Tuesday, December 17, 2013

How to fix the PCEHR and salvage eHealth

Fixing the PCeHR is entirely possible, all that is required is wherewithal to bite the proverbial bullet.

It can be done with 5 simple steps.

It can also be cash flow positive in the first year.

Step 1

Accept that the basic PCeHR concept is fundamentally flawed. It is flawed for all of the following reasons:

A) No average patient wakes up in the morning and goes "Gee, what I want today is a jolly good PCeHR".

Because of this fundamental reality there is no driver for "opt in" from the patient perspective, and, for better or worse, there never will be.

No amount of advertising will ever fix this because most patients will never really know what a medical record does, or why they need one. There is nothing wrong with that. They don't need to.

Medical records exist because clinicians want them to exist, both to facilitate communication, continuity of care, and to provide some degree of CYA protection in the event a particular patient's care becomes subject to legal overview.

Unless you tap into the key driver for a medical record to exist it will never be either wanted or useful.

This really means the PCeHR needs to do useful stuff for clinicians, not at some notional time in the future, but right this second.

B) A record is only useful if it exists.

I can neither put information into, nor extract information from something that does not exist.

While the vast majority of Australians continue not to have a record the system will remain useless, and as per 1 there is no driver for patients to covet one.

C) Privacy and utility are somewhat mutually exclusive concepts. Currently 95% of Australians have 100% privacy and 0% utility because they don't have a PCeHR. The remaining 5% still have near 0% utility because the PCeHR as it stands is virtually clinically useless.

D) Shared summaries as the premier item is a pretty silly idea.

It is efficient and easy to put all patient information into a record and then use search to find it (regardless of format) - look at the Internet. Putting everything in means there is no expensive curator function required. Just put it in, use search to find it and access control to protect it.

It is inefficient and expensive to expect doctors to add "shared health summaries". This provides both an incomplete record and carries high labour costs.

Data says this happened at this time is, by its very nature, timeless.  Data is event X happened at time Y. No judgement, no interpretation just this stuff happened then.

A shared summary is a rapidly ageing snapshot of decreasing utility with each passing second. It is also subject to recorder bias, right from very the moment it's created.

Data is clean, accurate, and objective. Shared summaries are almost certainly inaccurate, incomplete and highly subjective.

E) It must be possible to explain exactly why the PCeHR should exist.

Because we think it's a good idea is not good enough! Not for a billion dollars.

If you can't easily detail the benefits that will flow from the existence of a PCeHR then it has no right to life.

The only people who you need to want it are clinicians. Clinicians do stuff for patients and unless using the PCeHR delivers meaningful utility to clinicians in the course of treating their patients it won't see widespread use.

With key government infrastructure the commercial reality of a solid business case need not always apply, however there is no reason why this infrastructure should not have a quasi commercial eye towards identifying savings and efficiencies, and there are savings, huge savings.

Step 2

Declare that as of July 1st 2014 all Australians will now have both an IHI a PCeHR.

If you recall something similar was what was done with Tax File Numbers, although none of us can actually see the NPCTFR (Not Personally Controlled Tax File Record).

Let's face it we all know we all have an individual person identifier for Government. You might be listed on 2 Medicare cards but that is still a unique identifier. You almost certainly have a Tax File Number, another unique identifier. An IHI is just another one. In the background we all have an Australia Card Number, or near enough to it that it makes no difference.

Leverage the current complex and convoluted sign up process to allow patients to opt out, rather than opt in. All conscientious objectors would have 6 months to get their access, login and tick the box to make their record private. I would be willing to bet this would be less than 5% of the entire population, and probably less than 1%.

This preserves privacy perfectly for those that want it but gives 95-99% record coverage. We need this level of coverage to make the PCeHR useful because it is no use if it does not exit.

To augment utility people who want totally private records should be allowed to add in their chosen clinicians so they can have their cake and eat it too.

Step 3

Put some clinically relevant data into all these new records.

What is clinically relevant and would be easy to do?

Currently the government pays for 90% of all medications via the PBS, so put all this data in for the last year. Although it's not a complete record it is likely to be a far more accurate rendition of what a patient is actually taking than most patient management systems because not only was the medication prescribed it was actually paid for and picked up.

On that note am I the only person who thinks that the first task NeHTA should have attended to was to declare a unique identifier for every medication available in Australia? Without this any form of coherent patient A is on medication X, Y, Z communication between IT systems is damn near impossible.

Similarly for pathology. Currently pathology results are pushed out to individual medical practices. Why not make a small change and push them into a central repository (courtesy of the PCeHR) and then allow the practice management software to extract it from there?

It is said that 20% of all blood tests will be repeated by another GP within 60 days. Probably at least 50% of the time this is because they are not aware a clinically relevant result already exists. With a total pathology spend by Medicare of over 2.5 billion pa this 10% saving would provide significantly more then NeHTAs entire annual budget.

Similarly for radiology, although this could include not only reports but also the original images.

At this point we have a record that exists, pays for its own generation and upkeep in savings, and has genuine utility for the people the use it.

For example if I know what medications a patient has paid for an picked up I have a pretty good idea what they are actually taking. As a side benefit you also have what could be a near real time prescription shopping database. If a clinician can see a patient got Valium last week it makes the decision to not prescribe it again far easier, no matter how convincing the story.

If I can find blood test ordered by another doctor a few weeks ago the need to reorder it (unless clinically indicated) also disappears, and there is a $250+ million a year saving.

And the old chestnut from radiologists about "no comparison films". Not only would this be gone but more cancers would be caught sooner if comparison films were available. (Sorry George - a bit of poetic licence)

Step 4

Allow the uploading of any reasonable format of data. Text files, doc files, html files, image files and even HL7 can all be read on any desktop computer with a PMS. All bar HL7 can be read on any consumer PC.

Allow upload to the logical categories used by current PMS systems like "Notes", "Letters", "Dischagre Summaries", etc.

Use the power of search to make this data accessible.

Now we have a record where clinicians can share notes between different sites and there is no need to spend anything on secure messaging, just send it to the PCeHR where those that need to read it can read it.

Can anyone tell me who thought allowing 7 different secure messaging systems to come into existence was a good idea? None of then speak to each other (unless they have receive millions of dollars of tax payer dollars) and for all intents and purposes no one uses them.

Wouldn't the best way to send a secure message about a patient be to simply upload it to the PCeHR where it could be read by anyone who needed to?

Where should you put your advanced health directive so your final wishes are known? Where better than your PCeHR?

By accepting data in any reasonable format the modifications required to all the existing clinical software are trivial so both the time frame to implement these changes are short and the costs are small.

Step 5

Solve the fundamental problem of eHealth. "And what's that?", I hear you ask.

The fundamental question is simple. Any useful medical record contains a whole lot a sensitive patient information. You can't have it any other way. Can you imagine a bank that say "We're great we have no money in the vault so there's nothing to steal so you money is safe with us!"

Getting back to the fundamental question:

How do I as a patient make it known that I want a doctor I have yet to meet (because I have not yet had the accident that brought me to DEM unconscious) access my record?

There are exactly two options: black list or white list. The null option of having nothing there to steal is just stupid.

With the white list model everyone is banned from seeing everything unless they are specifically allowed. This is the privacy model and is high maintenance as every extra person needing access has to be individually added, and the question then becomes who adds who?

With a black list model everyone who is not specifically banned can see things. This is the utility model and it's how things work in the real world right now.

With a black list model any registered clinician would be able to access all patient data, however all access (to every document) must be logged. Access logging is the fundamental process used to "keep the bastards honest" where a large number of people need access to a large body of sensitive data. All Federal agencies use it because it works and why should health information be different? To be frank I personally would be less worried about you seeing my blood tests than my taxable income.

A back list model would provide the patient with a full record of who has looked at their stuff so they could if they wished perform an audit role (note both the cost savings and accuracy of a patient doing their own auditing). Add in personal control by allowing patients to block certain clinicians if required.

Automated systems could also perform auditing and pass on anomalies to human auditors. This is precisely the sort of system banks use to detect credit card fraud. Medicare, Centerlink and the ATO all use similar systems.

This basic black list model could be complicated by providing access levels but think about what we have now. A patient's notes are often a just a manila folder. There is no logging and there is no access control. We all use them, and the system works. An electronic system with access logging would be safer than what we have in use right now.

For that minority who want the ultimate in privacy, all then need is the ability to mark their record private and only allow access to clinicians they want to see their stuff they have flipped over to a white list model. They can handle all the acces details (therefore not a Government cost - user pays in time not cash)

With this simple approach we get the best of both worlds - utility and privacy, patients control whether their record runs in black list or white list mode, and in white list mode they themselves pay for (in time not cash) the access control

Step 6 (Optional)

To encourgage clinicians to put data into the record it would be quite simple to link Medicare benefit payments to data upload. This could be done for medical consults, pharmacy dispensing, pathology and radiology.

But do you know what?

I don't think you would need to use much of a stick because the record described would actually be useful, and people tend naturally to use stuff they find useful.

Just my 5c

Dr James Freeman


Friday, October 14, 2011

Video Conferencing 101

Video conferencing is actually a pretty old technology, and really dates back to the beginnings of television. Although it’s been in constant evolution for decades the revolution happens when high speed Internet meets cheap computing power.

Moving pictures are created by displaying many static images rapidly in sequence. Humans can process 10 to 12 separate images per second, perceiving them individually. Once this rate is exceeded the illusion of continuous movement is created. The early silent movies operated at 14 frames (images) per second (FPS). Modern TV and movies use 24-30 FPS.

When we look at the quality of a video image the detail in each of the images is just a important as FPS. Picture detail is typically quoted in terms of pixels, where one pixel is one “dot” that can be a specific colour. The more pixels you have the better the picture will look, and the larger you can blow it up before you begin to notice individual pixels. To put things in perspective here are some common horizontal x vertical pixel resolutions

iPhone 3 480x320

iPhone 4 960x640 (note 4 times as many pixels, but same size screen)

VGA 640x480 (probably what you had with your first computer monitor)

PAL TV 720x576 (standard Australian analogue TV)

XGA 1024x768 (any modern computer monitor will equal or exceed this)

HD Video 1280 x 720 (720p)

HD Video 1920 x 1080 (1080p)

So with video the more pixels we have, and the higher the frame rate, the better the picture we see will be.

There is however a very simple mathematical reality:

Data cost = FPS x Horizontal Pixels x Vertical Pixels

While a number of clever techniques, falling under the broad umbrella of compression (like zip files) can be used to reduce the data cost no one has a magic bullet that lets them compress video data much better than anyone else. In fact most companies use exactly the same techniques. You should probably read the last two sentences again.
Video conferencing technology works like this.

Connect a camera, monitor, microphone and speakers to a computer

Take lots of pictures every second

Convert and compress the pictures/audio into a stream of 0s and 1s using a piece of software called a codec.

Send that data stream over the Internet to another computer using a communication protocol.

During transmission over the Internet this data stream can be protected from eavesdropping by using encryption

Reverse the process at the recipient computer by using the same codec to convert the data stream back into pictures and audio for output via a monitor and speakers

Do that on both ends and the same time and there you have it – a videoconference.

In part 2 we will unravel codecs, protocols, and encryption.....

Dr James Freeman
GP2U Telehealth
173 Macquarie Street
Hobart 7000
Mobile: 0438 350 854
Email: james@gp2u.com.au
Web: https://gp2u.com.au/

Monday, October 10, 2011

ADSL Speed, Data Use, Contention Ratio


When it comes to video conferencing the primary determinant of picture and sound quality is the capacity of the "pipe" that joins the two sites.

A commonly quoted magic number is a capacity of > 384 kb/s (kilo bits per second) in each direction, with more being better. So if you have a 2 Mb/s (mega bits per second) ADSL line you should be right? Right?

Perhaps. ADSL stands for Asymmetric Digital Subscriber Line. The asymmetry refers to the fact that the download speed is much faster than the upload speed.

Most of the time this does not matter as we do a lot more downloading than uploading, however for video conferencing upload speed is critical, because it is upload speed that determines how good the picture will be at the other end of the connection.

You can test your connection using one or more of the speed testers gathered together here: https://gp2u.com.au/static/links.html

Data Use

So how much data do you use? 1 Byte contains 8 bits so 384 kb/s is close enough to 50 kB/s (kilo bytes per second) - and we use that much data in 2 directions making a total of 100 kB/s. 3600 seconds in an hour gives us minimum use rates of 360 Mega Bytes (0.36 Giga Bytes) per hour.

Although it depends on the software/hardware configuration most video conferencing equipment will happily use substantially more data than this (unless specifically configured not to). A data use budget of 0.5-1 Gig per hour is a good real world ball park.


The way cheaper ADSL providers manage to be cheaper and still make a profit is by selling the same chunk of capacity to more people. This is called the contention ratio.

If you have wireless ADSL at home and have kids you will have seen contention in action as you connection grinds to a halt while your kids simultaneously stream music, Skype friends and inbox frenemies on Facebook - they are competing for limited capacity. If you use the same provider as your neighbour it might not even be your kids slowing your connection down.....

Dr James Freeman

GP2U Telehealth
173 Macquarie Street
Hobart 7000
Mobile: 0438 350 854
Email: james@gp2u.com.au
Web: https://gp2u.com.au/

Sunday, August 28, 2011

Telehealth in Australia - GP2U

When our Health Minister Nicola Roxon announced that Telehealth was going to receive Medicare funding my first thought was fantastic, it's about time. Australia's a big country, and Telehealth is a potentially great solution to some of the problems we have. This was fairly rapidly followed by a whole series of practical questions like:

  1. How does a GP out the back of Bourke find a City Specialist willing to offer a Telehealth appointment?

  2. What technology choices make Telehealth widely accessible?

  3. How do the necessary documents change hands?

  4. How does the specialist get paid when the patient may be thousands of kilometres away? and quite importantly;

  5. Why would specialists want to be involved? - they are already busy.

If you can't provide practical answers to all these questions and more, you can't expect Telehealth to actually deliver improved health outcomes to patients because it won't see widespread use.

Looking purely at the booking logistics the wotif.com hotel booking system sprang to mind, and with that thought GP2U Telehealth was born. Imagine specialist doctors being like hotels and vacant rooms being like vacant appointment slots and you will see many of the logistical tasks required for an effective Telehealth system are quite similar.

Of course there ARE many differences between the system we've built and wotif but at it's heart GP2U is a bookings management system, specifically tailored with usability, accessibility and medical confidentiality in mind.

For a specialist using the system an entire appointment can be managed with less that half a dozen mouse clicks, with a single click being all that's required to connect a videoconference connection to a patient.

For a GP a specialist referral can be completed in less than a minute.

So how's it going? I'm sure a marketing guru would use words like "taking the market by storm" but that smells of hype and hyperbole to me. Enjoying widespread and rapidly expanding use would however be fair.

Have a look for yourself: https://gp2u.com.au/

Wednesday, April 16, 2008

2020 Summit

Ah the joys of a new government. Under Kevin 07 we have Nicola Roxon who is the Minister for Health but, as she is at pains to point out, "Not the Minister for Doctors". Power to you sister. Go girl. Forgive me for being naive, but isn't politics about being clever enough to get people to do what you want using a carrot and stick, give and take, don't burn your bridges approach?

So we are going to have a 2020 summit. I suppose it is better than 3 x 5 year plans. Now you may be wondering who is going? There are apparently 88 individuals invited for the 2 day event. Was the Australian Medical Association (representing circa 25% of doctors) invited?.....uhm no. Oh well we all know the AMA is just a lobby group for overpaid specialists but with 88 places up for grabs it might have been politic to at least invite them. Now many of us know, that amongst the many crises in medicine, there are big problems with medicine in the bush. So was anyone from the Australian College of Rural & Remote Medicine invited?.....uhm no. Well how about the Rural Doctors Association of Australia?.....uhm no. OK so given about 10-15% of the future medical workforce is currently training was a representative from the Australian Medical Students' Association invited?.....uhm no.

To me this is not a good start. The neglected groups mentioned "represent" about 50% of the doctors in Australia and have, to put it in the vernacular, been given the shaft. Yes there are lots of very clever and distinguished people going but were places so tight that there no room for the AMA, ACRRM or RDAA or AMSA but there was room for a female junior hospital doctor, who in her own words says: "I am attending as a private citizen. I was nominated by Nicola Roxon because of my work in health workforce and training, and my advocacy of public hospitals. I am not officially representing anyone." I think not.

So let's ignore the fact that half of medicine has been excluded from a presumably inclusive process. Let's consider what 88 people can do over 2 days. 2 days/7 hours per day is 14 hours or 840 minutes. With 88 luminaries that gives each one 9.5 minutes. Call it 5 minutes to talk and 2 questions. Hello? There is a reason we have a representative democracy. There is simply not time for every man and their dog to put in their 2c worth. The way it works is that groups of us elect representatives and they represent us. Sure they don't do what I personally want all the time, nor do they express my personal view all the time. But if enough of us don't like it we turf them. That is why the AMA, ACRRM, RDAA and AMSA should be there and at least 50% of the other delegates should not be. They don't represent anyone! With so many voices, offered so little time, no one will be heard and nothing will be resolved. 2020 is we are listening, feel good political bullshit at its worst.

So perhaps you think I am being unkind? Let's read the questions that have been sent to delegates. Here are the areas of health around which the government would like to see some conversation and brainstorming. These are the questions delegates are being asked:

1. What public conversation do we need around the broader population health challenges?

2. What are the responsibilities of the individual and the state in behavior related illnesses?

3. What should be the balance of investment between treatment and prevention?

4. What strategies will improve health outcomes and the disease risk factors in the general population, and in high need groups?

5. Why are healthy lifestyle messages regarding exercise, diet, smoking and alcohol abuse not being heeded more?

6. How can sectors outside 'health' contribute to a healthier population? For example, can we design cities in a way that promotes a healthier lifestyle?

7. Where should clinical research focus its energies?

8. How do we plan for emerging health challenges?

9. What is the future of health education in Australia, and the role of foreign-trained workers?

10. What can be done to improve safety and quality standards, including clinical protocols?

11. To what extent are the challenges in the health system resolved by extra monies rather than structural reform?

12. What strategies need to be considered to ensure equitable access to health services?

While some of the questions for the 2020 summit are sentient, others would appear to be almost laughable. It is disturbing to realise some committee, somewhere, presumably identified these 12 as the critical issues facing medicine.

So it's easy to poke holes in things. Anyone can do it. It only helps if there is a viable alternative. There is. Stay tuned for the next exciting episode but do not adjust your mind, there is a fault in reality.

Executive Summary Introduction

So here I am in the blogsphere at last. I've been ignoring it for years. So why here, why now? The reason is simple. Having sent a few well formulated letters to the editor and been resoundingly ignored I resolved to put up or shut up and a blog became the logical choice.

The key questions are of course: what do I have to say, and why would anyone bother to read it? Executive summaries are good if you're busy, so here it is: The only reason for reading this blog is if you have an interest in Australian medicine, what is currently really wrong with the system, what is about to go wrong, and how some of these issues might realistically be addressed.

So putting as many keywords into a sentence as I can this blog will cover: bed block, access block, Medicare, Nicola Roxon, Kevin Rudd, health policy, health bureaucracy, 2020 summit, the future of medical education, AMA, IMG, OTD, foreign trained doctors, rural health, aboriginal health, elective surgery waiting lists, quality standards, clinical protocols, healthy lifestyle, research, general practice, specialists, and procedural skills.

Disclosure: I am not (permanently) employed by a public hospital, nor do I have a political affiliation although most of my acquaintances put me only slightly to the left of Ghengis Khan. I work at the coal face of modern medicine in various DEM (Department of Emergency Medicine) and as a locum both in the city and in remote rural areas. I graduated from medicine many years ago and have been around the traps. I believe in calling a spade a spade not a carbon neutral, ergonomically designed, environmentally friendly digging implement. Without an editor to soften the wording expect a warts and all viewpoint. If you are looking for a sugar coated reality you are definitely in the wrong place.