We talk a big prevention game, but it’s mostly just talk. Can we do more to cut through these obstinate dynamics?
Prevention is the consistently stated nirvana of governments and our peak health organisations for a system soon to be overwhelmed by a burgeoning aged and chronic care crisis.
But outside a few, national screening programs and some, admittedly robust, anti-tobacco and vaping promotions and laws, it’s largely all still talk: position papers, visions around things like the potential of “sharing by default”, ad hoc programs to connect GPs in some regions, and, to a large extent, wishful thinking.
It’s almost got a bit of cargo cult aura to it: if we do enough different new things, as highly uncoordinated and unaligned as they all are, prevention will happen.
Step back and analyse our current and planned system settings and there is virtually no coordinated action being taken in the form of targeted long-term reform which would converge most points of the system to a primary focus on prevention.
Certainly, most talk of making general practice a connected hub of prevention in the community is so far just that, mostly talk, no matter how many state politicians, e-health heads and health secretaries protest otherwise.
There are, of course, a lot of new interventions going on – which is a much better situation than we had a few years ago – but there’s no actual nationally agreed and coordinated plan.
Prevention is usually split into two categories.
Primary prevention
This is managed mostly at the federal level through a series of risk determined screening programs such as bowel and breast cancer screening, a series of prevention promotion programs such as anti-tobacco and vaping, and, maybe some of the new Australian Centre for Disease Control programs (we’ll wait and see).
It’s perhaps not surprising that “primary” prevention programs don’t have that much to do with our “primary care” system. Just a little more confusion for everyone.
Secondary prevention
Secondary prevention, which you could easily confuse as being the role of hospitals, can be described simply as the management of patients with chronic disease, or at risk of it, in the community, who, unmanaged, will likely end up in hospital.
It’s secondary prevention which is the most dysfunctional, the one we incessantly say we are going to fix, and the one where the major point of meaningful impact would come if we could fix it.
The hub of secondary prevention is primary care, and the hub of that is general practice.
All this so far sounds pretty banal, doesn’t it? Been here, doing that. There’s a lot going on. Yeah, yeah, we still spend a lot on hospitals, but you try to get state governments to stop building them, and besides, we don’t have enough GPs. And so on.
There is a lot going on. But none of it is a coordinated strategic attack on true transition to a prevention system operating within so called planning for a “care economy”.
We don’t even have a national healthcare strategy. Worse, there isn’t any serious talk about developing one.
Without coordinating the Commonwealth and the states over a 10 to 20-year plan, where both synchronised their workflows, systems and funding arrangements and outcomes for prevention, and without some way of properly measuring progress if we could coordinate, how does anyone expect the system to change by itself?
Okay, that’s probably the worst of it.
As I mentioned there is a lot going on that is good: lots of digital health infrastructure being put in place, a lot of will on the part of all governments to do all they can to coordinate where they can – Sparked and standardised clinical coding is a best in class example, as is probably Healthdirect and 1800Medicare.
And, despite what many people keep saying, we have enough money – that’s a separate article – but organisation, coordination and vertical integration for productivity and AI have a lot to do with that argument.
If we were all sitting in a stylishly appointed meeting room, sucking on peppermints, looking at views of either Sydney Harbour or Docklands, facing a big white board, being facilitated by an expensive, but smart, consultant, the next step here might be to define what are our top three opportunities to move this stranded oil tanker.
And then, all using lots of different brightly coloured Post-it notes, we’d take turns going up to the whiteboard and sticking our ideas up to create a mess of colour.
Such processes can be very useful. Collective minds, well directed, can often surface what isn’t very obvious to us all working in our silos, thinking mostly about what we need to be doing.
But it’s just me for now, so I’m going to try to get us started.
I’m lying just a little. I had this conversation recently with a very good consultant (some are), and he had a couple of really good takes on the problem, which, in the tradition of any good consultant, I’m going to steal here.
This also gives me an out for anyone writing in saying these are actually dumb ideas – any of those are obviously from the consultant.
First, we need to assume there is and likely won’t be a 10-year national healthcare strategy within which we could all align and execute any of the good ideas in a coordinated manner. Not anytime soon anyway.
We’re going freestyle here: guerilla, if that image feels a little more appropriate to the situation.
Whatever we come up with needs to be doable within a few years and mostly within the constraints of what is going on now in terms of policy, technology, government programs and even funding – things that can nudge change from the bottom up.
Our starting shortlist of opportunities needs to be reality checked.
For instance, saying that “sharing by default”, which is a pretty large, complex and good set of programs, will connect everyone soon so the whole system can share data seamlessly, connecting providers to providers and providers to patients, and that is going to solve a lot, isn’t a very realistic dynamic to be making assumptions around, at least in the short- to mid-term.
It’s a great set of visions, goals and programs, but even with a 10-year plan it’s going to take a while to sort through, and who knows what will really come of it? Anyone who says they do know is selling something to you.
No, we want some immediately tangible stuff to work on here.
Healthdirect
One thought that comes immediately to mind as a first whiteboard heading is Healthdirect.
It fits as a major opportunity. The coloured Post-it notes might have a few of these thoughts on them:
- It’s a national body with its hooks into the Commonwealth and every state and territory, so it can coordinate efficiently between states and between the states and the Commonwealth;
- It’s already got a well established technical infrastructure that is capable of touching every patient and every provider in the country (maybe not hospitals that much yet, but we can get to that);
- It’s collecting valuable patient (population) data on a regional basis and the bigger it gets the better the data is getting;
- It’s pretty well run, is scoring goals, and it has a big focus on using AI to process its data and seek efficiencies.
Healthdirect is the most bleedingly obvious weapon we have to help governments to pivot faster to all things prevention. It’s a connector organisation, it’s a data group, it’s up and running, and it has points on the board.
That’s not to say it’s not going to need a lot of help though.
Our siloed and tribal healthcare system is suspicious of anything and anyone centralising the power of information. People will throw anchors out the back of this bus and try to slow it down or derail it.
Information and data are power, and if we do the efficient thing and centralise it in this manner, lots of people are going to scream blue murder in all sorts of ways, in part, because that power will be lost to them or their current role in the system.
Our governments need to run protection and kick heads a little more to make it all go faster, while keeping the organisation efficient, on point and edgy (won’t be easy) as it seems to be now.
A couple of other things before we leave Healthdirect:
- It’s likely a fallacy that Healthdirect will destroy local knowledge so you need to run data locally mostly. Run the right way and deploying AI the right way it should be able to collect local knowledge we’ve never seen before and help analyse it for the locals in more effective ways (eg, PHNs). Further it should be in a position to compare what regions are similar and share that knowledge to optimise one region via the knowledge gained from another;
- If we go back to the idea of primary prevention, with enough connection and knowledge, surely Healthdirect could form an important source of data for much better deployment and development of these programs, and, even, be directly involved more in the deployment given its expanding telehealth reach.
Our GP Data
Our next big whiteboard idea is from our consultant, and at first, I wasn’t convinced about it for a couple of reasons.
It’s about how we currently collect population data, analyse it, and use it to optimise prevention on a region-by-region basis.
My initial scepticism was that improving this dynamic was going to require the visionary data connectivity that is talked about in “sharing by default” – every provider connected with open API and FHIR-enabled platforms or connectors, with patients connected with apps, or a master Medicare app, that talks to every provider.
This might happen. But I wouldn’t bet the house on it just yet. The ghost of My Health Record is leaning over my shoulder tut-tutting when I think about the complexity of it all.
No, this idea is much more practical and simple and therefore probably doable in the short to mid-term. It involves just a little more coordination between existing organisations and just a little head kicking by government(s) of the odd vendor (and/or additional funding of said vendors).
It goes a bit like this.
The most important population data we currently try to access is deidentified patient data from GPs.
But we have a few problems with this data.
It’s extracted from GP patient management systems (mainly Best Practice and MedicalDirector), eclectically by every PHN in the country. Each PHN uses one of a variety of extractors, and the data between MedicalDirector and BP is almost impossible to compare because the coding systems on both programs are so old and so different.
There are a few problems here that could be fixed without too much trouble or money:
- PHNs aren’t data experts, either at extraction or storage, and maybe even analysis at this point (they should be good at the latter and that’s an opportunity);
- 31 different PHNs extracting two sets of non-matchable data using different extractors, each with different skillsets is wasteful and not focusing PHNs and their core function – analysis of their local population data, and commissioning for the needs that data reveals.
The possible fix
How about one extractor, managed by one organisation with the infrastructure, skills base and management capability to manage the extraction, storage and some centralised analysis nationally.
The obvious organisation feels like it is the Australian Institute of Health and Welfare (AIHW). It’s another national group – more efficiency again – led, like Healthdirect, by fairly smart and capable people.
Best Practice is allegedly 70% of the GP market and its quite a long way ahead in making its data more accessible via the connector app Halo Connect. We’re going to assume that MedicalDirector is getting its act together on this front as well, as it needs to, and, it now has Danielle Bancroft in there to help.
Related
Also, Sparked is developing a standardised coding regime, which both PMS systems are fast incorporating. And both are migrating their code sets to SNOWMED CT.
Could the government or the ADHA put together a program quickly that identified the most important patient data sets, aligned those sets between the two major PMS systems (others will have to follow) so that very soon we can extract standardised data sets no matter which PMS system a provider is using (we can also require it of GENTU which dominates specialists).
Anyone reading this might have already surmised that this is just a practical way of getting standards to the GP PMS systems so we can get sensible data out of them much faster.
The government’s been threatening mandated standards but seems to be having trouble getting to it. Don’t worry, just work directly in a practical program to get that data aligned between the PMS systems so it makes sense.
When you think about it, if BP does have 70% of the GP market, it’s just them you need to start with.
Now remove extraction from the 31 PHNs, go to market to tender for the two best extractors, and give the role entirely to the AIHW so all data comes to one centralised point in a nationally standardised way.
Of course, the AIHW should work closely (I hate the word but co-design comes to mind) with the PHNs, but not waste a lot of time doing it.
Maybe the AIHW could also start coordinating with Healthdirect to align that data into the centralised, deidentified, GP-sourced patient data to make the central set even more detailed and useful for when it gets sent back to PHNs.
The AIHW then works closely with every PHN to provide them with their local data. It’s probably a good idea to centrally train all the PHNs with a national program run out of the AIHW so they are all much more effective at analysing their data, and, they don’t all analyse it in different ways.
Currently they hire different people with different skills and different ideas, something that’s pretty inefficient.
It would be very important to keep the PHNs at the centre of this program, so that the AIHW and the PHNs work hand in hand.
This is because the PHNs live and work in the regions, so they are the local eyes on the ground who can pick up subtleties that the data and AI might not. They need to be the key points at which the data is analysed and then used to recommend commissioning programs to the Department of Health, Disability and Ageing.
As we all know, at the moment it’s the other way around.
How can a department in Canberra know how to optimise for prevention and other programs effectively? It needs to build standardised skillsets and core competencies in the PHNs and get them to do what even the Department has always maintained they should be doing.
Then the Department needs to use all this data going back and forth, to actually measure them for how effective they are at commissioning and managing them properly for outcomes on prevention, not for ticking boxes on doing stuff.
For all that infrastructure that’s been developed already for extraction and analysis, either by commercial outfits like PENCAT, or PHN-funded ones like POLAR and the data lake in WA run by WAPHA, none of it needs to go to waste (well, some of it will and should be wasted).
The best infrastructure that has been built by all these groups should be used by the AIWH where it makes sense, probably via a tender process.
The AIHW might also want to consider having two suppliers for everything they do, for innovation and competitive tension purposes. This is something the Department decided to drop in the electronic prescription market and it’s becoming obvious that only one commercial supplier to critical government infrastructure isn’t such a great idea.
Last point: GPs always think they want to be paid for their deidentified patient data. It’s sort of the patient’s data really, not the GPs, but let’s go with the feeling because feelings are important.
PHNs say they pay them by sending them back good data to manage their practices better, which largely GPs don’t buy as much of an argument for value.
This is a curly problem for the Department, which hasn’t been handled well to date – funding for ePIP for practices to submit patient summaries to the My Health Record has largely been useless because the data the practices submit is pretty hopeless.
There’s an argument here that it should simply be a compliance requirement of GP practices – that is, if the PMS is working and it’s all automatic, the data simply flows and a level of good data is automatically reached each year.
Maybe the government could pay for that, as a sign of respect, not that GPs are well enough paid, so more never hurts, but more is better than what we do with ePIP now.
One last idea, and quite different to the two above, which look almost most of the way there so just requiring a bit more organisation by government and just a little head kicking.
This idea is much harder and I’m proposing we move it out of the long term wait-for-everything-to-magically-connect-via-sharing-by-default box, to more like a short-term hackathon program, to promote quick progress.
That is, we get a group like the Australian Digital Health Agency to run a very agile program to hack a better short-term solution to what is surely the most obvious and biggest issue preventing prevention from actually being doable in any meaningful manner in this country: connect hospitals to all their local GP networks, in a manner that means hospitals essentially start “vertically integrating” with their local GP community.
What we have now is turning out to be a little bizarre.
The smarter public hospitals, and many not-for-profit hospital providers, are doing their utmost in an unfriendly funding regime to keep people out of hospitals who don’t really need to go there, but also, to then follow their patients back out into the community and manage them there so the need to come back is significantly reduced.
Embarrassingly for us all, in the latter part of this process, GPs are very rarely in the loop.
Not that hospitals wouldn’t want them in the loop, just that technically, and possibly funding-wise, it’s just too hard for a hospital to work with their local GP community with their outpatient cohort.
One giant issue is their systems just don’t integrate and connect well enough to do it.
This problem has to be the most shameful situation we’ve allowed to fester in our whole system.
It’s mostly been bad planning and management by the states and hospitals, who seem to think it’s much more important that their hospitals talk to each other seamlessly than to their surrounding communities. Hence expensive programs like NSW’s single digital patient record, which does virtually nothing to help hospitals to manage their patients outside the state hospital ecosystem.
You can imagine that under this whiteboard heading you’re going to get a lot of very interesting and colourful (pun intended) Post-it notes.
I’m running out of space so I’m going to mention just a few of the more obvious ones I think we might see and leave you to it:
- There’s a series of new web-based technologies that are cheaply and quickly capable of bridging the hospital to community communication gap. Consultmed is one. Some of the PMS systems, such as MediRecords, which is a cloud-first PMS, could always do it. The major GP PMS systems are either able to it, or could without much trouble. And all the PMS systems can integrate the web-based communication technologies such as Consultmed to do it as well – it’s integrated into BP already.
- The problem is at the hospital end mostly. In NSW and Queensland, these new technologies are being trialled or introduced ad hoc. In Victoria, which has a much more decentralised power to the hospitals for procurement, the term ad hoc doesn’t even come close to describing how hopelessly inefficient the process of rolling out such available technology is.
- Why can’t the states and the Commonwealth, maybe via the Australian Digital Health Agency, come together and make it a national program, for all hospitals that are EMR-enabled enough to introduce direct FHIR and web-based connectively to a local GP community, either directly via the PMS systems, or using a new technology integration such as Consultmed? Maybe we could tweak both hospital and GP funding to drive it.
- Go to the few hospital networks that are already at the leading edge of trialling and building out this technology and bring them into the middle, maybe.
- But roll out what they are doing, much more cohesively, and much faster, and see where it goes.
There’s a lot more, I’m guessing, where these few ideas have come from.
And as such Health Services Daily and Wild Health are proposing we actually have that consultant session, albeit in boring old Canberra.
If you’re interested in the ideas in this article, love them or hate them, but want to make a serious contribution to pivoting our system to prevention in a meaningful manner in the near term, then you might could attend HSD’s and Wild Health’s next Canberra Leadership workshop and summit, on 16 and 17 June next year.
Both the workshop and the summit are focusing almost entirely on the idea of practically pivoting to prevention in the short to mid-term.
You can see the program, some of our initial speakers and our workshop topics HERE. If you like what you see buy a ticket before Christmas to get the super early bird price, which is a 40% discount.
If you have any content ideas for the event you can contact michelle@wildhealth.net.au and if you’re a sponsor interested in getting involved in some way, you can talk to greta@healthservicesdaily.com.au.