E-Health

I get a lot of questions from medical colleagues about my interest in medical software, and in particular, my interest in e-health, particularly Web-based practice management software. As a group of professionals so busy thinking about patients, drugs, new therapies, and bureaucracy, I don’t blame them for not pushing the e-health agenda more.

This page is intended to explain where I think we should be going in the e-health domain.

Background

Australia is a mere underling in e-health. Despite discussions with several American e-health strategists I have never heard a good reason why we are so slow to adopt technology in this area. Consider that some West African nations are already using mobile phones for medical purposes, while many doctors here, reluctantly, and only recently, moved from paper based records, to client-server based software for GP’s. Doctors certainly don’t offer consultations or send results via the phone. This is despite evidence that good health IT is useful and cost-effective, even in primary care. Health IT data is the gatekeeper to the future of personalized medicine. As we implement electronic health records, new decision-support tools will help us facilitate the adoption of disease-specific standards of practice that can provide real-time data to help prioritize therapies based on potential drug interactions and patient clinical profiles.

Australia’s National E-Health Strategy Summary outlines the ongoing government and industry work to streamline e-health. Its focus is the backbone of creating regulations for health IT infrastructure.

Despite years of work by the NEHTA and other bodies, we have not changed the technology used in primary care in any substantial way. We are now in danger of over-regulating before serious e-health solutions have even gotten off the ground. I say serious because what currently exists does not in any way capitalize on the data-crunching potential IT has brought to other industries.

I believe that the basis for any health related software is threefold:

1. To allows consumers to involve themselves in their healthcare
2. To allows doctor to better manage their patients
3. To allows third parties such as government or billing services to easily interact with both patient and doctor.

The second point to highlight is the shift to internet based technologies.

Web-based software has a number of benefits, the primary ones being the benefits of access from any site, thus allowing, for example, medical consultations from home. The internet also offers a number of other efficiencies such as being a more open platform – part of the web 2.0 revolution you might say. The web is also the only real way we will satisfy patients demand for information control. This great whitepaper gives some of the stats showing how little patients listen to their doctors and how much they are turning to e-information for answers. Both Google and Microsoft have weighed into the e-health arena with web-based offerings, and are critical that governments are focusing on enterprise solutions thus far.

Let’s focus on software in the primary care setting. In Australia we primarily use on-premise software such as MD, Locum,Practice Studio, VO, Genie, and Best Practice. See http://www.drsref.com.au/medsoftware.html for a comprehensive list.

Overseas there exists Software as a Service (Saas)/ web based software such as AdvancedMD, OfficeEMR,Waitingroomsolutions, Integrate and Practicefusion, whom I mentioned in a previous post.

There is new Saas/on-premise combo software available for the aged-care market – see Healthsolve Care Solutions, an Adelaide based company.

Saas is something perhaps best explained by good examples. One of the best known is Salesforce.com. On-line software is the antidote to many of the IT headaches associated with the traditional on-premise software model. With Saas there is no software or hardware to buy, install, maintain, or upgrade.

Here are two articles that compare Saas with traditional software in medical practices:
http://www.futurehealthcareus.com/?mc=web-based-saas&page=fht-viewarticle

Thus, in summary, the direction is fairly clear, I would think, yet none of our practice management software makers are announcing moves into this market!

I think it is alo helpful to consider some of the features we should already begin to expect.

Telehealth

In future we may just see medicine moving well away from doctors offices into the actual home. The concept of the medical home and online physician or telemedicine consultations is gathering steam. Of course, those of us practicing medicine cannot forget the importance of the patient-doctor relationship that is so key to many diagnoses and complex management problems. Rather, technology will have it’s first impact on the simple things, such as a parent trying to decide whether to take a child with a chronic cold into an emergency department in the middle of the night.

Telehealth has many aspects. We could talk about video-conferencing, text-message reminders to patients, PDA-based health records, and numerous other technologies in development.

I believe that a major test for Telehealth will be the growing the aged-care market. This change is already happening in North America, and some analysts are predicting a huge uptake.

Telehealth on non-traditional medical consultations cause some doctors to shiver, yet some research shows that people – particularly the younger generation, are more open ‘medical tourism’ and ‘retail clinics’. While perhaps disruptive innovations, consumers are entitled to seek better care and greater access at lower costs. Health IT is another extension of this openness to new models of healthcare.

Interoperability

As it stands, in-practice systems are not easily made interoperable – by virtue of their enginerring, installation and their ownership. In Australia, for example, any studies that seek to understand doctors diagnoses or prescribing practices are required to build add-on software to collect the required data from doctor’s in-practice systems.

The need for interoperability is already apparent by the difficulties we face setting up e-prescribing.

A pharmacy-driven electronic prescribing project announced with much fanfare earlier this year has hit a setback with one partner, prescribing software company Medical Director, going cold on the project. The Pharmacy Guild announced a ScriptX project to start in October 2008 which would allow GPs to create electronic scripts on a central encrypted hub that any participating pharmacy could access and dispense.But original partners HCN, the vendors of Medical Director had decided not to go ahead with the SciptX project as planned.

A related feature that would help prevent prescription mix ups is the use of online services for safe medication use, of which it seems there are already quite a few in the USA.

Home-monitoring

Intel, the US-based technology giant is making its foray into the medical market with the Sept. 1 launch of a high-tech care management system that allows doctors to monitor chronic disease patients at home.

The new device, dubbed the Intel Health Guide, is a touch-screen computer with a 10.5 inch screen that includes video conferencing capabilities and a multimedia health education library for patients. The device can initiate scheduled “check-ups” with patients several times a day, asking health-related questions and collecting vital signs, which are sent to medical providers.

Several compatible medical-monitoring devices measuring weight, blood pressure and blood-oxygen levels may accompany the device, depending on patient needs.

Open-source

Another great benefit I see in Web-based software is the ability to make aspects of the software open-source. This has been a great success for Facebook with their applications, the iPhone, and many new software and hardware systems offers similar adaptability. This adaptibility allows for innovation by outside sources.

In a good move in this direction IBA Health’s Lorenzo is going to open it’s platform for developers to write applications.

The reality is that any medical software is always going to behind the eight-ball as new technology becomes available. as it becomes available you really want it to link to your own practice management system, much like anyone can add a new app to their iPhone, or new widget to their blog. Doctors simply don’t have the time or technical knowledge to install updates etc.

Knowledge-bank

In the ideal world, medical theory and statistical knowledge is free. The idea is that every doctor has the best-practice guidelines at his fingertips. The reality today is that, at best, doctors are said to know best-practice guidelines for perhaps 50% of what they do. Many would argue this is not the case. Yet the stats say otherwise. For example, only 40% in this study said they reviewed the appropriate data regularly.

Decision support at the point of care is not a new concept, but at present it is a static one. Guidelines are written, then accessed at a later point in time. The lag time for best-practice evidence to become well-used is often 5-10 years in medicine – incredibly slow! What we really need is data crunching tools that regularly update doctors as to how a particular treatment is succeeding in a certain type of patient.

Patient e-Records

A key part of any e-health solution is Electronic Health records (EHR), or Personal Health Records (PHR) depending on whether you are the doctor or patient respectively.

The purpose is rather obvious, I would say, though the nature of many of the PHR solutions thus far would suggest that creators don’t comprehend their full potential. In particular, I don’t believe they add value to the work of a doctor at present. They are not tools for clinical use, but merely electronic forms of old paper documents.

Overseas and in Australia there are companies, including Google, designing online PHR’s.

In Australia it is key that these be useful for doctors for there to be any take up. Sure patients can keep their own records, but these are of limited use if not somehow maintained by medical practitioners.

A health record is supposed to be a collaborative tool. Yet they are precisely the opposite, GP’s and physicians keep separate records of the same patient that often conflict on issues such as current medications etc. With each visit such simplicities need much time to be clarified.

From this the benefit of social networking as a feature of EHR/PHR’s is clear. Though the need for physicians and nurses’ notes, in their classic stilted style, would not evaporate, largely because of regulatory and billing requirements.

Driving Health Change

Once you start collaborating with patients records, why not extend this to other collaborative tools? For example, running updates of a patient’s condition, including meds, problems lists, and –- most importantly –- to do lists and reminders.

Online programs, such as Liveandworkwell.com from Optumhealth, are already being used to create incentives and drive behaviour change. We do afterall, spend a lot of time on the computer.

July, 2009: A list of tools I wasn’t aware of that another blogger, Ben, of ausmedweb.blogspot put me onto includes-

Sites for finding doctors, dentists, chiropractors or other allied health professionals:

www.healthengine.com.au – find a doctor or specialist

Sites for engaging in social discussion:

www.multimedix.com.au – facebook for Doctors

Information to Doctors:

http://www.mediadoctor.org.au/ – analysis of medically related news

www.medicalupdate.com.au – online CME attendance

http://www.thinkgp.com.au – more online CME courses

Online Prescription Exchanges:

http://www.medisecure.com.au (backed by RACGP)

http://www.erx.com.au/ (backed by Pharmacy Guild)

Medical Advice online:

www.ozdocsonline.com.au – consult a doctor online

www.teledr.com.au – consult a doctor online

Miscellaneous

www.surgeonline.com – easily record and bill patients where you have assisted online

History of the Australian Web – see what’s getting all the traffic and how sites have ranked over time.

I’m also looking for any Australian companies that offer telephone based consultations. Please leave me a note if you know of one.

Last Updated: 5 Aug 2009