Public Health Opinion

By Prof Stephen Leeder

I received recently my certificate of registration from the Australian Health Practitioner Regulation Agency and felt that my life was about to take a completely unforeseen turn.

I was certified as registered with the national nursing and midwifery board.  Several good friends are nurses and midwives said the idea was interesting. 

Two weeks later an unapologetic letter (OK, so this was not a mistake, so what was it?) arrived with my correct registration certificate. Subsequently I received a further letter asking me to prove every one of my medical qualifications with testamurs, certificates and so forth.  After all these years!!

It is mix-ups like this that lead many doctors to be sceptical about the role that information technology can play in medical practice.  Most fundamental though is their concern that individuality – of the patient and the doctor – can easily be lost in records that impose rigid data structures. It requires unusual imagination among information engineers for that individuality to be honoured.

I had the privilege last year to see a splendid health IT system at Kaiser Permanente in California in which these concerns had been dealt with.  I rave on about this achievement so often that I have been asked who paid for my visit and what commission I receive!  My visit was paid for by the NSW Department of Health and I receive no commission!

But at Kaiser, huge economies and improvements in clinical quality have been achieved through IT by maintaining highly personal contact among patients, their clinical carers (doctors, nurses and doctor/nurses such as I am now!), pharmacists, physios, dietitians and others through a comprehensive, open electronic record that can be accessed with permission by any practitioner managing the patient.

In addition, secure electronic messaging, email and the use of the telephone extends the range of consultation considerably, and relatively cheaply.  Texting your doctor is the done thing among the 9 million enrolees and the 14,000 doctors in eight American states, or emailing them – and doctors set aside time each day to attend to inquiries and to check on patients in the community through this means.  The data structures are solid for clinical and lab data, and open for personal and clinical data. 

The system has taken a decade to implement and has cost US$4 billion, of which one-half has gone into change management – helping the user become versatile in doing their work in the new environment.  We have yet to recognise in Australia how much we need to spend to get such a system and how much effort is required to manage the change.

When such a system underpins integrated patient care, investing in community and hospital services to secure better health, good things happen.  Bloomberg Businessweek reported in 2009 “that a nonprofit organisation called the National Committee for Quality Assurance indicated that in Northern California, Kaiser Permanente had reduced death from heart disease so significantly among the region's then-3 million members that it no longer was the leading cause of death in that population, though it remained so in the general population.”

The report gave partial credit to Kaiser's databases, reports, and tracking and reminder systems. Smoking rates (because the IT system is great for assisting clinically-based preventive efforts) are the lowest in the US, several percentage points below ours.

And no, this cannot be explained by the enrolees in Kaiser being healthier at the outset than the average person.

Next time you are offended by an IT system going wrong, ask whether there has been sufficient investment of money, imagination and sensitivity, or whether it is in error simply because we have not done the hard yards of design or been prepared to pay the price to produce a system of high fidelity.