record, then called the Personally Controlled Electronic Health Record or PCEHR:

“The PCEHR Act 2012 states that the data in the PCEHR can be used for law enforcement purposes, indemnity insurance purposes for health care providers, research, public health purposes and ‘other purposes authorised by law’. This is far from reassuring. There are many grey areas and unanswered questions. There are too many agendas. The PCEHR should first be a useful clinical tool to improve patient care.”

Five years later and there are still ambiguities about when, how and for what reason law enforcement agencies and other non-medical parties can access the national My Health Record system. This should have been crystal clear by now. Here’s is what I posted in 2015:

“(…) at the moment the information in the PCEHR may be used by the Government for data mining, law enforcement purposes and ‘other purposes authorised by law’, for up to 130 years, even after a patient or provider has opted out. (…) The legal framework should be reviewed, and any changes must be agreed upon by consumers and clinicians.”

When asked about this issue at yesterday’s Press Club AMA president Dr Tony Bartone indicated that he is prepared to push for legislative amendments to improve the confidence of Australians in the My Health Record.

I was glad to hear this. I’m all for amendments of the My Health Record legislation but at the same time the Department of Health is on a journey to get its hands on GP patient data – and this is unlikely to change.

For example, the Department of Health is preparing a new data extraction scheme, to be introduced in May 2019. To remain eligible for practice incentive payments GP clinics have to agree that de-identified patient data will be extracted from their clinical software by, perhaps, Primary Health Networks. From there the data may flow to, possibly, the Australian Institute of Health and Welfare, the organisation responsible for the secondary use of data in the My Health Record.

If this scheme goes ahead, government organisations will begin to take over data and quality control of general practice. The argument will be that it is in the interest of the health of the nation. Perhaps it’s my well-worn tin foil hat, but I have a sneaking suspicion what I will be blogging about in the years to come.

This is how your data in the My Health Record will be used

On Friday the Federal Government quietly released its long-awaited framework for secondary use of information contained within the My Health Record. It will generate discussion as it is controversial.

The release of the framework to guide the secondary use of My Health Record (MyHR) system data comes just months before the participation rules for the Australian national health record change from opt-in to opt-out.

Consent for secondary use is implied if consumers don’t opt out of the MyHR. In other words, people need to take action if they don’t want their health data to be used for purposes other than direct clinical care.

To stop information flowing to third parties, consumers will have to press the ‘withdraw participation button’.

Another hot topic is the use of the data by commercial organisations which, interestingly, is permitted under the framework, provided it is ‘in the public interest’.

And, as expected, one of the main purposes of secondary use is the monitoring of outcomes of care. It remains to be seen what this will mean for the interaction and relationship between consumers and health providers.

The release of data is expected to commence from 2020.

Commercial use

The Australian Institute of Health and Welfare (AIHW) will act as the data custodian.

A ‘My Health Record secondary use of data governance board’ will assess applications for access to MyHR data ‘based on the use of data, not the user’.

Any Australian-based entity, except insurance companies, can apply to get access to the data. The board will take a ‘case and precedent’ approach to determining what uses will be permitted and not permitted for secondary use.

Although information in the MyHR cannot be used for commercial purposes, such as direct marketing to consumers, data may be released to commercial organisations if they can demonstrate that the use is consistent with ‘research and public health purposes’ and is likely to be ‘in the public interest’.

I suspect that this backdoor will be in high demand by third parties such as the pharmaceutical industry.

The board can permit the linkage of myHR data with other data sources once the applicant’s use is assessed to be of public benefit. In an example provided in the framework, researchers link MyHR information to a database of clinical trial participants to investigate hospitalisations, morbidity and mortality.

Data may also be linked to other datasets such as hospitals, MBS, PBS and registry data.

Examples

The framework gives examples of the use of health data for secondary purposes, including:

  • Evaluation of health interventions and health programs (e.g. determine if an intervention or service is generating outcomes/benefits consistent with funding approvals)
  • Examining practice variations for the purposes of quality improvement or adherence to best-practice guidelines at a health service level
  • Construction of clinical registries (e.g. create or supplement data in clinical registries to evaluate the effectiveness of interventions)
  • Improvement of existing health services and development of new services
  • Enhancing post-market surveillance insights for new products
  • Improvements to patient pathways research
  • Increased visibility and insights into population health matters
  • Development of government health policy
  • Develop/enable technology innovations
  • Preparation of publications
  • Recruitment to clinical trials (e.g. identify people who may be suitable for a new product/service)
  • Development of clinical decision support systems (e.g. link data on individual’s health with best practice to influence treatment choices)
  • Health services research relevant to public health (e.g. examine the health service utilisation patterns for potentially avoidable hospitalisations; research that leads to changes in other government policies, such as welfare, and ultimately reduces impact on the health system).

A review will be performed after two years, which may identify additional uses.

The MyHR 'withdraw participation button’
Consumers can stop their My Health Record (MyHR) data being used for secondary purposes by pressing the ‘withdraw participation button’.

Not permitted 

The following uses of MyHR data are not permitted:

  • Determination of funds allocation for a health service (e.g. set the level of funds allocated to an individual community health service)
  • Remuneration of individual clinicians (e.g. to make/modify payments)
  • Individual clinician audit (note: this does not exclude examining practice variations for the purposes of quality improvement or adherence to best-practice guidelines at a health service level).
  • Direct marketing to consumers
  • Assessment of insurance premiums and/or claims
  • Assessment of eligibility for benefits (e.g. use by Centrelink and/or the Australian Taxation Office to make determinations relating to an individual)
  • Criminal and/or national security investigations, except as required by law (e.g. use to investigate the interactions of individuals with the health system as part of assessing their behaviour).

Withdrawing participation

Data that has been removed or classified by consumers as ‘restricted access’ will not be retrieved for secondary use purposes. Similarly, when people cancel their MyHR record, the data will no longer be used.

Consumers can stop their data being used for secondary purposes by clicking on the ‘withdraw participation button’. It is expected that a dynamic consent model will be introduced later, which allows consumers to give consent for secondary use on a case-by-case basis (which would also open the door for the use of identified data).

In the light of the recent Facebook Cambridge Analytica Scandal I suspect that many consumers will press the button – or will be advised by health professionals to do so.

You can’t have your cake and eat it too

The Practice Incentive Program is shrinking but the government expects new quality improvement systems and general practice data.

Most GPs were underwhelmed, to say the least, when they heard about the changes (read: cuts) to the Practice Incentive Program (PIP). Cutting the funding for nursing home visits is a hard sell for the Department of Health and the Federal Health Minister.

This is the wrong message at a time when there are more elderly people with complex chronic health problems in need of appropriate medical care, preferably in the community.

I have heard about various ‘fixes’, including improvements to the Medicare Benefits Schedule (MBS) schedule (good idea) and introducing nurse practitioners (not necessarily a good idea) – but nothing has been confirmed and it all sounds a bit like policy on the run, not a planned and coordinated strategy.

Quality improvement

The scrapped incentives, including the aged care service incentive payment (SIP), will be used to set up a quality incentive payment system (QI–PIP) in GP practices. There are certainly arguments for supporting an enhanced quality improvement system in general practice, but was it the right decision to sacrifice the aged care payments?

We need practice data to review and improve patient care. I agree with the RACGP position that the development of a QI–PIP should assist general practices to undertake quality improvement activities.

However, the RACGP has also indicated that it will not support measuring performance against key performance indicators (KPIs) or so-called ‘quality indicators’ in combination with performance payments. There is just not enough evidence that this will significantly improve care in the long-run, but there is evidence of harm, including detrimental effects on the doctor–patient relationship and practitioner burnout.

Although we have had verbal assurance from the Department of Health that the new QI–PIP – to be introduced in May next year – will not be a pay-for-performance system, the longer-term plans are unclear. This has raised many concerns and it will hinder business planning for general practices.

Data deal

In return for the quality improvement payments, practices will be required to hand over their patient data to Primary Health Networks (PHNs) under the current proposal. From there, the data will flow to other agencies but – just like the My Health Record data – we have not yet heard for what purposes it will be used, and what the implications will be for individual GPs within practices. Many GPs have indicated that they are not prepared to hand over data to their PHN or the Government.

Another big issue is the eHealth Practice Incentive Payment (ePIP), which was originally introduced to strengthen practice IT systems, but is now used to make practices – often practice nurses – upload shared health summaries to the My Health Record. As we are moving to a My Health Record opt-out system later this year, the time may have come to review the ePIP and make it more meaningful for general practice.

Lastly, the practice incentive funding was introduced in the 1990s and has never been indexed. In 2016, $21 million was earmarked for removal and used to partially fund the Health Care Home trials.

It all sounds like another example of the Government wanting more for less. You can’t have your cake and eat it, too.

This article was originally published on newsGP.

It has begun: Australians will soon have a digital health record

By the end of the year Australians will have an online digital health record, unless they opt out of the system. The details of the move towards opt-out will be released soon.

The Australian Digital Health Agency (ADHA) is ramping up its activities to prepare for the change to opt-out. The large-scale operation will involve extensive stakeholder engagement, a nation-wide communication and advertising campaign and increased support for consumers and clinicians.

For consumers who have not opted out at the end of the defined three-month period later this year, a My Health Record (myHR) will be created. The record will be activated when used for the first time by consumers or clinicians.

A clean slate

ADHA has opened a new call centre, launched a revamped website myhealthrecord.com.au and is now present on Twitter (@MyHealthRec).

Staff levels of the call centre – transferred from the Department of Health to ADHA – will increase from thirty to two hundred and will operate around the clock during the opt-out period.

The record will initially be empty apart from two years worth of retrospective MBS and PBS data. Consumers have the option to remove this data.

Pathology and imaging reports are uploaded into the MyHR one week after the test date. Some sensitive tests, such as HIV, may not be automatically uploaded depending on the various State or Territory legislation.

Clinicians and consumers will have the opportunity to stop the upload of results and other reports if desired. Consumers can restrict access to or remove reports from their MyHR.

No stone left unturned

No stone has been left unturned in finding ways to make Australians aware of their right to opt out: a wide scale advertising campaign will use various media including radio, social media, billboards and cinemas.

Materials such as waiting room brochures, tear-off pamphlets and reception cards will be made available to providers. Medicare will be sending out brochures to Australians. Consumer organisations have been engaged to help with awareness.

It is expected that the adoption and active use of the MyHR will vary across Australia as a result of the availability of already existing digital health solutions in various states and regions.

For example, in areas where discharge summaries are not always easily made available by hospitals, the uptake of the MyHR may be higher.

Opt-out procedure

Currently there are about twenty million Australians without a MyHR. Based on the trials it is expected that only a small percentage, about 2%, will opt-out.

It looks like the opt-out procedure will be relatively simple and can be done via an online self-service portal or by phone through the help desk. Hard copy opt-out and ‘election-to-not-be-registered’ forms will also be available through post-offices, and will be made available to hard-to-reach populations.

Although care has been taken to make sure there is no coercion not to opt-out, those who do will receive a notification that their medical information may not be accessible during emergencies. They will also be asked to give a reason after they have opted out.

The MyHR website will shortly contain information about the opt-out procedure. It is also expected that the FAQ section will be expanded to assist consumers in making a well-informed decision.

Risks and challenges

The MyHR offers clear benefits as clinicians will have increased access to information such as shared health summaries, discharge summaries, prescription and dispense records, pathology reports and diagnostic imaging reports.

However, every digital solution has its pros and cons. It has been decided that the risks associated with the MyHR will not be explicitly discussed on the website.

Behind the scenes however, risk mitigation has been one of the priorities of ADHA. This obviously includes the risk of cyber attacks and public confidence in the security of the data.

Change management

Another challenge for ADHA will be to manage expectations – before, during and after the opt-out period. The reality is that the MyHR is not a be-all and end-all, and is still on a development journey.

As a result of the troubled past of the digital record there is a large group of skeptics. It appears that so far ADHD nor the Department of Health have been able to get this group on board. The usual promotional material, touting benefits, is unlikely to change anything. A more effective approach would involve addressing the concerns, issues and perceived obstacles.

Primary Health Networks (PHNs) will assist in spreading the message. The PHNs involved in the opt-out trials reported high levels of success in engaging providers.

Other parties including the Royal Australian College of General Practitioners (RACGP) will provide peer-to-peer education, which may help to balance the message, address some of the concerns and manage expectations.

Edwin Kruys is a member of the My Health Record expansion program steering group.

The information in this blog post is intended for informational purposes only. It may not be complete and is subject to change. Please refer to offical ADHA sources for MyHR updates.

Is the medical software industry holding us back?

There’s a Dutch theory called ‘De wet van de remmende voorsprong’ which, according to Wikipedia, translates as ‘The law of the handicap of a head start’. The theory suggests that an initial head start by an individual, group or company often results in stagnation due to lack of competition or growth stimuli. This may eventually lead to losing pole position.

General practice was one of the first fully digitalised, more or less paperless, medical disciplines in Australia. The question is, are GP software packages keeping up with the times or is the profession at risk of falling behind and being overtaking by others?

Good job

Overall I am satisfied with the desktop software I use to look after my patients. It does the basics very well such as recording patient demographics and medical history, medication management, printing scripts and investigation referrals.

It also checks if medications agree with each other and if the patient happens to be allergic to a new pill I am about to prescribe.

But compared to, let’s say, ten years ago there haven’t been any breakthrough innovations. Sure, we can now check the national My Health Record and upload a shared health summary, but there’s also a lot to wish for.

GP Desktop Software
Are GP desktop software vendors holding general practice back?

We’re still relying on the good old fax machine and over the years I have seen more and more third-party software solutions appear on our system to perform tasks the desktop software can’t. Occasionally these packages clash with each other or slow the practice system down.

The wish list

Here’s a list of 7 basic things that should be included in all GP desktop software. I believe it would improve patient care and satisfaction.

  1. I’d love to have the option to communicate securely with patients and other providers, asynchronously or via video link.
  2. Our patients should be able to send digital health data or electronic script requests via a secure connection.
  3. An online appointments booking system.
  4. GPs should be able to send scripts electronically to the pharmacy.
  5. It would be really nice if the software would help us to write (and send) smart electronic referrals by automatically inserting the data required by the specialty or provider we are referring our patients to.
  6. Decision support tools offer benefits such as increased diagnostic accuracy and a reduction of unnecessary tests.
  7. We also need integrated data analysis and data cleansing tools to help improve the quality of general practice data, so it can be better used for in-practice quality improvement processes.

What’s on your wish list?

Where did our health data go?

Data is like garbage, you’d better know what you are going to do with it before you collect it ~ Unknown

It took a while, but the Department of Health is now inviting submissions about the various ways digital health information in the national My Health Record (MyHR) should, and could, be used.

By law information in the MyHR can be collected, used and disclosed ‘for any purpose.’ This ‘secondary use’ of health data includes purposes other than the primary use of delivering healthcare to patients.

The consultation paper is not an easy-read and I wonder how many people will be able to make heads or tails of the document – but then again it is a complex subject.

Nevertheless, secondary use of health data seems to make sense in certain cases. As the paper states:

“Secondary use of health data has the potential to enhance future healthcare experiences for patients by enabling the expansion of knowledge about disease and appropriate treatments, strengthening the understanding about effectiveness and efficiency of service delivery, supporting public health and security goals, and assisting providers in meeting consumer needs

Risks and red flags

There are risks. For example, I would be concerned if insurance companies or the pharmaceutical industry would get access to the data or if the information would not be de-identified.

The consultation paper also mentions performance management of providers, and driving ‘more competitive markets’. These are red flags for many health providers because there is little evidence these purposes will benefit patient care.

For example, performance management has gone wrong in the British Quality and Outcome Framework pay-for-performance system and has resulted in:

  • only modest improvements in quality, often not long-lasting
  • decreased quality of care for conditions not part of the pay-for-performance system
  • no reduction of premature mortality
  • loss of the person-centeredness of care
  • reduced trust in the doctor-patient relationship
  • loss of continuity of care and less effective primary care
  • decreased doctors morale
  • billions of pounds implementation costs

According to the consultation paper it is ‘not the intention’ to use MyHR data to determine remuneration or the appropriateness of rebate claiming by healthcare providers.

Interestingly, a similar discussion is currently happening around the changes to the quality improvement incentive payments (PIP) to general practices and the proposed requirement to hand over patient data to Primary Health Networks without, at this stage, a clear data framework.

Research & public health

It seems reasonable to use the information in the MyHR for research or public health purposes with the aim to improve health outcomes. The access, release, usage and storage of the data should obviously be safeguarded by proper governance principles.

A good idea mentioned in the paper is a public register showing which organisations or researchers have requested data, for what purposes, what they have found by using the data and any subsequent publications.

I hope the MyHR health data will never be used for e.g.:

  • commercial purposes including by insurance companies
  • performance management or pay-for-performance systems
  • sharing or creating identifiable information for example via integration with other sources
  • low value research

The My Health Record is far from perfect but still has much to offer. Unfortunately it has an image problem and its value proposition will need to be clearly communicated to health professionals. There are also several loose ends that need fixing, such as workflow challenges and the medicolegal issues around uploading and accessing of pathology and diagnostic imaging reports.

Knowing exactly what MyHR data will be used for and by whom will be an important factor for many in deciding whether to participate and at what level. ‘Where did our health data go?’ is a question health professionals and consumers should never have to ask.

You can complete the public survey here. Submissions must be received no later than midnight Friday 17th November, 2017.

A new hope for the My Health Record?

It looks like we’ve entered a new chapter in the Australian digital health story. After several rocky episodes it seems the force is with us and Australia’s digital health record system is on the road to recovery. At the same time there are challenges ahead.

When it comes to the national electronic My Health Record (formerly PCEHR) there is no shortage of scepticism among health professionals. Many have disengaged after unsuccessful encounters with earlier clunky versions of the system.

A lot of work has been done to make the interface easier to use. Accessing the system and uploading a shared health health summary has now become a fairly simple process – as it should be.

Towards opt-out in 2018

The My Health Record will get a massive boost in the middle of 2018 when the system changes to opt-out. Currently Australians have to actively sign up if they want a digital shared health record but next year every Australian will have a record – unless they opt out.

Earlier this month the Council of Australian Governments (COAG) approved Australia’s new digital strategy which carries the title ‘Safe, seamless and secure: evolving health and care to meet the needs of modern Australia‘.

The strategy outlines plans between now and 2022 for secure messaging between providers and with patients, telehealth, interconnectivity and interoperability, electronic prescribing and dispensing, test beds for new digital health technologies, development of health apps & tools and workforce training and upskilling.

Digital health strategic priorities
Digital health strategic priorities 2018-2022. Source: National Digital Health Strategy

The Australian Digital Health Agency (ADHA) has indicated it wants to co-design an implementation framework with the broader healthcare sector.

ADHA CEO Tim Kelsey said on Norman Swan’s RN that it is not just another strategy document: “I want to reassure people that this is going to be about delivery and people should hold me and the agency to account for delivering actual real benefit.”

Kelsey also admitted that at the moment the My Health Record doesn’t have as much clinical value as most doctors would want, but that a record of dispensed PBS medications is currently available. More clinical content will be coming soon, such as radiology and pathology.

Challenges ahead

The strategy document acknowledges some of the issues doctors have with regards to security, safety and use of the data: “They [doctors] need assurance that the digital systems they use support them to meet their obligations to keep their patients’ health information secure and private, and that health data will be used safely and appropriately to improve patient outcomes.”

Doctors have also voiced concerns about the medicolegal risks that come with accessing a patient’s My Health Record, for example when diagnostic tests and images will be available that may not have been reviewed and actioned by the requesting clinician. Clear guidance is required on how the reports are to be handled and who is responsible.

Most clinicians will not have an issue with de-identified data in the My Health Record being used for research or public health purposes, but transparency around secondary use of data will be welcomed and would encourage engagement with the system.

Uploading of shared health summaries is happening in general practice but concerns have been raised about the quality of some of the data. The current incentive payments seem to encourage volume. However, if the uploaded clinical content is not useful, others may not engage or upload data from their end. A classic case of the chicken and the egg.

New hope

It seems the Australian Digital Health Agency has sorted out many of the governance issues and is becoming a more transparent, engaging enterprise. An effective implementation strategy will genuinely address the barriers to engagement with the MyHealth Record and not just sprout benefits. I believe there is hope for Australia’s digital health record.

Time for real-time prescription monitoring

It’s a sobering fact: apparently more people die from drug overdose than road traffic crashes.

Perhaps even more concerning is that most of these overdose deaths in Australia are not caused by illicit drugs, but by the fatal mixture of two or more pharmaceuticals – often medications I and my colleagues prescribe to help people improve the quality of their lives.

Take-home message one: The combination of opioids (like oxycontin) and medications such as benzodiazepines (e.g. valium) can be fatal – even more so if mixed with alcohol.

Dealing with drug dependence

Abuse of prescription drugs is a big problem and doctors and pharmacists are often unaware that some of their patients collect prescriptions from several prescribers and pharmacies. This can go unnoticed because our computer systems are not yet linked and the reporting systems have flaws.

For several years the RACGP, AMA and other health bodies have called for the introduction of Australia-wide Electronic Reporting and Recording of Controlled Drugs (ERRCD). Coroners have also been advocating fiercely for an ERRCD system.

Prescribers and dispensers should be able to access and share prescription information but this has only been happening in real-time in Tasmania.

Since 2009 doctors and pharmacists in Tasmania can access prescription information if there is a legitimate clinical need, via a secured, encrypted website. The information includes what opioid medications have been dispensed and when, and if there are concerns about drug dependence or ‘drug seeking’ behaviour.

The Tasmanian real-time prescription monitoring system has stopped doctor-shopping for restricted drugs. Similar data comes from overseas: New York has seen in a 75% drop in patients seeing multiple prescribers after the introduction of ERRCD.

Some sources claim the Tasmanian system has reduced opioid-related deaths, although it has been argued we need a better way of analysing prescription drug deaths.

ERRCD is an essential tool to help prescribers and dispensers, but is only one part of the solution to reduce opioid prescription misuse. We also need to review how we look after at-risk patients, including those living with mental health problems or substance use disorder.

Road to recovery

Chances are that I may actually not improve the quality of my patients’ lives by prescribing opioids or benzodiazepines long-term. There are drawbacks: side effects, risk of dependence, serious bodily harm and death. Occasionally the drugs can make the pain worse, a phenomenon called opioid-induced hyperalgesia.

Take-home message two: There is limited evidence of the long-term efficacy of opioids for the management of chronic non-cancer pain.

Some have argued that opiates such as Endone (oxycodone) have become the new paracetamol and that we also need to reappraise the treatment of pain in the acute setting.

GP teams, allied health practitioners and pharmacists will play a crucial role to help tackle the issues around drugs of addiction – while supporting their patients at the same time. Sometimes input will be required from addiction, mental health or pain disciplines.

Many resourcestools and education opportunities are available to assist doctors. Meanwhile, state governments need to get on with the much-needed introduction of real-time prescription monitoring programs that will ultimately connect into a national network.

The doctor will see you… never. Issues with online referral services.

There are many benefits of online health services and they can complement traditional face-to-face GP visits. But there are also examples that raise questions.

The young woman was in tears. When she came in she had initially asked for a referral to a surgeon for a breast augmentation. During the conversation it turned out that her partner had made it clear her breasts were too small.

We ended up having a chat about relationships and body image. At the end of the consultation she decided she needed some time to think things over and talk to good friends, and that she would come back if she needed further assistance.

The problem with online referrals

At first sight, the Qoctor website seems an easy, convenient online medical service that provides sick certificates and referrals.

The site tells visitors: “(…) we understand that a well person who simply needs a letter to see a specialist should be able to get one without requiring a GP consultation.”

I’d like to challenge that. The woman in the example above was well but did she need a referral to undergo an expensive procedure that would change her body?

There are many issues with a system that allows access to specialist care without a review by a primary care doctor. Unnecessary referrals, increased costs and further pressure on the hospital system are just the beginning.

Once a visitor has selected a specialist the system asks a few simple questions about allergies and previous surgery and there are some boxes to tick (see image). I wonder how many people will just enter through to get to the section where you pay and automatically receive the referral letter (as pdf file).

How many people will just enter through to get to the section where you pay and receive the referral letter?

Good telehealth principles

Sometimes writing referrals is a straightforward process but often it is not. What is missing here are the safeguards with regards to other management options, coordination of care, the communication between the usual doctor and specialist, and follow-up. What about whole patient care?

Interestingly the service seems to assume that – after automatically cashing in the online referral fee – the patient’s usual GP will be responsible for the follow-up if required.

The Royal Australian College of General Practitioners (RACGP) has developed some common-sense principles for telehealth services, including on-demand online health services. These principles include the following:

  • On-demand telehealth services should preferably be provided by a patient’s usual GP or practice
  • On-demand telehealth services to unknown patients should only be provided when the patient’s usual practice cannot provide care for them, either in person (at the practice or by a home visit) or online, and no other general practices are physically accessible
  • Patient notes should always be sent to the patient’s usual GP or practice (with the patient’s permission). This ensures continuity of care and centralises patient records.

Commercially enticing 

I suspect that most people are aware of the risks of online health services and will consult their GP first. At the same time there will always be people who are attracted to these services because they are quick and easy. It is also commercially enticing: if you sign up for Qoctor you may win a $100 Coles Meyer gift card.

The patient testimonials on the website, which probably go against AHPRA’s advertising guidelines for regulated health services, seem positive. The question is usually: are these real testimonials?

As always with disruptive technologies there is the convenience aspect for consumers – but is bypassing the most efficient and cost-effective part of healthcare by printing out an online ticket to the expensive part in the best interest of Australians? I doubt it.

The (patient) case discussion in this blog post is fictional and based on similar consultations. Disclaimer and disclosure notice. Follow me on Twitter: @EdwinKruys.

Rest In Peace, BEACH

To raise new questions, new possibilities, to regard old problems from a new angle, requires creative imagination and marks real advance in science ~ Albert Einstein.

Here’s a little quiz. True or false? (Answers below)

  1. Herpes Zoster (shingles) in Australia continues to increase over time.
  2. Gastro-oesophageal reflux disease imposes a high level of societal and financial burden on the community in Australia.
  3. Of all GP consultations conducted in a language other than English, more than eighty percent are conducted by multilingual GPs who speak the patient’s language.
  4. For 15% of people living with schizophrenia in Australia, ongoing management is provided by their GP alone.

Before you scroll down to the answers, you need to know that the common source of this information is the research program BEACH, short for Bettering the Evaluation of Care in Health.

For the past eighteen years BEACH has provided us with important information to improve patient care and primary care services in Australia.

Government funding for the research program will cease which means BEACH will be closed. The government will also stop funding the Primary Health Care Research & Information Services (PCHRIS).

This has caused another shock wave through Australian general practice and primary care.

A sad day for patients, GPs and health providers.

Answers: 1 true, 2 true, 3 true, 4 false (this should be 30-40%)

Brand new eHealth strategy off to a bad start

I recently participated in a webinar organised by the Department of Health. It was supposed to be a consultation about the uptake of eHealth.

It went something like this: “We want to gain feedback from GPs about how we can get you to use the eHealth. This is how we’re going to do it; we’ve already organised training and we’re kicking off after the Christmas break. But before we start this session you must know that we cannot consider other options or timeframes.”

I was speechless. Literally – as I was not allowed to speak. I could only send little text messages via the closed online question platform. I was unable to see the feedback from other online participants.

Meaningful use

For years health providers have repeatedly said, if you want to make eHealth a success please take us with you.

The government is talking about new incentive payments to practices, ‘refreshed’ training programs and opt-out instead of opt-in, but there is little mention about improvements that make health providers want to use the PCEHR (now called ‘My Health Record’).

It is concerning is that the current plan mainly encourages uploading of documents. What should be facilitated is safe and more efficient care for our patients. At the moment it seems to be all about the number of uploads to the system. I cannot help but wonder what higher level performance indicators are at work here.

Any incentive has to be effective at provider level to create behavioural change. In other words, we must encourage individual practitioners to use eHealth, not just organisations and practices.

It is no surprise that the government failed again to enlist support from the profession. In its submission to the Department of Health, the RACGP wrote:

“(…) the RACGP cannot support the proposed mandatory requirements for the uploading of a specified quota of clinical documents to My Health Record. Meaningful use is not just uploading information to My Health Record, and nor is uploading information an acceptable starting point for meaningful use. Meaningful use relates to safety, quality, communication and healthcare outcomes – not merely numbers.

Unresolved issues

E-health experts have warned that the system is still unsafe. For example, some software programs merge medication dose and instructions. Others have warned that the uploaded clinical information does not always arrive in the My Health Record database.

Then there are the unanswered medicolegal issues. As I said in MJA Insight, I would be happy if the data in My Health Record was used for other purposes such as disease surveillance or even feedback on my clinical management but, in the end, it is the patient’s record and they must have a say in it. A proper consent procedure is essential for any use of PCEHR data outside individual patient care.

It appears the  system operator is currently authorised to collect information in individual health records for law enforcement, health provider indemnity insurance cover, research and public health purposes, and as required or authorised by law. This process should be more transparent with a better explanation of what it means for both patients and providers.

Removing the need for provider participation agreements is needed as these documents are very one-sided. It is not clear to me what this will mean for the liability of organisations, practices and individual practitioners.

A failing strategy

It is challenging to have a  discussion about incentivising uptake of eHealth when there are so many unknowns. It’s like trying to sell a house that’s still being built and everyone knows there are construction issues. Pushing people to live in the house does not make it a safer or a better building.

The RACGP warns against hastily implementing incentives and advises the department to wait for the outcomes of the Primary Health Care Advisory Group review, the MBS review, and the opt-out trials which are due to start.

Once the identified problems with My Health Record have been addressed and resolved, the RACGP believes that uploading of patient information to My Health Record would be best supported by a practitioner incentive payment (SIP) or an MBS rebate.

It will be interesting to see the response from the department. I’m afraid that history will repeat itself: they’ll go full steam ahead, only to discover in one or two years time that the strategy didn’t work. What do you think?

Online therapy? It works.

Mental health care is not accessible to everyone. It’s a fact that less than fifty percent of people who need treatment actually get it. But access to an internet connection is available to most people. So it makes sense to offer more health services online.

Although the opinions are divided about Dr Google, health experts now agree on one thing: internet therapy for many mental health problems works.

5 benefits

E-mental health is a broad term used for mental health services delivered via internet programs, telehealth, mobile phone applications and websites. There are five benefits:

  1. It can be accessed anytime and anywhere
  2. There are no or low costs to patients
  3. It fills service gaps
  4. It reduces wait lists
  5. It’s cost-effective to the health system.

Some patient groups will benefit less from online therapy, such as people with complex or severe mental illness, personality disorders, substance dependence, or people who have a higher risk of self-harm or suicide and need urgent clinical management.

Who is it for?

E-mental health probably works best for people at risk of illness or people with mild to moderate symptoms. It is used in many ways including first-line treatment and relapse prevention. Evidence shows that it can be as effective as face-to-face therapy. Using the services in combination with regular visits to a doctor is ideal.

If you want to know what e-mental health services are available and how reliable they are, click here (free registration). The site uses a smiley system to show how much evidence there is that a service works.

More information and free e-mental health training for health professionals can be found here. The RACGP has published a handy e-mental guide for GPs.

Have a look at the video as well. Before you use any of the online services it is recommended to check the terms and conditions so you know what happens with the personal information you provide.

Sources:

The Danish health IT solution: small-scale brilliance

When his wife attended a conference in Copenhagen, Adelaide GP and RACGP board member Dr Daniel Byrne took the opportunity to find out why Denmark is one of the world leaders in the use of e-health.

One of Australia’s problems is the reliance on paper documents. For example, almost every healthcare organisation designs their own referral forms and we still fax and post a lot of documents. In Denmark a ‘one-letter solution’ was introduced years ago: one electronic form used by thousands of health organisations.

“No patient ever left the surgery with any paper,” said Dr Byrne. “It seemed very well organised with a great e-health network. No faxes were used as everything is connected via secure networks – prescriptions, referrals, pathology and radiology ordering, even email consults.”

E-mail consultations

Dr Daniel Byrne
Dr Daniel Byrne about the Danish e-health system: “The live medication list was too good to be true.” Image: Linkedin.

There are no incentives for Australian GPs to communicate with their patients by phone and email, whereas Danish GPs are paid to to take calls from patients every morning. They are also paid for e-mail communications with patients.

Dr Byrne: “The email consults are excellent. The patient has to send their email via a government secure email system. Every citizen in Denmark has a government email address – maybe similar to our MyGov system.”

“Only simple non urgent requests are done by email. I think the GP has three days to answer. The payment was around $10 per email for the GP and this seemed to work fine. If there is a bit of to and fro with a patient via email the GP asks the patient to come in for a proper consult.”

Shared medication record

National databases exist for medications and laboratory results. Dr Byrne: “The live medication list was too good to be true! Click on the medication list in any GP software or hospital system and within 2-3 seconds up pops the same real-time live medication list.”

“The GP I was with could see the prednisolone dosing schedule for a patient with polymyalgia from hospital and then just take over future prescriptions. Everyone is working off the same list. I am sure it is not perfect but a pretty good starting point compared to our nothing.”

It appears the system encourages continuity of care. After hours medical services use the same computer system as GPs and hospital discharge summaries arrive electronically at the GP surgery within two days. Scripts are sent electronically to the patient’s preferred pharmacy.

Patient access

Compared to many other European countries Denmark has a high public satisfaction with the health care system.

An interesting aspect is the access patients have to the system. Via the Danish National Health Portal patients can access hospital discharge information, laboratory results, the live medication list and waiting list information.

Patients can electronically schedule GP appointments, send e-mails to their GP and renew prescriptions. They can also see who has accessed their health records.

All doctors are allowed to access the health records, but other health professionals require patient consent first. Danish law does not allow the interconnection of IT systems across sectors, such as health and taxation.

Miles ahead

With a population of 5.6 million Denmark is one of the smaller European countries, which may make it easier to roll out e-health. The system is not perfect and there are always issues, such as interoperability.

Overall Denmark seems to be miles ahead of many other countries, including Australia where we still rely heavily on the fax machine. Dr Byrne: “In Denmark it is illegal to fax anything as the system works on a national ID number that has to be kept secure.”

Is this the e-health breakthrough we’ve been waiting for?

Bill Gates once said “your most unhappy customers are your greatest source of learning”.

It seems the Australian Government has understood this message, as it is now considering major legislative changes to the personally controlled electronic health record (PCEHR) system.

This is good news. Doctors and patients are often confused about the rules regarding the collection, use and disclosure of information on a PCEHR.

An example of ambiguities includes doctors being advised not to use PCEHR data when providing third-party reports. But what happens to PCEHR information that, over time, has been incorporated in local databases? And are doctors allowed to access a PCEHR in the patient’s absence?

What’s the purpose?

This lack of clarity reflects a bigger problem — the absence of a clearly articulated and shared goal underpinning the national e-health system.

In the absence of an agreed purpose, rules and systems can become arbitrary or misguided, restrictive and lacking in consistency. Doctors, patients and policymakers first need to agree on the main purpose of the PCEHR.

Ultimately it is a tool intended to improve the provision of care: patients disclose their personal data to doctors and, in return, receive more effective and personalised care. I would be happy if the data were used for other purposes such as disease surveillance or even feedback on my clinical management but, in the end, it is the patient’s record and they must have a say in it.

Proper consent

A proper consent procedure is essential for any use of PCEHR data outside individual patient care. It appears the PCEHR system operator is currently authorised to collect information in individual PCEHRs for law enforcement, health provider indemnity insurance cover, research and public health purposes, and as required or authorised by law.

This should be more transparent with a better explanation of what it means for both patients and clinicians.
Patients should also understand the pros and cons of setting advanced access controls, especially now an opt-out system is on the cards. Adequate support will be required for specific groups including the elderly, people with a disability or mental illness, and some 14–17-year-olds.

The right to be forgotten

At the moment, PCEHR data are required to be held for up to 130 years. An interesting concept to consider is the “right to be forgotten”, which has been introduced in the European Union Court of Justice to give people the right to remove data from search engines under specific circumstances.

This concept is applicable to e-health. Patients, for example those with a mental health diagnosis early in life, may want to have part or all of their PCEHR record erased at some point (not just deactivated) to avoid stigmatisation or other repercussions — rather like the expunging of juvenile criminal records to give young people a fresh start.

Liabilities & incentives

Removing the need for participation agreements seems like a good idea. The Department of Health proposes that the liability provisions in the agreements be disposed of, rather than transferred to the legislation.

It is unclear what this would mean for the liability of doctors and health care organisations.

It seems new incentives will be paid to doctors who upload records to the PCEHR on behalf of patients with care plans. Although this will be welcomed by most doctors, it excludes other patients who don’t have a care plan but who would also benefit from a PCEHR.

Linking payments for chronic disease management to the uploading of documents is complicated. If it is introduced without other improvements to the PCEHR system, it could create more resentment among doctors and may lead to poor-quality uploads

What happens if patients do opt out of the PCEHR? Will their doctors be paid less to look after them?

And what if a patient who would benefit from a PCEHR declines to have a care plan, or the doctor provides chronic care without creating care plan documents or health assessments? In that case, there would be no incentive for the doctor to upload data to the PCEHR.

An upload incentive across the board would avoid these issues.

More criminal penalties?

The government is also considering introducing more criminal penalties, including jail terms, additional to the monetary civil penalties that already exist for data breaches. If we want to increase participation and engagement by doctors, I’m not sure that more penalties will help.

The challenge is to make e-health an integral part of health care, and align its purposes and values with usual clinical practice.

Training & education

Astronomer Carl Sagan said: “We live in a society exquisitely dependent on science and technology, in which hardly anyone knows anything about science and technology.” If e-health is to succeed we need to invest in information and communication technology skills. We must train the next generation of e-health designers, builders, managers and users to ensure our e-health system is safe and effective.

This article has previously been published in MJA InsightMany thanks to Ms Jen Morris, Dr Karen Price and Dr Michael Tam for their valuable feedback and suggestions on the draft of this article.

Warning: digital challenges ahead

There were a few interesting tech news facts this week. I thought this one was interesting: a Dutch campaign group used a drone to deliver abortion pills to Polish women, in an attempt to highlight Poland’s restrictive laws against pregnancy terminations.

There was scary news too: a private health insurer encouraged its members to use a Facebook-owned exercise app to qualify for free cinema tickets. Not surprisingly, Facebook was entitled to disclose all information shared via the app, including personal identity information, to its affiliates.

But there was also this: Telstra has launched its ReadyCare telehealth service. For those willing to pay $76, a doctor on the other end of the phone or video link is ready to care for you. No need to visit a GP or emergency department.

The telecom provider will offer the service to other parties like aged-care facilities and health insurance funds. Telstra is aiming for a $1 billion annual revenue.

Digital revolution

Digital developments increasingly create new opportunities, challenges and risks, but we have yet to find ways to incorporate the new technologies in our existing healthcare system.

In an interview in the Weekend Australian Magazine Google Australia boss Maile Carnegie warned that the digital revolution has only just started and that Australia is not ready for the digital challenges ahead.

Carnegie said that 99% of the internet’s uses have yet to be discovered and although Australia is the 12th largest economy in the world, it ranks only 17th on the Global Innovation Index.

She said that Australia has become a world expert at risk-minimisation and rule-making. Unfortunately this seems to slow down innovation.

“We are either going to put in place the incentives and the enablers to create the next version of Australia as a best-in-class innovation country or we’re not,” she said. “And I think it’s going to be a very stark choice that we have to make as a community.”

Who’s taking the lead?

In the last ten years we have seen major progress in for example mobile technology, but my day-to-day work hasn’t changed much. Healthcare has difficulty harnessing the benefits of the digital revolution.

Is the industry leading the way and letting governments, software developers and other parties know what is required? Do we have industry-wide think tanks to prepare for the near future? Have we listened to what our patients need and expect from us in the 21st century?