The article provides a simple overview of clinical informatics. It discusses the driving forces behind health informatics, including the need to provide better care to more patients with constrained resources. It explains how clinical informatics aims to achieve these goals by optimizing various stages of the patient journey through the use of technologies like electronic health records, clinical decision support, and data analytics. The focus of clinical informatics has narrowed to using IT systems to support clinicians. While the core principles remain the same, technology is now more pervasive in healthcare. Clinical informaticists play an important role in bridging clinicians and IT to effectively apply technologies for improved patient care.

1. The Health ISSUE 9 • JUNE 2011
The official magazine of the Australian Your voice in public healthcare
Healthcare & Hospitals Association
The e-health imperative Clinical informatics
Why we need to improve our for dummies
e-health capability Providing better health
care by using technology
E-health
In Australia
The development of e-health
A history of pathology informatics
ALSO
in this • Governance • Who’s moving in • AHHA news
issue training for health the health sector and events

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3. The Health
AHHA Council
and supporters
Prue Power Executive Director
Cydde Miller Policy and Networks
Manager and Editor
Terrie Paul Business and
Membership Manager
The AHHA Board has overall Luise Zakosteletzki Trainee
responsibility for governance Policy and Planning Manager
Adjunct Professor Annette
including the strategic direction
Schmiede ( NSW) AHHA Office
and operational efficiency of the
Ms Joan Scott (ACT) Unit 2, 1 Napier Close
organisation, the protection of its Deakin ACT 2600
assets and the quality of its Mr John Smith (VIC)
Postal address
services. The 2010-2011 Board is: Mr Mark Sullivan (VIC) PO Box 78
Dr David Panter (SA) Ms Sandy Thomson (WA) Deakin West ACT 2600
National President T: 02 6162 0780
Dr Annette Turley (QLD)
Dr Patrick Bolton (NSW) F: 02 6162 0779
Ms Anna Fletcher (Personal E: admin@ahha.asn.au
National Vice President
Member representative) W: www.ahha.asn.au
Dr Paul Scown (VIC)
National Vice President Dr Owen Curteis (Asian Hospital
Editorial and general enquiries
Mr Felix Pintado (VIC) Federation) Cydde Miller
National Treasurer Professor Helen Lapsley T: 02 6162 0780
Ms Siobhan Harpur (TAS) E: cmiller@ahha.asn.au
(International Hospital
Director
Federation) Membership and
Dr Yvonne Luxford (Associate
Member Representative) subscription enquiries
Director AHHA Sponsors Terrie Paul
T: 02 6162 0780
The AHHA is grateful to the E: tpaul@ahha.asn.au
The AHHA National Council following companies who support
oversees our policy development Advertising enquiries
our work:
program. It includes the AHHA Frank Risvanis
Board above and the following Globe Publishing
members for 2010-2011: Primary sponsor T: 03 9699 4279
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Ms Jan Evans (NT)
Ms Jane Holden (TAS) Other organisations support The Health ISSUE 9 • JUNE 2011
Mr Graem Kelly (VIC) the AHHA with Institutional,
Ms Shaune Noble (NSW) Corporate and Associate
The official magazine of the Australian
Healthcare & Hospitals Association
Your voice in public healthcare
Mr Patrick O’Brien (QLD) The e-health imperative Clinical informatics
for dummies
membership. To find out about
Why we need to improve our
e-health capability Providing better health
Dr Tony O’Connell (QLD) care by using technology
joining the AHHA and having
Associate Professor Alan
your organisation listed,
O’Connor (QLD)
Mr Ross O’Donoghue (ACT) contact Terrie Paul. E-health
In Australia
The development of e-health
A history of pathology informatics
ALSO
in this • Governance • Who’s moving in • AHHA news
issue training for health the health sector and events
The views expressed in The Health
Advocate are those of the authors
and do not necessarily reflect the
views of the Australian Healthcare
and Hospitals Association.
The Health Advocate June 2011 3

5. 36
Contents
28
Every issue In depth
06 President’s view 8 Clinical informatics for
13 News dummies
16 Events By Tony Sara
39 Who’s moving 19 The development of
40 Become an AHHA Member e-health in Australia
42 Snippets By Michael Legg
25 Is the Personally Controlled
Electronic Health Record
Brie ng an evidence-based
intervention?
34 Governance training for
By David More
the health sector
28 Computer says NO!
38 Book review – Improving
The challenges of e-health
Health Care Safety
8
implementation
and Quality: Reluctant
By Philip Darbyshire
Regulators
30 The e-health imperative:
By Christopher Baggoley
the latest e-health news
and developments
By Peter Fleming
19 Opinion
36 What does health ICT
actually achieve?
By Patrick Bolton

6. President’s
view
Dr DaviD Panter
President of the
Australian Healthcare and
Hospitals Association
w e are almost half way through
the year already and, while health
has been fairly quiet in the media,
those of us in the health system have been
working harder than ever.
Networks in all states and territories as well as the
first group of medicare locals, which will begin
operating from 1 July 2011.
some of the issues being immediately felt
are the uncertainties around the precise roles of
In this issue of The Health Advocate our these organisations and how service integration
focus is on e-health and health informatics, a will be achieved – an objective we have long been
critical element of health service delivery that toiling to realise in the australian health system.
has received recent attention with the Federal For instance, which of these bodies will take
Government’s release of the draft Concept of prime responsibility at the local level for helping
Operations for the personally controlled electronic consumers and patients navigate the system?
This year has health record (PCeHr) due to start in July 2012. What are the practical mechanisms for local
at the aHHa we have been spending a lot of our Hospital Networks and medicare locals to work
already been a time setting up two new arms of the organisation together to ensure the right care in the right place?
– consulting and research – building on our the aHHa, along with a number of other
busy one with the already strong foundation of policy development, organisations, has also raised serious issues with
advocacy and information dissemination. the Federal Government’s legislation to establish
AHHA establishing JustHealth Consultants is a new service offered the National Health Performance authority. our
new arms of the by the aHHa designed to easily connect health
services with experts in a range of fields. our panel
members expressed consternation that state
and territory governments were not consulted
organisation in already includes Chartered secretaries australia
(Csa) who will be providing nationally consistent
in the drafting of the legislation and that, as
tabled, there was little recognition of the states as
consulting and clinical and corporate governance training for new hospital ‘system managers’ in terms of reporting
and existing bodies under the reforms. We also have and accountability. You can find a more detailed
research leaders and experts in health law, strategic planning, summary of our concerns on page 13.
health service planning, industrial relations, health of course, health performance data relies
informatics and financial/audit support. heavily on information and communication
the Australian Institute of Health Services and technology to ensure accuracy, consistency and
Policy Research is the aHHa’s second major change timeliness. In this issue we hear from some key
this year, being built on university membership figures in the e-health domain, including the Chief
emanating from the australian Institute of Health executive of the National e-Health transition
Policy studies. the new Institute provides a central authority, Peter Fleming.
point through which research and evaluation is associate Professor tony sara gives us a simple
linked directly with health services – to the benefit guide to clinical informatics – that is, the use of
of services themselves, managers and practitioners, electronic systems and information to help guide
as well as academics and the public as a whole. and improve clinical practice. We also have the
the Institute is the first active endeavour to close first of a two-part article from Dr michael legg,
the loop through implementation, evaluation and Past President of the Health Informatics society
improvement of health service delivery. of australia, on his personal experience during the
If you are interested in being involved in these evolution of ‘e-health’ in australia through the
new activities or would like to know more about lens of pathology.
what services the aHHa can offer you, please Dr David more, a well-known clinician,
contact our Business Director, terrie Paul, on commentator and blogger on e-health, shares his
02 6162 0780. concerns about the e-health record and the need
another reason for our increased fervour is the for australia to learn from implementation of such
rapidly approaching ‘go-live’ date for a number systems in other countries.
of bodies and organisations being established so please read on! the next time you hear from
under the National Health reform agenda. among me we will be in the full swing of making the
these entities are the local Hospital and Health health reforms work.
6 The Health Advocate June 2011

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8. In depth
CLINICAL
INFORMATICS
for dummies
8 The Health Advocate June 2011

9. TONY SARA
Director of Clinical
Information Systems
South Eastern Sydney and
Illawarra Local
Health Network
i
HAVE BEEN doing ‘clinical informatics’ becoming more public (eg the Bristol Royal
Trying to make the for more than 10 years, but was forced to Infirmary1), the information explosion, and also
re-evaluate just what it is that I do, and the need to provide more care in the context
most of health the context in which I do so, following the of the greying of the population, higher costs,
request from AHHA for this article. I used to increasing expectations and increasing cost of
information systems give lectures to Masters students five years ago technology, but a reducing workforce.
on ‘Introductory Health Informatics’, so I went Essentially, this means the need to provide
back to those slides to see how little, or how demonstrably better care to more patients
much, the landscape has changed. with constrained resources and proportionally
The principles are the same – health fewer staff.
informatics is about providing better
care to patients using technology. It sits How does health
at the intersection of computer science,
information science, health care and
informatics expect to
healthcare management. achieve these aims?
The definitions all congregate around the
notion of the art and science of providing Let’s follow the patient journey to analyse
better health care using IT. But what are the where health informatics can assist.
driving forces behind health informatics? The patient presents and is registered.
Firstly, there has to be a ‘desire to take Have we uniquely identified the person to
better care of patients’, deep and right at ensure we have the right person and the
the core. Others include the increasing right information held against them? If we
power of technology and the internet, an have a robust unique person identification
increasingly stronger need to demonstrate
public accountability in the context of errors
system and process then we have made
a good start. >
The Health Advocate June 2011 9

10. In depth
e focus of clinical informatics has narrowed
onto the use of information in IT systems
”
”
in health care by clinicians
> Do we have relevant history available of the triggering of the rules engine noted enough about health and health care, and
from past encounters with our practice and above, but more importantly as to outcomes its work processes, and have learnt enough
others? Immunisation status? Medications? of care, by disease, by patient group, by about information and computer sciences
Important lab and imaging results? Alerts ward, by operation and by clinician. that they can assist both their clinical
and allergies? Again, an encounter summary Lastly, the monitoring of the processes colleagues and the IT groups to achieve
with unique person identification will help and outcomes of care should be able to be common aims.
the process of care. applied to the population as a whole by the Bill Gates said it fairly succinctly in 1999 in
Can we compare the images from the aggregation of de-identified patient data. his book Business at the Speed of Thought:
past to those captured today? A Research An interesting example of the latter was the “It’s impossible to properly re-engineer a
Information System (RIS) or Picture analysis by Kaiser Permanente of its large data process using technology in an area without
Archiving and Communication System store that identified that Vioxx contributed to oversight of someone who can bridge [the
(PACS) program will do this, assuming it is an excess rate of myocardial ischaemia2. different] teams.”
fed by the unique identity system already The various academic definitions have not The technologists just don’t understand
in place. Perhaps the symptoms and signs changed in a real sense over the last decades. healthcare processes; and clinicians,
are not diagnostic – decision support listing So what has changed? without further training or experience, don’t
differential diagnoses will assist. The focus of clinical informatics has understand the technology. It has become
The condition found is unusual – what narrowed during the last years onto the use the solid perceived wisdom that it is easier
is the best care? Access to the internet will of information in IT systems in health care to train a doctor or a nurse to have enough
quickly determine what is evidence-based by clinicians. understanding of the broad brush strokes
medicine. The prescription process, one of the What has also changed has been the and some of the detail of technology so they
four main sources of errors in health, should increasing pervasiveness of technology. can effectively bridge the teams.
be monitored by clinical decision support Google, similarly, has made significant In fact, in the USA, there arose, in
software that applies expert rules devised by changes to the way we work and study. 2009, the clinical sub-specialty of clinical
senior clinicians along with graded drug/drug Some of this article was sourced from informatics3,4.
interaction alerts. The process of clinical care Google, the depth and reach of which was
on the ward should be monitored for unusual unthinkable when I started this job. So, what do Clinical
observations, again by expert IT systems.
Informaticians do and
When the care pathway is over, the Who are Clinical
transfer of care should be electronic and what do they use?
seamless. The monitoring of the processes
Informaticians?
of care in the facility should be able to be Clinical Informaticians are doctors, or nurses, These professionals use their knowledge
supervised by the clinicians, by both analysis or health information managers who know of healthcare processes, of informatics
10 The Health Advocate June 2011

11. principles and processes, and
How does the clinical from before the inception of a clinical project
health informatics tools5. Clinical informatician seek to or system, to well after the (nominal) project
processes need no introduction – but do this? had finished – it is a truism that health
what are the latter two? Informatics information systems projects are never
principles are about IT technology, privacy In essence, they achieve these goals by finished until the data and information have
and health law, database concepts, project bridging the different teams. Specifically, been passed onto the next system and the
management, change management, this means to develop, implement and original system has been turned off.
statistics, health and IT standards, refine clinical decision support systems, The last of the queries is where and the
messaging, person identification and so understanding both the clinical processes in answer is fairly intuitive – wherever clinical
on. Health informatics tools are things like depth and the technology in a broad way. As care is delivered and close to the point of care.
clinical guidelines, pathways, order sets and well, it means to lead or participate in the The state of play for clinical informatics
staff education processes, to name a few. procurement, customisation, development, in Australia is not optimum – there are a
So, what does the clinical informatician implementation, management, evaluation handful of doctors who do it full-time and a
seek to do? (S)he seeks to: and continuous improvement of clinical much larger number who do so part-time.
• Assess and inform the information needs information systems, again understanding There are no training positions and some
of clinicians, managers and patients both the clinical world and the IT world5. tertiary courses.
• Characterise, evaluate and improve It would be understood that clinical What I find the most gratifying, as a doctor
clinical processes. informaticians, then, would do this work in this field, is the capacity to improve the
care that large numbers of patients receive,
and interestingly, from a ‘life satisfaction’
perspective, problem-solve with my colleagues
how we will practice medicine tomorrow.
References
1. Treasure T, ‘Lessons from the Bristol case’,
BMJ 1998; 316: 1685-1686
2. http://www.fda.gov/NewsEvents/Testimony/
ucm113235.htm, accessed 15 March 2011
3. Gardner RM, Overhage JM, Steen EB, et al.
(2009), ‘Core content for the subspecialty of
clinical informatics’, Journal of the American
Medical Informatics Association 16 (2): 153–7.
doi:10.1197/jamia.M3045
4. Safran C, Shabot MM, Munger BS, et al.
(2009), ‘Program requirements for fellowship
education in the subspecialty of clinical
informatics’, Journal of the American Medical
Informatics Association 16 (2): 158–66.
doi:10.1197/jamia.M3046
5. http://en.wikipedia.org/wiki/Health_
informatics, accessed 14 March 2011
The Health Advocate June 2011 11

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13. In the
Have your say…
We’d like to hear your opinion on these
or any other healthcare issues. Write to
us at admin@aushealthcare.com.au or
news
PO Box 78, Deakin West, ACT, 2600
Dental probe welcome,
but not the solution
has been allowed to run for so
Cautious first steps long when it is clearly wasting
valuable health resources which
in health reform could be used to help those in
genuine need – particularly low
income earners, Indigenous
In March the ahha the states and territories. communities, others in rural
➧ expressed serious
concern about the
lack of consultation by
the Federal Government on
“as a result of the lack of
consultation, the legislative
framework for the nhPa has a
number of critical flaws which
and remote areas and older
australians.
the ahha urges the
government to consider a
legislation to establish the will reduce the body’s capacity new proposal we developed
national health Performance to fulfil its role. hospital and in consultation with our Oral
authority and warned of the health service performance is and Dental health network, in
risk to future health reform if a complex area in which the conjunction with dental health
similar approaches continued states and territories have experts and peak groups, to
to be used. considerable knowledge and the ahha WelcOMeD address the growing oral health
“the Bill establishes the
infrastructure and legislative
mechanisms for the nhPa.
however, the legislation fails to
expertise,” said Ms Power.
the ahha therefore called
on the commonwealth to make
critical amendments to the
➧ the Federal Government’s
intention to further
investigate widespread
misuse of the Medicare chronic
crisis in the australian community.
the proposal focuses on the
provision of medically necessary
oral health care for those with
recognise the role of state and Bill in consultation with state Disease Dental Program, but genuine chronic conditions
territory governments as the and territory governments. We expressed disappointment and targeted assistance to
majority funders and system have also sought an ongoing that our earlier warnings went the 30 percent of australians
managers of our public health commitment to involving the unheeded, which has resulted who currently have difficulties
services as agreed at cOaG,” states and territories, as system in massive over-spending on a affording private dental care.
said ahha’s executive Director, managers of public healthcare, program with limited scope in It involves integrating the
Prue Power. “this is despite in the following processes: the community. Medicare chronic Disease Dental
the fact that health Ministers • nhPa strategic planning; We have for years been Program into a revised version
are accountable to their local • Developing performance highlighting the problems with of the commonwealth Dental
populations, along with their indicators to assess quality; the Medicare dental program health Program, which was
senior officials, to meet the and while lauding its focus on proposed by the government
demands of a dynamic and • Dealing with improving the oral and general before the 2007 election.
complex system and for underperforming hospitals health of people with genuine the proposal focuses on
making sure services are when necessary. chronic conditions. ensuring funding is directed to
available at all times.” two years ago the ahha delivering cost-effective, essential
the approach threatened as originally drafted, the proposed a solution to the and preventive oral health care for
to undermine the national legislation prevents the problems inherent in the those who need it most. It would
health reform agreement jurisdictions from participating program that would have also include universal dental care
formulated at the cOaG in all these activities. We dramatically reduced spending for children aged 0-18.
meeting in February as well as will keep you posted on the under this scheme and delivered You can read more about the
the commonwealth’s stated establishment of the nhPa and much better value for money. outcomes from our Oral and
commitment to a cooperative other new organisations over It is frustrating that this poorly Dental health network meeting
approach to health reform with coming issues. designed and targeted program in adelaide on page 16.
The Health Advocate June 2011 13

14. In the news
Increased ambulance use
putting pressure on hospitals
A study from emergency department
➧ february’s Australian
Health Review has found
that the increased demand
for ambulance services over
attendances. Pressures on
hospital systems are well
recognised, with congestion
and overcrowding reported
the past two decades is putting regularly in the media and peer-
pressure on health care resources reviewed literature.
potentially resulting in reduced this study involved a review of
access, safety and quality of care the literature concerning trends
for patients. in utilisation of emergency
“In Australia, as in other ambulances throughout the
developed countries, there is developed world and discusses
an expectation that the health the major underlying drivers
system will fulfil our care needs, perceived to be contributing
especially those that are urgent to this increase. A better
and life-threatening. the role of understanding of causes of
ambulance services has evolved increased demand is essential the authors recommend
over the past 20 years into a vital to enable the development of further investigation of the major
community resource embedded strategies to manage demand causes of rising demand. for this
in the health system,” said in the future. to be undertaken, there must
study author, Judy Lowthian, the review found evidence be collection and recording of
an NHmrC post-graduate that patient transportation by standardised data with common
research scholar. emergency ambulances has definitions of demographic,
Initially designed as an been increasing over the last socioeconomic and health-
emergency transport service, 20 years. many contributing related factors. Effective
ambulance services now factors have been postulated, management of future demand
provide a range of healthcare related to changes in the needs will depend on a comprehensive
needs, including pre-hospital of the community arising from analysis that goes beyond
emergency and urgent primary ageing, declining health, social simple demographics of age and
care, emergency and non- structural change, and changes population growth. until we have
emergency patient transport in organisation of primary a better understanding of the
and referrals to alternative healthcare. Limited price signals drivers of demand for ambulance
healthcare professionals. and improved accessibility of services we cannot ensure the
In recent years escalating ambulances, alongside improved future sustainability of this
growth in demand for community health awareness and essential healthcare service.
emergency patient services expectations possibly contribute you can access the Australian
has placed increasing strain on to a degree of avoidable use. Health Review by becoming
both ambulance and hospital the relative contribution of these a member of the AHHA. find
resources. rising utilisation factors to the continuing rise in out more about the AHr and
of ambulances is occurring transportations has not been our other publications on our
in common with increased well studied. website at www.ahha.asn.au.
14 The Health Advocate June 2011

15. Private health insurance needs change
The sTrucTure and regulation health status), that contributors were to take out PhI) has insulated the health
➧ of private health insurance needs
to change radically in order to
meet consumers’ need within our
current health system. The new research
treated fairly and that the organisations
were prudentially managed.
competition between funds on
price and product innovation and
funds from the conventional business
imperatives to satisfy customers and
contain costs in the industry, and inflated
their significance in the funding of
was reported in the February issue of the differentiation has been deliberately healthcare in australia.
ahha’s peer-reviewed journal, Australian stifled in order to realise these objectives. If the commonwealth wishes to
Health Review. This may have made good policy preserve a system of private hospital
“Most australians are familiar with sense when the private health funds treatment employing user charges as an
high profile private health insurance were the financial lynchpins of the alternative to its own hospital Medicare, it
(PhI) companies, like Medibank Private commonwealth’s national health scheme, should consider redirecting its subsidies to
and hcF, but few people understand prior to the introduction of a universal the hospitals themselves. PhI could then
how this unique sector of the economy health insurance scheme. however, its be reconfigured as an option for accessing
operates and the influence it exerts on rationale is questionable in the current private hospitals rather than the privileged
the delivery of health care in australia,” environment given bipartisan support for mechanism for doing so. a deregulated
said study author dr ardel shamsullah of Medicare as a universal public insurer. industry using insurance principles of risk-
La Trobe university. The result of this system is that rating and allowing competition between
The company structure of the PhI private health funds are now wedded firms would emerge, and it may attract a
sector has always been markedly different to a highly regulated and subsidised more diverse contributor demographic,
from typical commercial industries, in system that assures their existence which would consist of more demanding
part due to the comprehensive framework while they deliver expensive insurance and price-sensitive customers.
of commonwealth regulation within packages to a segment of the australian “This would result in a PhI industry that
which they operate. This regulatory population covering a select set of supports, rather than hinders, innovation
regime was designed to ensure that PhI, healthcare services. The commonwealth within the health sector and which is
heavily subsidised from the public purse, guarantee of a certain level of income genuinely centred around consumers’
was accessible to all (irrespective of their (from subsidies and incentives for people needs,” dr shamsullah said.
Safety and quality a
focus for health
ausTraLIans can over several years the
➧ Look forward to safer
health care in the future
with a permanent
organisation dedicated to
commission, and before it
the council, has undertaken
excellent work in raising the
profile and evidence base for process of receiving health care. within individual hospitals.
promoting safety and quality improved safety and quality in The ahha believes that every This is why it is crucial that
throughout the health system – a range of health care settings. person has a right to receive safe we have a body dedicated to
the australian commission This has included major and high quality care and that identifying and addressing the
on safety and Quality in campaigns to increase hand each avoidable adverse event is policies, structures, practices
health care. washing and hygiene, reduce one too many. and cultures that can make our
While we were concerned hospital-acquired infections Most harm caused in health system safer.
with parts of the legislation to and improve medication health care is not the result The permanent establishment
establish the national health management. of individual errors but due to of the commission enshrines
Performance authority, the other australia’s health system is underlying problems such as a the critical imperative for safe
component of the Bill to make very safe by world standards lack of consistent information and high quality healthcare in
the commission a permanent but too many australians are systems across jurisdictions, all public, private and non-profit
body was most welcome. still harmed unnecessarily in the health services and sometimes health services.
The Health Advocate June 2011 15

16. Events &
meetings
Oral health experts agree
on a way forward
The AhhA convened oral health reform – including health foundation year that proposal formulated at the
➧ its oral and dental health
network in Adelaide on 11
March 2011. The meeting
brought together directors of
stronger links to the evolving
national health Reform agenda,
such as through the national
Preventive health Agency
in the first instance will be an
application-based (and therefore
voluntary) program. For instance,
20 foundation year placements
AhhA’s oral and dental health
network meeting. You can find
the nRhA’s priorities on their
website at:
state and territory public dental and possible inclusion in the may be offered in the first year, 11nrhc.ruralhealth.org.au.
services (most of which are national health Agreement – expanding over time. Using this We look forward to working
members of the AhhA) as well and emphasises that the starting model, a focus can be placed with our partners, members
as representatives from the point must be a program to squarely on rural and remote and the government to ensure
national Rural health Alliance, address the oral health problems placements in the initial roll-out. that another year does not pass
the Public health Association of those most in need. At the ensuing national without action on oral health.
of Australia and the Australian We are seeking integration of conference of the national Rural If you would like more
dental and oral health the existing Medicare chronic health Alliance held in Perth over information on the AhhA’s oral
Therapists’ Association. disease dental Program into a 13-16 March, one of the priority and dental campaign, contact us
The discussion centred on revised commonwealth dental recommendations agreed by on 02 6162 0780.
building a campaign for the ‘poor health Program (with a new delegates was this combined
cousin’ of hospital and primary name) that will mean all care
health care reform, oral health. provided is on the basis of highest
Along with mental health, oral need while ensuring best value for
health has been put on the back the taxpayer dollar. As originally
burner to simmer away while intended for the cdhP, the new
hundreds of thousands of needy combined program would ensure
Australians continue to struggle care for the 500,000 people on
with accessing affordable and public dental waiting lists as well
timely oral and dental care. as specific early intervention and
The group worked from the treatment targets for those with
basis of the RePAIR proposal chronic conditions, Indigenous
agreed during the 2010 election and rural/remote communities,
campaign by the national the aged and children/young
oral health Alliance (of which people (aged 0-18).
the AhhA is a member). This The group also agreed to
proposal is available on the put forward more specific
nohA website at: recommendations in relation to
www.oralhealth.asn.au. the workforce plan of an intern
The revised proposal reworks year for oral health professionals.
some of the touchstones for We would prefer to see an oral
16 The Health Advocate June 2011

17. Moving towards health
governance in regional areas
ON 18 APRIL, a beautiful
➧ autumn day in Canberra,
the AHHA convened its
first Policy Think Tank for
the year in partnership with the
Australasian College of Health
Service Management (ACHSM).
Our focus for the day was on the
distinct governance issues facing
rural and remote health services,
particularly under the national
health reforms.
The day was facilitated with
great skill by Associate Professor
Paul Dugdale from the Australian
National University. We had a
fantastic range of speakers who
impressed the delegates with
their perspectives:
• Prue Power and Daryl
Sadgrove, Directors of the
host organisations, gave tranche of Medicare Locals on strategies for community As a follow-up from the event,
good overviews of the reform 1 July; engagement in health service the AHHA wrote to the Federal
context on which discussions • Carole Bain travelled all the governance and planning. Minister for Health, Nicola
focussed throughout the day; way from Silver Chain in Roxon, to outline some of the key
• Jodi Hallas and Jenni Pilcher Western Australia to discuss Delegates commented on why issues and possible strategies for
from Queensland Health the issues facing a community they liked the Policy Think Tank: making health reform work in
detailed state-wide work care and nursing service that “The discussion and different the bush. We will be advancing
on health service planning, needs to work across all parts perspectives in the presentations the outcomes from the day in
particularly to support rural and of the reforming health system and linking back to on-the-ground a formal policy development
remote health service districts; in metropolitan, rural and issues. [It was] well facilitated program that will contribute
• Terry Findlay from the Transition remote towns; and with a great variance of people to our inputs to the National
Team in the Australian General ark
• Mark Ashcroft from Alpine with real commitment to rural Rural Health Alliance. For more
Practice Network shared some health, a multi-purpose service and remote health.” information or a report from the
substantial insights to the in the Victorian high country, “The practical and advocacy- day, please contact us.
imminent roll-out of the first shared some very interesting
It was well facilitated with a great variance
of people with real committment to rural
”
”
directed focus of the whole day.” Our next Policy Think Tank
will be focussing on community
health in the reforms. We would
love to welcome you to Canberra
in winter (it’s not as bad as you
think!) on Friday 22 July. For
more information or to register
and remote health your interest in attending, please
email the AHHA at admin@
ahha.asn.au.
The Health Advocate June 2011 17

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19. In depth
MICHAEL LEGG
Principal of Michael Legg
and Associates
The development
of e-health Michael Legg provides the first instalment of a personal
history of health informatics in Australia
a
LTHOUGH CHATHAM HOUSE rules
were invoked at the recent meeting
of the CEOs of the Medical Software
Industry Association, I hope Minister Roxon
won't mind me picking up on a comment she
The early years
It began for me in 1977 when, in my third year
at Sydney University, I was in a physiology
course taught by Michael Taylor - what
multi track FM recorder and then digitised
over hours producing washing baskets full of
punched paper tape. These were subsequently
submitted to Fourier analysis to determine
the frequency spectrum of pressure waves
made recognising that many in the room turned out to be his last. Michael Taylor was using the University’s SILLIAC and KDF9
had been working in the field for a long time a mathematician2¬ physician-physiologist computers. The point of this is that SILLIAC
and that a debt was owed. Her comment interested in optimisation. Fascinated by his was the replacement for the first computer
and a recent article by Robert Flanagan1 on account of this field, I undertook to do an in the southern hemisphere the CSIR Mk 1!
‘why IT is all so hard’ prompted me to record honours year with him. These were computers that took up the whole
something of what I knew of the history of Taylor had a distinguished research career basement of a very big building!3 Of course
health informatics in Australia. Because the looking at the physical properties of arteries now this can now be done on your phone.
space is small and since I have had the privilege and how well-designed they turn out to be. He What was to be my honours year however,
of spanning most of it, this will be somewhat
personal and focused around pathology.
and his colleagues had built various pressure
and displacement sensors that fed into a huge
saw Taylor move to be Deputy Vice
>
Chancellor and so I joined his student,
The Health Advocate June 2011 19

20. In depth
>
Barry Gow, who had inherited the laboratory.
With Barry, I looked at the conundrum of
why aneurysms formed on the low pressure
side of a constriction in arteries. Barry was a
dentist who made organs and harpsichords in
his spare time but in the lab we built our own
microprocessor-based computers including a
DEC LSI-11 and used these to drive machines
to prod and scan arteries as well as for real-
time Fourier
analysis of vibrations. Grant Carter4, a medical
student, helped with the programming of
the Intel 8080 microprocessor5 following his
success at writing the BASIC compiler for the
Australian Microbee.
Arthur Guyton, arguably the last person
to have a complete understanding of known
human physiology, also visited during this time
and gave us his FORTRAN dynamic model of
the human cardiovascular system; we were
able to run it on our home-grown machine.
The laboratory next door was David Read’s,
a respiratory physician who had formed
a relationship with Ita Buttrose and the
Programming then was in assembler (the bits and
bytes level) because that was the only way to
”
”
Australian Women's Weekly in support of his
cot-death research. Needless to say we were
jealous of their funding. David, who was a
make the computer work fast enough
good scientist and great teacher, attracted a
number of bright young clinician-researchers
keen to be associated with this cutting edge GE in the US. After a spirited New Year’s party I and a couple of others ended up doing time.
laboratory. Among them were those who are found myself being interviewed for the role of Interestingly, many remember these news
well recognised now in health informatics and Coordinator of Computing and Quality Control items but few could tell you that seven of the
the medical technology sector, including Vince in the largest NSW pathology laboratory 10 Australian Nobel prize winners were/are
McCauley6, David Rowed7 and Colin Sullivan8. (Macquarie). In many respects this was a role pathologists or physiologists.
Vince and David were programming then in and job title well before its time. It showed a At Macquarie, I specified a laboratory
assembler (the bits and bytes level) because clear recognition of the link between quality information system and it was put out to
that was the only way to make the computer and informatics in pathology. tender. Relying on contractual promises and
work fast enough for the experiments. Macquarie Pathology was founded in a judgement that the ‘new’ language ‘C’ with
the early 1970s by Tom Wenkart9. Tom was, an approach then called ‘parameter driven’
Pathology and still is, a visionary in what has become (and now called archetypes) was the way to
known as e-health. From the outset Tom had go, and following my forecast of the demise
You may be wondering now how this has the vision for the digitally connected health of MUMPS, we embarked on implementation
anything to do with pathology informatics. system. Indeed in the very early 1970s he had with a partner – the specification was okay
Where I had seen myself as an academic and printing computer terminals in surgeries for but the implementation a failure. For the
was set to go to UNSW in what was, and still pathology reports but these were removed record the successful non-winners, Alex
is, an exciting area of research, Functional because they were seen as inducements. Anderson’s Détente10 and Sonic’s Apollo
MRI, the project collapsed when at the last Times were interesting in Sydney and system, still use MUMPS (Cache) today very
minute the Australian research leader, who pathology then. It was the ‘underbelly period’, successfully.
was returning to Sydney after working with during which a principal of a Sydney pathology At Macquarie we also tested the value of
the Nobel Prize winning Nottingham Group, practice was shot outside his Concord computerisation to a pathology laboratory
got an order-of-magnitude better offer from laboratory over a ‘business related matter’ with a somewhat unnatural experiment.
20 The Health Advocate June 2011

21. I arrived one day to find the place on fire – an was a CIO before George. In a twist of fate siders saw a working computer for the first
arsonist had broken into the secure data I came back some years later leading the time. A patient would sit in a perspex pod to
centre, opened the data safe and set it and the ‘occupation team’ after Mayne bought answer a computerised questionnaire in full
computer centre alight. The laboratory, which Macquarie laboratory. view of the computer with spinning tapes and
was downstairs, was saved and continued to flashing lights behind glass. This was highly
function but it took a week of 24-hour days to Medicheck controversial and on a number of occasions
rebuild a computer room and to get the system made front-page news. There was real concern
running again. There was a disaster recovery After Macquarie I moved to be CEO at another from the less well-informed profession that
plan and no loss of patient data but we went highly innovative organisation, Medicheck. In computers were being pitched to replace
manual and it was absolute mayhem. 1970 after having sold his transformer business doctors. Of the many eminent people
No pathology practice would think to GE, Sir William Tyree13 established a trust. associated with this organisation, Branko
of starting (even 25 years ago) without With Sir Eric Willis14 and Sir George Halliday15 Celler17, who was Director of Research, and
electronic health records and no laboratory the funds were used to build a preventative Bruce Barraclough18, who was a leading breast
can operate now for more than a few minutes health facility which had the dual aims of surgeon at the associated Sydney Square
without its information systems. On the systematising medicine and moving the Diagnostic Breast Clinic, have important roles
subject of records, another well-known emphasis toward prevention. Medicheck16 in health informatics now.
health informatician George Margelis11 broke new ground in many areas. It introduced I arrived at Medicheck in the mid-1980s
later joined Tom at Macquarie as CIO and mammography to Australia, created the first and led the third generation replacement
together they worked on an early version
of the Personal Health Record. Klaus Veil12
mental health atlas of Sydney and, relevant
here, it was the place that many Sydney-
of the information systems in this
organisation that had always had
>
The Health Advocate June 2011 21

22. In depth
>
fully electronic records (replacing one from of Medical Services with the Red Cross
BUPA). Having learned from my previous 5
Intel’s second-generation 8 bit
experience and with a talented computer microprocessor
scientist19 we used prototyping directly 6
Emergency doctor; developer of a
with the doctors, nurses and scientists who laboratory information system; Past
were working in the organisation to build President of the Medical Software
an information system from the ground up Industry Association and current
including a laboratory information system Chairman of IHE;
(LIS). From the technology point of view and standards developer
this was a time when relational databases 7
Electrical Engineer; GP; one of the
were just becoming commercialised. We OpenEHR founders and standards
purchased Oracle before they had established developer
an office in Sydney, ran it on one of the first 8
Respiratory physician and ResMed the Board without a knighthood for some time
MicroVAX’s and had networked PCs attached. co-founder 16
Medicheck and its sister organisation in
Medicheck became a technology showcase 9
Entrepreneur, GP, private hospital operator, Melbourne, the Shepherd Foundation, were
with weekly visits from people mostly outside PHR developer and now with an interest closed down when medical benefits were
health. Because of my role at Medicheck in Pen Computing - he was also a one-time withdrawn by DoHA because the value
I became a director of the International large-scale computer bureau operator for couldn’t be demonstrated to their satisfaction
Health Evaluation Association with Morris local government and provided microfilming – the protocols and testing have since been
Collen after whom the highest honour of the and microficheing for the NSW police among well-proven but no organisation exists where
American College of Medical Informatics is others it can all be done in a single visit including
named. That also meant I got the privilege 10
Now Integrated Software Solutions counselling in 90 minutes
of visiting with him at Kaiser and using those 11
Optometrist; medical practitioner; 17
Electrical engineer, computer scientist,
learnings in the Medicheck system. informatician and now lead of the Intel GE founder of Telmedcare and now Executive
In the next issue I will complete this personal Healthcare Alliance in Australia Dean of the College of Health and Science at
history of informatics in pathology and how 12
Informatician; standards developer; past the University of Western Sydney
these developments influenced the broader Chairman of HL7 Australia and Board member 18
AO, past President The International Society
application of ICT in healthcare. of HL7; current President of the Australian for Quality in Health Care, past Chair of the
College of Health Informatics Clinical Excellence Commission and current
References 13
Electrical Engineer; Entrepreneur Chair of the CSIRO Australian E-Health
14
Former Premier of NSW Research Centre
1
http://www.pulseitmagazine. 15
ENT surgeon and former President of the 19
Mark Abel - still an Oracle contractor
com.au/index.php?option=com_ BMA in Australia. I was the only member of
content&view=article&id=511: why-is-it-all-
so-hard-in-pathology
2
Mathematics is a branch of informatics.
Taylor would play chess with the head of the Take home messages
electronics workshop by making moves as Here are some morals to the story so far: science development;
they passed in the corridor – without a board! • There are more than 40 years of history • Australia has been keeping pace
3
The Basser Department of Computer Science in health informatics in Australia; intellectually and has led at times but
(so named because Harry Messel was able to • Health is not a laggard as some argue does not always realise its potential
procure part-funding for the computers from when it comes to the application of when it comes to recognising the value of
the Melbourne cup winnings of jeweller Adolf information technology; what it has and commercialising that;
Basser) was located in the basement of the • Some pretty smart and dynamic people • One of the reasons there hasn’t been
Physics building have and continue to contribute to the more progress is because it is hard; and
4
A fellow called Bill Gates had done a similar development of e-health; • It would be inefficient not to learn from
thing, but for the IBM microcomputer. Grant • There is more to health informatics (and the history so we must provide specific
went on to do biomedical engineering. He e-health) than shared records; education in what is a knowledge
developed CRS, was IT Director for Western • Pathology has been at the vanguard of domain in its own right – health
Sydney, headed GE’s Medical IT group and was health informatics and computer informatics.
a VP at ResMed, and is now Qld State Manager
22 The Health Advocate June 2011

24. Operating e ciencies up
Carbon footprint down
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25. In depth
DAVID MORE
Clinician and Health
Informatician
Where’s the
evidence?
David More asks is the Personally Controlled Electronic
Health Record an evidence based intervention?
a
S A CONSEQUENCE of a series of
recommendations in the National
Health and Hospitals Reform
Commission's A healthier future for all
Australians – Final Report June 2009, the
basic individual demographic details and
the information that is normally held, either
electronically or on paper, in the General
Practitioners Summary Record. This would
include allergies, regular medications, key
Commonwealth Government, that will be
accessible via a web portal for the clinician,
with permission, to review. At a later date,
the patient will also be able to contribute
their personal information and comments
subsequent Commonwealth Budget allocated elements of history and current diagnoses. should they choose. The system is apparently
almost half a billion dollars over two years to The Event Summaries are envisaged to be intended to be a lifelong record that will be
make a Personally Controlled Electronic Health such things as a set of pathology results, accumulated over time.
Record (PCEHR) available to all citizens who referral letters and so on. At present the system is intended to be
wanted one by July 2012. The idea is that the patient will be in control available to patients who choose to have a
As the PCEHR has evolved – largely away of this information and will, if they agree and PCEHR and register for access by July 2012, now
from the public gaze and in secret – it has consent, make the information held in this just 14 months away. The system is presently
morphed into a conceptual Health Summary record available to clinicians caring for them. planned to operate in an ‘opt-in’ fashion where
and a series of Event Summaries. The Health The patient PCEHR record is to be held an individual takes a positive decision
>
Summary contents are intended to be the by a PCEHR system, presumably run by the to register for and establish a PCEHR.
The Health Advocate June 2011 25

26. In depth
>
Concerns regarding is designed as the minimum necessary for the evidence for the value of provider
emergency care, not as an information rich Electronic Medical Records (EMRs),
the concept long-term longitudinal record. especially with embedded clinical decision
In mid-April the Department of Health and Second, the evidence from the UK suggests support, is very strong indeed.
Ageing released the draft PCEHR Concept that even when such summary information is Sixth, adoption of and the value of patient
of Operations for public review and this made available, actual use of the information access to their clinical records is best seen
information has been considered in the is quite low and the clinical impact, if any, is in situations where the PHR is a linked
following comments. hard to determine. extension of the provider EMR (as in Kaiser
On the basis of what is presently known, just Third, designing systems to be ‘opt-in’, while Permanente in the US) and where other
how based in evidence of real positive clinical politically easier, means adoption is slow – over functions are possible.
impact are the present proposals? years – and for this reason few will bother to Seventh, it is clear that the so-called ‘digital
I would suggest they are not and that the look up such systems. divide’ is alive and well with patient portals,
claimed rationale for this very substantial Fourth, the present plans for seeking where often those who need them most are
program is based on a combination of consent for both access and for information the least likely to be able to obtain access.
wishful thinking and ignorance. My reading provision into the PCEHR will have very Eighth, it was obvious from a recent
of the global literature leads me to the significant clinician workflow impacts, i.e. slow workshop conducted by NEHTA on the
following conclusions. clinicians down, which will ensure that without PCEHR that there was considerable concern
First, there is no working example anywhere major financial incentives to compensate for and disquiet from clinicians regarding just
in the world of a parallel longitudinal patient- the time costs, clinician usage will be minimal. how well the available funds were planned to
controlled electronic health record. There Fifth, while there has been much research be deployed given other perceived priorities
are successful examples in small countries on the topic, it has not been possible to in e-health, such as improved standards,
(Wales and Scotland) of emergency health consistently demonstrate positive clinical better clinical systems and improved
summaries derived from GP systems being outcomes through the use of Personal Health information flows between clinicians, are
implemented, but the information content Records (PHRs). On the other hand, very high on the list.
Key points of the PCEHR
Key points to be noted about the presently proposed
model of the PCEHR include:
• The PCEHR is an additional and clearly parallel health
record to that held by the health care provider. The
PCEHR is conceived of being a secondary record
in some senses – as far as clinician contributed
information is concerned – and a primary storage of
some consumer generated content.
• The PCEHR will contain a summary of the full patient
record, with a variety of other information (lab results,
discharge summaries and so on).
• There is no clarity just what arrangements are intended
to ensure the copy of the clinical information held in
the PCEHR is properly synchronised and consistent
with the current practitioner record.
• All the documentation made available to date has been
silent on just how the situation of a patient attending
multiple practitioners is handled.
• The PCEHR is not linked / attached to the practitioner
record in any direct way. This means that functionality
such as secure direct communication between clinician
and patient, appointment and repeat prescription
requests, and access to current information in the
provider system is not available.
26 The Health Advocate June 2011

27. e PCEHR lacks an evidence base in
circumstances where there are evidence
”
” As presently announced, the entire program
has unrealistic timelines, lacks clear objectives,
is excessively politically driven and will, when
based interventions it inevitably fails, set the prospect for rational
adoption of e-health back a good decade.
Ninth, there is no mention so far from based interventions that would make a more You can read David More’s blog on e-health at
anyone on just what advantages the significant and important difference to health www.aushealthit.blogspot.com.
PCEHR proposal has over the wide range care delivery in Australia.
of alternatives that have been successfully In response to a direct question at the
implemented elsewhere and just why Health-e-Nation Conference in early April, the Useful links
clinicians would find access to a record of this Department of Health and Ageing confirmed
sort of any great value compared with known that there was not an evidence base supporting Australian Government website
alternatives. Indeed the claimed benefits the planned approach but that Australia had Your Health. The draft PCEHR
have in no way been proven for the planned chosen to proceed down its own path. Concept of Operations document can
approach as pointed out above. The PCEHR has been termed by one wag the be found here – http://bit.ly/3mUayY
Finally, again from the recent workshop, it ‘Politically Correct’ EHR. I would suggest it is
is clear many stakeholders recognise that the a proposal that requires very active evidence Seminar outcomes on the PCEHR
scale and complexity of the PCEHR program based review that it is presently not receiving (30 March 2011) – http://bit.ly/
means successful delivery in the politically – due in part to the very large sums of money gJ9UwN
determined time frames is very unlikely. being splashed around by the Department
It is thus my contention that the of Health and Ageing on the project – which David’s submission to the NHHRC
PCEHR proposal lacks an evidence base in seems to be resulting in some form of on the PCEHR – http://bit.ly/efu2HN
circumstances where there are evidence unthinking and uncritical e-health ‘goldrush’.
The Health Advocate June 2011 27

28. In depth
Computer says
NO
The healthcare community’s current relationship with computerisation
may be the biggest challenge in the future of e-health
28 The Health Advocate June 2011