Martin Bowles: using health information to improve care

By Martin Bowles

Friday December 4, 2015

It is an exciting time to be a steward of the Australian health system. Our government has committed to reforms across the system: to improve co-ordination of care; efficiency of care; and sustainability of the system to improve health outcomes for all Australians.

I firmly believe data and information technology can provide breakthrough opportunities to enable and support this change. Adopting new treatment technology has never been a problem for health providers and professionals in Australia.

But changing their thinking about data and analytics and how this can help the patient and the system has proven to be more challenging.

Right now the Australian government has multiple reform processes under way which will encourage and support such a paradigm shift. When successful they will deliver the greatest improvements in our system in decades. We have reform activities in almost all parts of our system:

  • Primary health care;
  • Medical Benefits Schedule reviews;
  • Mental health;
  • Private health insurance;
  • Pharmaceutical Benefits Schedule;
  • Aged care;
  • Digital health; and
  • Jurisdictional responsibilities.

The results of these reviews will make our very good health system, which is under pressure, much better for patients’ health and also more sustainable. They will put data, analytics, evaluation and research at the centre of our policy thinking and our healthcare system.

A major challenge for achieving change in Australian health care is the complexity of the system. This can lead to duplication of services, gaps in care and poor integration of care. None of which are good for patients.

Adding to the complexity is the nation’s geographic vastness and low population density, which brings with it the challenge of meeting the needs of people living in rural and remote areas. Fragmentation and disconnect exists between:

  • Primary, secondary, and aged care;
  • Between private and public services;
  • Across the different types of care that we might receive; and
  • Between our states and the federal government.

Further challenges faced by the Australian health system are largely driven by:

  • Rising consumer expectations;
  • Costs rising faster than growth in our GDP;
  • Rapid advances in health technologies with associated increases in costs; and
  • An increasing need across the health system to deal with chronic and complex conditions.

The question is how to change it to make it more effective. We are looking at new structures and models for funding and delivering healthcare services. But we are also requiring improved collection, analysis of data and above all exchange of information across the system to drive better system performance and patient outcomes. This applies to individual patient information, and information that can be aggregated to provider, regional and national level.

Changes being made now will greatly improve our analysis of the information available at each level, advance our knowledge and understanding of the health of the nation, and facilitate new ways of delivering better healthcare, in ways never before envisaged.

Our Medicare system and Pharmaceutical Benefits Scheme provide excellent data on use of health care services. But we do not use it to its full potential. This is partly because of the complexity. But it is also because different parts of the system own and protect the Pharmaceutical Benefits Schedule, Medicare benefits, private, and public hospital data and have tended to block, rather than clear the way for, data sharing.

When I was first appointed I naively asked whether I could provide the Pharmaceutical Benefits Schedule and Medical Benefits Schedule data to our states and territories, I was given 100 pages of legal advice around privacy explaining why this was impossible.

When I then said — I want to do this. How could we make it happen? I received just four pages of advice. They now have the data. You need to ask the right question.

So it is possible. It requires the will, and the goodwill. Both of which now exist. It has not been seriously attempted before, but now we at the federal level are starting to share information with the other levels of government in Australia. We’ve still got a way to go.

Protecting privacy, using public data

To date our main thinking on data has been focused on privacy –- how to protect health data from being “leaked”, preventing it from being shared. I can agree with that if it is truly personal to me. But there is a great deal of data that is not really private. There is a lot of personal patient specific information which is best used by sharing with your doctor and other healthcare providers, to enable them to provide better health services for me as the patient.

And there is a lot more data which in aggregate, and de-identified, should just be openly available to researchers and others; and become a foundation for policy discussions.

We have data on what doctors are actually doing — because their services are claimed on Medicare. For the first time, this data has been used in conjunction with data from our pharmaceutical benefits schedule and public hospitals and this has thrown up some fascinating and disturbing insights. Even more so when we use our socioeconomic data.

A first Atlas of Australian Health Care Variation has now been prepared, which recommends co-ordinated action across the health system to investigate and reduce unwarranted variation in the health care treatments being provided to patients.

Through analysis of the data, it has proposed priority attention be given to the following areas to reduce waste, outdated or unnecessary treatments:

  • The use of antimicrobials;
  • The use of psychotropic medicines;
  • Fibre optic colonoscopy;
  • Knee arthroscopy; and
  • Hysterectomy and endometrial ablation.

It has also recommended investigation of inequitable access to cataract surgery. This links nicely with our review of the Medical Benefits Schedule, some 5700 items, which is focusing on appropriateness. In the immediate future, this atlas will be very helpful to the 31 new Primary Health Networks that have been set up in every part of Australia. These networks are commissioners of service for their defined population. They are a major step forward to creating a single, co-ordinated health system from the complex array of stovepiped health systems that we now have.

The Primary Health Networks will work with Local Hospital Networks to co-ordinate services regionally and locally. They will analyse local data, identify gaps in services and have funding to commission health and medical services to fill those gaps and meet the needs of local people.

To do that properly, data needs to be at the centre of their business operations. What is the burden of disease? What does that population need? How do we actually meet that need? How do we commission services to actually make that happen?

This data is not only useful for policymakers, we are moving to make this data easily available beyond traditional government partners, I have asked that data is accessible through a user friendly website/portal that can be used by innovators, both in technology development, but in systems design that Primary Health Networks could use to commission more efficient and effective health services.

Better information leads to better understanding of our system and therefore to better health care at every level. Instead of focusing on health services data on payments or as a way of catching out doctors, we can now use it for insights into doctor and consumer behaviours to better understand what is affecting health outcomes. We have a way to go but we will continue to push the boundaries because it is one of the important issues for us to conquer.

Using this data we are coming up with new ways of looking at the same old issues. We have the Medical Benefits Schedule which is a fee-for-service based model therefore very transactional in nature and open to perverse incentives. We will look to change models of care as well as moving to a more blended funding model to address these issues.

We have the burden of chronic disease that, like in the rest of the world, is increasing at a rapid rate, with population and sedentary lifestyles. Around half of Australia’s population has at least one chronic condition and 20% have two or more such conditions.

Our current system is not dealing with chronic disease sustainably and we’re seeing increasing evidence of that, with continued growth in our fee for service MBS payments, recently reaching the benchmark of 1 million payments per day. We know a blended funding model will support more of a team based approach to dealing with these patients.

We are also introducing a “Healthcare Home” concept similar to the medical homes models in the US and Canada that would provide an extra layer to integration of care for individual patients through enrolment with primary healthcare providers.

The role of technology

There is a significant role for information technology here, and this leads me to another major reform process that I mentioned earlier that is under way in Australia right now. There has been a lot of work done on digital or electronic health in various parts of Australia.

In July 2012 the Personally Controlled Electronic Health Record system was introduced. It was built on the foundation of the consumer at the centre of their healthcare, and in control of their own health information. We are proud of the consumer consent, access controls and privacy protection framework that underpins our system in Australia.

But our national shared electronic health record system was not a raging success in its first iteration. For individuals to have an electronic health record, they need to register for and provide a range of consents.

The registration process was cumbersome and hard to use for most people, both provider and consumer. Many gave up trying. Those who were successful at registering for a health record were disappointed to find that their record was just a shell — their health information wasn’t in their record and their doctors weren’t interested in adding any.

Healthcare providers need to share the information they have about the patients — with the patients and with the patients’ other care providers.

Healthcare providers haven’t been willing to invest in learning how to use and contribute information to a system that has low take-up from consumers. “Why would I learn to use a system that is not relevant to 90% of my patients?” So we had a classic catch 22 situation.

In this years federal budget, the Australian government committed funds to redevelop and operate the Personally Controlled Electronic Health Record system for the long term. The system will be reconfigured and has been renamed as the My Health Record.

As part of the reform, we will be addressing the issue of consumer registration and take-up. Next year we will conduct trials where individuals will automatically have a My Health Record created for them, unless they opt out. This will replace the current system that relies on patients actively choosing and registering to participate.

We are, in parallel, working on encouraging healthcare providers to participate, which involves understanding and addressing their barriers to take-up. Healthcare providers will see the value of a shared electronic health record when they can access clinical information about their patient which they otherwise would not have known.

This could be about a hospital admission and discharge or a visit to a specialist, pathology results, diagnostic imaging, or medications — perhaps even a consultation with another GP. We have started to see this with almost all capable public hospitals now signing up and some of the larger privates.

My Health Record, if well accepted, can improve treatment decisions, reduce adverse events, avoidable hospital admissions, and reduce duplication of medical tests.

And it will make it easier for health professionals to work as a co- ordinated team to care for a patient — sharing their health information and advice to create holistic care in place of fragmented and misinformed care. The functions of the system are also being steadily expanded.

But we have a long way to go to get national coverage of doctors and patients actively using the system.

We can do better. We need to better understand how consumers want to interact with the health care system. We have seen big shifts in this in the banking and services sectors and enablers in the App market so by mid-2016 the My Health Record system will be able to interact securely with mobile devices. It can currently be viewed through a web based portal, or by a direct connection through the hospital’s or the GP’s clinical information system — these are technology and services provided by third parties.

Having the My Health Record system accessible by mobile devices and apps raises a world of great opportunities from new technology and analytical health services which are reaching an exciting maturity right now.

There is huge untapped potential to engage consumers more in the management of their own health and wellness and focus on prevention of sickness. This can provide a significant shift from a health system focussed on treating illness.

People are increasingly engaging with wearable technology to help them manage their own health and wellbeing. There are opportunities for consumers to choose to connect their wearable and other personal health technology to their My Health Record to send information to it, or provide access to information in it.

Consumers will be able to choose to use their health information to personalise health services to their individual needs, including how the information might be integrated with the data from their mobile and wearable devices.

The power of this integrated data, combined with the computational and analytical capacity of third-party vendors, will improve capacity to predict health outcomes and provide proactive personalised advice to the consumer and their carers.

In addition, access to a shared health information system of this scale could provide carers and policy makers with insights from anonymised data on wellness, illness, disease and treatment profiles, patterns and predictions for the population. This will help policy makers to better shape the health system and more cost-efficiently direct prevention and treatment policies.

If we do this well, and in a co-ordinated way across the nation, there is a significant body of international evidence to suggest that investment in digital health will improve the performance and sustainability of the Australian healthcare system.

In my view, the use of smart technology has the greatest potential to dramatically change our approach to health and health care.

With all the these changes happening at the moment and the world’s knowledge and information doubling about every 70 days we in the public sector are not necessarily going to be the great innovator in this space. That’s not really our job.

Our job is continuing to evolve and enable national infrastructure, in a way that allows innovative healthcare service providers and software companies to pick up the ball. We need to be open to these new approaches and understand what might be possible as the company who may come up with the next great innovation may not even exist today. The creation of permission cultures is important. Permission to try different things and sometimes fail is critical to success.

It’s an absolutely fascinating world that will change how we look at health care by empowering consumers to manage their own health.

This is an edited speech delivered by Martin Bowles to the New York E-Health Collaborative Forum at the Academy of Sciences on December 3.

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