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A report prepared for NOIE in September 1999 on trends and policy issues in the evolution of electronic service delivery in the health sector in Australia

The Commonwealth Government has closely monitored, reported on and sought to influence the direction of the information economy in Australia, through a series of studies in recent years. This chapter provides a brief summary of key points raised in a number of the studies, where they relate to the health sector.

Background reports

Two national Government reports on the information economy were issued in 1997:

• A national policy framework for structural adjustment within the new Commonwealth of Information. A report to the Minister of Communications and the Arts from the Information Policy Advisory Council, July 1997.
• The Global Information Economy. The Way Ahead. The Information Industries Taskforce (the 'Goldsworthy Report'), July 1997.

The report, A national policy framework for structural adjustment within the new Commonwealth of Information, advocated that early priorities for industry and business attention include:

1. leadership and promotion, for instance through promoting business take-up and innovation, including the education of Australia's boardrooms to the opportunities and threats of the information economy; and promoting and supporting a much greater focus on entrepreneurialism and innovation within Australia's business community.
2. market regulation, for instance by playing a leadership role in establishing robust industry codes of practice, promoting quality standards for service delivery, and enforcing codes of practice; and establishing productive and collaborative relationships with consumers and user organisations to develop an operating environment of trust and confidence.
3. industry development, for instance, through peak industry bodies surveying their constituencies with regard to the rate of adoption of information and communication technology platforms within firms and the rate of deployment of electronic services and transactions. (pp. 27-28)

The 'Goldsworthy Report' (1997) argued that Australia needed to graduate to being a leading user and producer of information and communication technologies. Australia needed to act as a nation, not as competing States, particularly in the global marketplace. The Goldsworthy Report also emphasised the need to obtain export revenue from businesses based on information technology.

These two reports on the importance of the information economy provided the broad background for more specific reports on telehealth.

The following case study is an example of using leading edge technologies to improve processes in the health sector.

Case Study: Secure Email System for Health

Medi-safe Communications is a 1999 Commonwealth Government funded pilot of a secure email system within the health sector on the Gold Coast. It will electronically link general practitioners to both hospitals and other health service providers and will demonstrate the efficiency of online communication to the traditionally paper-based health care sector. The project is funded by the National Office for the Information Economy's Information Technology Online Program (ITOL).

The members of the Medi-safe Communications Consortium include The Competitive Option (TCO); Software Agencies Australia Pty Ltd (SAA); Health Insurance Commission (HIC); and medical practitioners and medical service providers including: Queensland Medical Laboratories (QML), Gold Coast Medical Imaging, South Coast Radiology and general practitioners.

The health sector has the potential to benefit significantly from the adoption of secure online communications. Requirements of the Health Insurance Commission (HIC) to maintain paper records of medical service requests, largely unfounded fears of data transmission security, and industry and cultural inertia have hampered the sector's adoption of online technologies. Consequently communication within the health sector remains predominantly paper based.

General Practitioners (GPs) are the coal face workers within the health sector, and are reliant on numerous medical service providers to complete patient diagnosis and treatment. Those service providers include hospitals; medical specialists such as surgeons, anaesthetists and psychiatrists, often housed within hospital infrastructure; and health professional service providers such as pathologists, radiographers, pharmacists, physiotherapists and psychologists.

Communication between these entities is very manual. Doctors request services on hand written forms and diagnoses are returned via typed reports that are faxed or mailed to the GP. By moving to an electronic messaging system, the service provider will be assured of receiving the service request, the patient service can be scheduled immediately, and the GP can view the diagnostic report more quickly than under the current system. All relevant documentation can be filed either electronically or copied into subsequent reports.

Discussions with members of the Gold Coast's health community reveal that the highest frequency of communications is between GPs and pathologists, radiologists and hospital administrators. Hence these communication processes were targeted for trial in this pilot.

Medi-safe Communications will utilise generic email systems, familiar to users, and cost-effective, publicly available communications infrastructure. Privacy will be provided by encryption and authentication, via the use of third-party key management. The project will electronically link GPs with health service providers including hospitals and pathology, radiography, pharmacy and other medical service groups.

Each of the medical practices and service providers participating in the pilot will be equipped with a smartcard reader to be attached to the PC used for email, and each authorised user within the organisation will be issued a smartcard. These tools will enable the participants to safely communicate with other members of the service network. That is, only authenticated users will be able to read or send mail via the secure system.

Medi-safe Communications will be one of the first installations of a trusted third party certification, PKI-based, secure email system operating via the Internet in Australia. It will allow GPs and their related service providers to reduce administration costs and improve service quality to their patients. Administration savings will be immediately evident in reductions in transport, record search and clerical duplication costs. Furthermore service provider patient scheduling will be improved, promoting a more efficient throughput of patients.

Forty per cent of Australian general practices utilise computer technology to aid practice management. Only fourteen  per cent use computers in the clinical side of their practice, and Gold Coast estimates indicate that only eleven  per cent have any form of email facilities. The Medi-safe project will demonstrate to the relatively computer illiterate health care community the safety and efficiency of contemporary online technologies. If this can be achieved within the highly confidential world of healthcare, the task of encouraging economy-wide adoption of such technologies will be boosted.

Telehealth reports

Recent Commonwealth reports that specifically address health in this new age of technological convergence, are:

• Health Online. A Report on Health Information Management and Telemedicine, October 1997
• Fragmentation to Integration: the Telemedicine Industry in Australia, July 1998
• Report of the National Health I.T. Standards Workshop, August 1998
• the Australian Health Ministers Advisory Committee's sub-committee, the National Telehealth Committee (re-named the Australasian Telehealth Committee) issued a number of papers in 1998-99 on aspects of telehealth.

Following the publication of Health Online (1997), a paper was released in 1998 by the Minister for Health, called 'Information Management and Information Technology Imperative in the Australian Health Sector.' The paper sought to address crucial issues such as the lack of leadership in the field of information management and information technology (IM & IT); the need for national coordination to avoid the railway gauge States-rights problem; problems of privacy; and the necessity to evaluate innovations, to establish benchmarks and to promote best practice. It also suggests some structured, national mechanisms for advising Government.

Fragmentation to Integration: the Telemedicine Industry in Australia, (Mitchell, 1998), was the focus of workshops in five capital cities in November 1998-May 1999, to examine the findings of the report. The report is referred to throughout this paper and the findings from the workshops are discussed in a later chapter.

Following is a case study of the innovative bundling of health services using a range of technologies.

Case Study: Doctors take to Sea Containers in the Bush

The DocTel telemedical clinic is housed in a specially constructed 20 foot sea container and is designed for use in remote mining towns or Aboriginal communities, or on ships or oil rigs. The DocTel unit uses cutting edge technology to facilitate links between isolated communities and highly qualified medical personnel in Adelaide, South Australia. The units are transportable and can be easily set up in remote areas.

Videoconferencing is possible from the DocTel unit, using ISDN or satellite or standard telephone lines. It is in effect a GP/specialist surgery for remote areas. The unit is often staffed by a nurse who is linked to a medical professional in Adelaide and it is claimed that the equipment can be used for 85-90 per cent of the primary care work currently seen in metropolitan GP clinics. The DocTel unit can be modified to suit telerenal, teleradiology or telepathology applications.

Flexible finance arrangements are available, to suit the purchaser, ranging from subscriptions to leases to purchase. For those wanting a complete service, covering equipment, transmission costs and medical services, a package is available.

Besides the use of videoconferencing, DocTel doctors can be consulted via email, fax or telephone. Set charges for each type of consultation are set out on the web page at http://www.doctel.com.au. The following recent example of DocTel's use of the Internet was provided by Dr Gary Shanks, Managing Director of DocTel: "A patient from the USA wanted advice on managing her migraines. She had been through all the high tech tests and tried all the new drugs and still had no relief. Having all the history from her I suggested an old fashioned treatment, Inderal, which seems to have worked. So the Internet for accessing additional personalised health advice works."

National bodies

Several national bodies that focus on health informatics and health information have existed for some time. The Health Informatics Association Australia (HISA) focuses on healthcare informatics, providing benefits to healthcare practitioners and others. The Health Information Management Association of Australia (HIMAA) is the peak national professional association representing health information managers.

Two new national bodies in the field of health information technology have been formed in recent times: the Collaborative Health Informatics Centre and The Centre for Online Health. Both have as one of their aims the development of telehealth or telemedicine.

With its focus on defining, stimulating and expanding industry, the Department of Industry, Science and Tourism granted funding each year for three years to the Queensland initiative, the Collaborative Health Informatics Centre (CHIC). CHIC Ltd is a national, not-for-profit company whose focus is to facilitate improvements in business processes and patient care in the health sector through the application of appropriate information technologies. CHIC is not about competing with existing organisations or activities, but about helping industry participants to achieve greater leverage and share in the opportunities in health informatics. CHIC acts as a clearing house for the collection and dissemination of information about the Australian Health Informatics Industry.

The Centre for Online Health is a research, teaching, education and service provider within the University of Queensland's Faculty of Health Sciences. The Centre's mission is to pursue improvements in health care through the application of information technology. The Centre has four areas of activity: a focus on research in the area of online health; teaching about online health; commercialisation of research outcomes; and delivery of services in online health. The research program within The Centre for Online Health is divided into five research streams: homecare; preventive health education, electronic medical records, smart hospitals and telemedicine. The streams are divided up according to end user types, however much of the underlying IT technology and research is common to each stream. For example, the telemedicine research stream has implications for the homecare stream because a homecare system will potentially have a teleconferencing system as part of the overall homecare package.

A strategic framework for the information economy

The Commonwealth's report 'A Strategic Framework for the Information Economy: Identifying Priorities for Action' (Department of Communications, Information Technology and the Arts, December 1998) included a section on 'Unlock the Potential of the Health Sector' where it set out the following context for using technologies:

Australia's health system is among the best in the world. The information economy allows us to package our strengths in this service area and offer tangible benefits to Australians. Online technologies can assist the sector to expand its reach, deepen its quality and usefulness, and improve the efficiency of delivery. The health sector is well placed to take advantage of export opportunities such as the delivery of online health education and telemedicine consultations. (p. 24)

The report argued that the clever use of integrated information technologies could provide extensive benefits to all Australian consumers:

The provision of appropriate health services is a vital element of Australia's social fabric. Information technology can help to connect and consolidate the communications and information sources of many players in the health field, and to generate efficiencies in information management. In the long term, Australian consumers and providers of health care will benefit from better access to information, clinical advice, specialist referrals, diagnostic tests, results and other telehealth services. More informed policy and planning, better integrated and coordinated services and more timely information for decision makers will create better health outcomes. (pp. 24-25)

In the report the Commonwealth Government expressed its commitment to the following two objectives:

1. The use of information and communications technology to achieve better health for all Australians, and to enable Australia to benefit from the export of health services.
2. The development of a comprehensive health sector strategy, encompassing policies to ensure the necessary infrastructure, skills and legal and regulatory frameworks to achieve enhanced outcomes. (p. 25)

The report acknowledged that there is a substantial body of work in progress across Australia that is aimed at the better management of health information and use of information technologies.

This includes projects aimed at better coordinating care, Evidence Based Medicine (EBM), more streamlined messaging and billing practices and the use of online technology for the remote delivery of services. Many hospitals have plans to develop fully integrated information systems and are already using videoconferencing and related technology to provide a range of services for patients, professionals and communities who are distant from the hospital. (p. 25)

The report concludes that 'getting health online' will depend on leadership and coordination between the Commonwealth, States and Territories. The report highlights the need for effective planning, the development of standards, attention to privacy and the sharing of information, winning consumers' confidence and the need for appropriate training in information technology for the health care workforce.

The following case study is an example of an Australian company working with the public and private sectors to get health online.

Case Study: HCN puts Knowledge Bases Online

Health Communication Network (HCN) http://www.hcn.net.au continues to build its range of knowledge bases. Recently added were the Antibiotic Guidelines (and the other guidelines books will be added soon); Harrison's Online; St Vincent's Formulary; Altmedex (an alternative medicines database); and an ECG training programme.

HCN now hosts an online library for health professionals that, it claims, does not have a peer anywhere in the world. According to HCN, the requirements of the recent NSW Health Knowledge Base Tender could not have been met by any other group in the world. HCN has been selected as the successful tenderer for that tender which will see NSW Health extend their world-leading Clinical Information Access Project (CIAP) for another three years.

HCN now has over 300 hospitals in Australia using its online library. Most excitement has come from rural areas where clinicians are suddenly able to access world-best practice reference material in the ward or at home using the Internet. Feedback has been enormously positive. This is telehealth at work on a grand scale. It is estimated that in NSW Health alone, 25 000 clinicians (many of them nurses) have used the CIAP/HCN resource online.

HCN continues to work with Australian doctors helping them introduce computers and clinical and practice management software to their practices. Several hundreds have been helped and trained. It is also working with several organisations to send clinical information such as patient records and diagnostic information securely over the Internet.

HCN is a partner in the Integrated Care Program providing modified software and web best practice information (locally modified) for GPs in three Divisions: Central Bayside, Hunter Urban and Hornsby Kuringai, treating three groups of patients in three disease areas. Again, this is about providing best practice information at the point of care, using technology. HCN provides support and training for the GPs involved. This project is taking HCN into the clinical software area, as it sees clinical software interfaces to HCN's library as being a logical way for busy GPs to quickly and easily have access to best practice material during consultation, if it is required.

Australia's e-commerce report card

To progress the objectives set out in A Strategic Framework for the Information Economy - Identifying Priorities for Action, the Commonwealth released the report Australia's e-commerce Report Card (Department of Communications, Information Technology and the Arts, April 1999). The Report Card initiates a range of e-commerce priorities and activities are outlined below.

1. Establishing the environment conducive to the widespread adoption of e-commerce. The Commonwealth has a range of initiatives that ensure a balanced and predictable legal and regulatory environment for e-commerce. Australia also participates on a number of fora to ensure our interests are represented in international developments around e-commerce.
2. Demonstrating the business case. A number of initiatives are designed to demonstrate the business case of using e-commerce. These initiatives are the next step beyond the initial awareness raising activities conducted last year to educate business and consumers of the benefits of doing business electronically. The Commonwealth is partnering with industry and other governments in the Online Australia Year program and a range of collaborative projects designed to provide business solutions.
3. Targeting barriers to the development of e-commerce. There are certain barriers that are being addressed to stimulate the growth of business-to-business e-commerce. For example, a national inquiry is under way into bandwidth capacity and the impact of incompatible information technology systems on business efficiencies.
4. Maximising the efficiency dividend from e-commerce for the economy at large. The Commonwealth is partnering with industry to ensure widespread returns from e-commerce uptake are maximised throughout the economy. This includes work in exemplar supply chain management models and key enabling business-to-business e-commerce projects. In addition, the Commonwealth is developing business friendly e-commerce systems to improve the efficiency and quality of service to the community and industry. (p. 2)

A number of case studies are highlighted throughout the Report Card to demonstrate real business examples of adopting e-commerce. These show businesses using e-commerce as a key tool to improve efficiencies and increase revenue as they adopt e-commerce strategies as part of a broader business plan.

The following case study is an example of e-commerce in the health sector.

Case Study: PECC introduces e-commerce into Australian health care industry

The PECC project is introducing electronic commerce into the health care industry's supply chain. Initially the project worked with six pharmaceutical wholesalers who supply to hospitals and the 700 manufacturers that they purchase from. This Pharmaceuticals Extranet Gateway is a world's first and is establishing a gateway and common e-forms for the exchange of $5 billion of orders between suppliers, distributors, manufacturers and hospitals.

The project has also analysed several supply chains within hospitals in Australia, identifying potential areas and orders of efficiency that can be achieved through the application of methodologies relating to E-commerce. It was estimated that Australia could save at least $340 million annually if supply chain reforms were implemented in the health sector. The project is now focussing on developing an electronic catalogue for standardising the order of all health care products. This catalogue will be part of the European Article Number (EAN) Australia's catalogue, initially developed for the grocery industry in Australia.

PECC has been instrumental in raising awareness in the health care industry of the degree of wastage and potential for savings through the implementation of more efficient purchasing, distribution and administration methods. The project has also been ground-breaking in its development of Internet based trading platforms and the use of innovative supply chain techniques (including fundamentals such as the use of European Article Numbering to track and trace product).

This project began as a joint venture between the CSIRO and the Department of Industry, Science and Tourism, and has now grown to become a mature industry led project, with over $1.5 million of industry and government monies committed to date. Initiatives planned for this year include several awareness raising projects including one for Chief Executive Officers, one targeted at private hospitals and insurers, and one targeted at nurses. Ongoing work is occurring to align and expose public and private hospitals to the Extranet Gateway and the EAN catalogue for health care products. A comprehensive review of the PECC Project highlighting the value of strategic alliances between industry players and between industry players and government will be published by NOIE and the Macquarie Graduate School of Management in the final quarter of 1999.

The Project is governed by an Executive Council and a wider industry and government council. The Secretariat for this is provided by the National Office for the Information Economy (NOIE). The Project is internationally aligned to complementary work underway in the United States and Europe, and the European Article Numbering Association (EAN) sits on the Council. The industry leader and Project Manager is Pat Gallagher who can be reached by telephone on (02) 9396 1259, and the project's website featuring comprehensive benchmarking studies and other policy findings is at http://apsem.anu.edu.au/auspecc/

At the ACT E-health Workshop in May 1999, NOIE's Tom Dale, General Manager, Electronic Commerce, reported that the Government is putting in place a Framework for the Information Economy that will make electronic transactions a reality. Key planks of this framework are pieces of legislation such as the Electronic Transactions Legislation, the National Privacy Legislation and the revised Copyright Legislation. NOIE and others in Government are consulting all sectors of the economy to ensure that their needs are monitored and acknowledged in the development of legal and regulatory frameworks.

NOIE is also sponsoring a project on the Economic Impacts of E-Commerce to pilot the effects of e-commerce across the economy. This project will involve a rigorous economic analysis using a general equilibrium model of the Australian economy. The 'Monash' model is an internationally leading economic model, which is well suited to assessing dynamic flows through the economy from business changes such as e-commerce, and includes the use of new products and services and industry restructuring. This project will use input/output industry data from the Australian National Accounts to measure the flow-on effects of e-commerce uptake against a range of scenarios (short, medium and longer-term) for specific industry sectors including Health. The results of this project will be shared with industry sponsors and the general public in October 1999.

Summary

The sequence of reports issued by the Commonwealth demonstrates a consistent focus on identifying the triggers that will enable Australia to benefit from the information economy. Health is viewed as one of the key sectors that need to benefit from the information economy.

The case study following is an example of the arrival of e-health in Australia.

Case Study: Med-E-Serv's Internet Health

Med-E-Serv www.medeserv.com.au, formed in 1994, is a leading Australian Internet community for healthcare professionals. Med-E-Serv supports best practice in the healthcare sector by facilitating the use of innovative Internet technologies for the creation and delivery of continuing education, cost-effective promotion and the development of electronic business processes.

Med-E-Serv has a membership base of over 15 000 medical professionals in Australia and New Zealand, which represents around 40 per cent of medical professionals with access to the Internet. Currently, new members are joining at the rate of over 1 000 a month.

Med-E-Serv's mission is to work closely with its clients to improve the delivery of cost-effective, high quality healthcare throughout the appropriate use of telecommunications and information technology. Med-E-Serv's focus is on the support of health team collaborations for learning, working and delivering better health care and health outcomes to patients.

Over four years, Med-E-Serv has delivered more than 200 successful online projects in health. They include support of College membership services; distance professional development; clinical project teams (for guideline development or research); web-enabled data collection, analysis, evaluation and display; and virtual conferences. The common characteristics of these projects are the focus on groups of clinicians creating their own content and the groups collaborating online.

National Asthma Outcomes Project

airwaves.medeserv.com.au

In 1998 Med-E-Serv launched Australia's first online clinical quality improvement project, "National Asthma Outcomes Project." It is an innovative program whereby General Practitioners, via a secure website, submit clinical data on their asthmatic patients, view real time comparative reports and discuss the results.

The clinical audit tools (printable from the website), web-enabled database, comparative reports and online collaborative environment are all designed, developed and hosted by Med-E-Serv. The project is endorsed by the National Asthma Campaign, accredited by the Royal Australian College of General Practitioners and funded by GlaxoWellcome Australia.

Online collaboration - Discussing results and developing strategies - Clinical Audit

At the launch of this project Dr Christine Jenkins, Chairman of the National Asthma Campaign, said "This first major review of outcomes of asthma management should help improve patient quality of life and health outcomes. The clinical audit system is more than just a measurement tool - it provides an online forum for GPs to discuss with each other and with an online panel of experts the comparative data as well as strategies to improve patient outcomes."

After nine months, data collected by 70 GPs for over 400 patients from throughout Australia had been the subject of two online reviews by GPs and asthma experts who have collaborated to develop strategies for improving health outcomes in their asthmatic patients. Almost all GPs have reported a change in clinical practice during the project so far. Changes included incorporating the data collection tools into their standard history taking techniques, implementing more asthma management plans and changing prescribing protocols. Strategies for improving patient compliance have also been discussed.

Over time, the project will demonstrate the relationship between improving clinical practice and patient outcomes. Patient follow-up data is showing early indications that the changes in clinical practice may be flowing on to patient outcomes.

The future of this type of project is to involve patients in online data entry and collaboration with their GPs in active partnership in the management of their disease. Med-E-Serv projects such as online CME, case discussions and virtual conferences have demonstrated that clinicians will use Internet technology. They share information resources and collaborate provided the tools are very intuitive and require virtually no IT skills beyond the use of a browser.

Med-E-Serv's Research and Development has produced the tools to accomplish this goal. For example,

• Royal Australasian College of Surgeons - Virtual Conference
  virtualcongress.racs.edu.au/open/index.htm
  Over 600 surgeons attended the Virtual Congress designed and developed by Med-E-Serv. More significantly, almost 100 surgeons and other clinicians presented and discussed papers at the online Conference. Mini-papers were published using simple online forms to create multimedia presentations to which discussion forums were automatically attached. Surgeons needed no computer skills beyond web browsing to do this.
• University of Wollongong - Youth Suicide Prevention Resource Guide
  www.ysp.medeserv.com.au
  This online resource guide has been developed as a web-enabled database, which allows for both the authorised owners of the educational resource and an expert panel to directly update the site with current information. This project has been funded under the Commonwealth Youth Suicide Prevention Campaign.
• Australasian Faculty of Public Health Medicine - Rural Health Training Project
  http://afphm.racp.edu.au/
  A series of web-based collaborative training modules have been developed for rural health workers (Aboriginal health workers, community nurses, general practitioners and Royal Flying Doctor Service). Online collaborative workshops have been developed in the areas of immunisation, mental health, counseling, health promotion (smoking and diabetes) and substance abuse.

These case studies demonstrate that online technologies can form the basis of clinical collaborations that will improve communications between healthcare professionals and improve health outcomes. The exciting prospect for the future is the online collaboration that includes the patient as a member of the healthcare team.

RACS Virtual Conference 

Entering Patient Data - Clinical Audit

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• Last modified: 6 February 2008, 10:20am