When it comes to e-health, we know at least some of the reasons why it should be a good thing (quite apart from the fact that the e-revolution is bringing benefits to so many other aspects of life).
As a new Canadian study suggests, electronic drug information systems can help reduce adverse drug events and increase pharmacist and prescriber productivity. The study also finds that they increase “medication compliance”, but I hate that term so will instead report that they are associated with a more appropriate use of medicines.
The study, which estimates Canada’s investments in drug information systems will generate $436 million in cost savings and efficiencies in 2010, was released by Canada Health Infoway, “an independent not-for-profit corporation created by Canada’s First Ministers in 2001 to foster and accelerate the development and adoption of electronic health record systems with compatible standards and communications technologies”.
E-health: WHY NOT?*
Two articles in the latest Medical Journal of Australia explore some of the reasons why the promises of e-health haven’t eventuated, as did a presentation to the recent Public Health Association of Australia conference in Adelaide.
Dr Christopher Pearce and Dr Mukesh Haikerwal from the National E-Health Transition Authority note that Australia’s health care system lags behind all other sectors of our economy in the use of computerised systems. We are in the middle in rankings of health systems among industrialised nations, and our use of modern electronic technologies for communication and clinical information transfer within health systems is low.
• Multiple funding streams and jurisdictions with confusion about responsibilities
• The lack of an implementation strategy
• Government programs underestimate the costs of change management and the need for training and technology.
Meanwhile, Dr Johanna Westbrook and Professor Jeffrey Braithwaite from the University of New South Wales argue that we need to see information and communication technology as an opportunity for truly reforming health care rather than as a mere tool for automating existing activities.
And doesn’t this give the real insight into some of the barriers facing e-health?!
They argue that ICT has the potential to revolutionise work practices and processes by creating opportunities for health professionals to take on new roles and to provide care in different and innovative ways. They write:
Decision support within computerised ordering systems and telemedicine are only two examples. Such systems create opportunities for health professionals other than doctors to order certain tests and to make treatment decisions when experts may not be at hand. Available evidence suggests outcomes do not suffer.
For instance, nurses’ performance in answering clinical questions unaided generally falls below that of doctors, but when supported by online evidence systems, their performance matches that of their medical colleagues. As other industries have shown, substitution and role changes are areas in which ICT can lead to the greatest gains.
…As ICT markedly alters people’s roles and shifts responsibilities, it challenges the status quo, and this is seen by many as a threat to the established routines that enable organisations to function, as well as to other valuable practices. Small wonder that ICT is viewed by some health professionals as a danger to the things they cherish.
Meanwhile, Mary Osborn, a researcher with a background in public health policy, reports on a survey showing just how much work lies ahead for those who would like to see the benefits of ICT realised.
Mary Osborn writes:
The National Broadband Network to date has cost the Labor government more than $1billion and is scheduled to cost $43billion subject to changes as the roll out proceeds. It was very noticeable while I was recently in Tasmania, where most of the State has only one provider, that the delivery of broadband was painfully slow.
Why is this a health issue?
In 2007, a survey that I conducted among practising physicians across Australia and New Zealand reported that most (97.5%) had access to computers at work and 96.5% used home computers for work purposes.
Physicians in public hospitals (72.6%) were more likely to use computers for work (65.6%) than those in private hospitals (12.6%) or consulting rooms (27.3%). Overall physicians working in public hospitals used a wider range of applications with 70.5% using their computers for searching the internet, 53.7% for receiving results and 52.7% used their computers to engage in specific educational activities.
Physicians working from their consulting rooms (33.6%) were more likely to use electronic prescribing (11%) compared with physicians working in public hospitals (5.7%).
This survey clearly illustrates that physicians in Australia and New Zealand have not incorporated computers into their consulting rooms over which they have control.
This is in contrast to general practitioners who have embraced computers after the provision of various incentives.
The rate of use of computers by physicians for electronic prescribing in consulting rooms (11%) is very low in comparison with general practitioners (98%). One reason may be that physicians work in multiple locations whereas general practitioners are more likely to work from one location.
The implementation of clinical information and decision support systems in hospitals will change the way in which care is provided, with the promise of improved efficiency and safety.
Further, the greater emphasis on connections between healthcare sectors and settings to support greater continuity of care will demand electronic transfer of data between individual healthcare providers and facilities in the future.
The success of these clinical information systems to deliver the benefits promised will be largely dependent upon the capacity of the health workforce to integrate computers into their everyday practice. As clinical leaders, physicians are often sought out as champions of these systems in hospitals.
One way physicians could improve their use of electronic applications is through an incentive program similar to general practitioners. The GP incentive program has been shown to be very successful in increasing the use of electronic applications in general practice.
The government needs to consider physicians in the roll-out of the National Broadband and could consider developing a user friendly physician soft ware package that meets the needs of physician practice. This package would have the capacity to transfer clinical information electronically including a patient medical record, linkages to existing electronic prescribing software, discharge information, access to prescribing information such as the “Australian Medicines Handbook”.
This is has worked very well in other countries such as Denmark, where physicians are able to access a nationwide health information exchange that comprises a repository of information on individual citizens, including electronic prescriptions, laboratory and imaging orders and test results, specialist consultation reports, and hospital discharge letters. This repository is accessible to patients as well as authorized physicians, pharmacists and home health nurses.
• Mary Osborn has a background in public health policy and is currently doing a PhD looking at the impact of ethical guidelines among physicians when dealing with the pharmaceutical industry. She presented this survey at the PHAA Conference in Adelaide in September.
As everyone knows (most especially journalists), it is far easier to describe a problem than to solve it.
Perhaps we could learn from those countries which have had some success.
Christopher Pearce and Mukesh Haikerwal say the poster child for e-health is Denmark, “which has a comprehensive end-to-end system that has reduced some errors to almost zero and improved working conditions and health outcomes”. Italy, the Czech Republic and Spain are apparently also doing good work.
Can we learn from their experiences?
(* Perhaps this should read: how long is a piece of string?)