eHealth: where digital meets surgical

It’s 2025 and you’re on the light hover-rail to work. The trim of your Samsung Glass glows green indicating an incoming message. Into your visual field, your doctor pops up to tell you that the remote sensing of your general health signs - blood pressure, aerobic capacity, weight, and cell count all suggest the optimum period for reconstructive work on your busted leg has arrived.

More to the point, it's a good thing you skipped breakfast you’re doctor tells you (that’s something else the sensors noted) as a spot has opened up in surgery this morning. She wants you to divert to the Royal North Shore immediately where a 3D printer is already producing  the spare parts for your knee replacement.

“And lay off the cheese burgers, your body fat count is up three points since we last spoke.”

That’s the future of ehealth. The mobile internet, automated knowledge work, big data and The Internet of Things all aligning to provide the best possible healthcare outcomes - and with less staff and cost than anyone could have imagined a decade ago.

Healthcare is set to be one of the biggest winners from the emergence of new and disruptive technologies over the next decade, however even advanced economies like Australia's remain  ill equipped to seize the advantage.

The basic infrastructure of a genuinely national digital health platform is still being put in place. That will require significant investments but the immediate outlook for health IT investment in Australia is subdued.

Gartner for instance has IT spending by healthcare providers in Australia growing from $2.073 billion last year to $2.25 billion by 2015. That is roughly a three per cent CAGR and barely a clip above national GDP or inflation.

IT spending – healthcare providers – Australia 2012 – 2015

In other words in real terms health IT spending it is hardly growing at all. But those figures mask a more interesting story.

Now compare those investment levels with the potential identified by researchers in the sector.

The mobile Internet, the Internet of things, personal genomics and even 3D printing are all identified in McKinsey and Company's recent study in disruptive technologies as offering huge advances  in patient care.  Just as importantly they offer a big opportunity to rein in the burgeoning costs of service delivery through greater efficiencies.

Just take one example – The Internet of Things.  In this section of its report  McKinsey and Company rates healthcare as the biggest winner and says the greatest benefits  accrue  from improved efficiencies in the treatment of chronic illness.

According to the study treatment  costs for chronic diseases represent 60 per cent of total healthcare spending worldwide (Gartner says 70 percent) and these could be cut by up to 20 per cent through remote patient monitoring,  although the report's authors caution, "Realized value might be reduced by factors such as adoption rates and patient acceptance."

And therein lies the rub. In Australia the health community has only recently started to move the dial on issues such as electronic medical records, a bare minimum refrom.

Depending on who you talk to and which side of the debate they occupy the 500,000 consumers now on the PCEHR (personally controlled electronic health records)  systems either indicates a growing acceptance of the digitization of health records, or is indicative of the tardy uptake of what should be core infrastructure for ehealth.

But while the headline numbers look subdued, drill beneath the figures and you start to get a strong sense of the opportunity available for smart resellers who can build expertise in the sector.

That’s because while spending is only bumping along in real terms, demands on the healthcare system brought about by demographics such as an aging population means service providers need IT more than ever to feed into productivity and enable new ways of working.

Global health IT specialist at Gartner Anurag Gupta, observes "Rising healthcare costs pressure healthcare providers to leverage technology for innovation, efficiency, national e-health initiatives and operational cost reduction measures, thus driving IT spending through 2017.”

He writes that the rising cost for providing both public and private healthcare, married with the push by government’s around the world for e-health initiatives are “driving healthcare providers to leverage technologies in remote diagnostics and remote patient monitoring, clinical care delivery, digitizing medical records and patient information, connected communications infrastructure for hospitals and staff as well as back-office support and administrative functions.

Gupta says that with  such a large percentage of  healthcare spending committed to chronic illness, health care providers are already re-examining IT's ability to reduce cost and deliver active prevention and targeted care programs.

“IT is transforming from being an operational cost center to being a critical strategic differentiator for healthcare delivery organizations.”

X-HEAD] Opportunity for IT providers.

Gupta outlined three important impacts of technology in the healthcare sector around the world.

•           The healthcare delivery organizations need to reduce costs and achieve efficiencies will drive demand for virtualization from non-vertical-specific software and service providers

•           Growth of cloud computing in the healthcare industry will favorably alter the market dynamics for traditional hardware and professional services companies

•           The Healthcare industry’s transition from paper based electronic health records  will create opportunities for software providers.

In order to fulfill this opportunity, Gartner recommends IT providers create very clear cost benefit cases around virtualization for Hospital CIOs, and that they emphasis costs benefits, opex versus capex and the flexibility and scalability of using cloud.

"Finally," says Gupta, "Generic software providers looking to break into the healthcare sector should consider differentiation based on a verticalisation strategy."

FIGURE ONE Impacts and Top Recommendations for Providers. (GARTNER)

While Gupta is writing about the heath IT sector globally, on the local scale, consulting group Accenture says there are some specific opportunities for technology providers in Australia.

According to senior executive, health & public sector at Accenture, Leigh Donoghue the level of adoption of electronic medical records in Australian hospitals is a serious concern and this is likely to be a major area of investment over the next three to five years.

 Hospitals are likely to choose one of the following paths, he says. The first is an integrated EMR approach where they progressively replace existing packages and move to a single solution across core services

Alternatively they may opt for  the “best of breed” approach and  focus on connecting rather than replacing existing packages. This would also involve introducing a clinical viewer or workbench to provide a more complete view of patients and improve productivity, says Donoghue.

Accenture also identifies corporate systems and mobile apps are big opportunities for tech providers.

On corporate systems, Donoghue notes, "Health providers face major cost pressures.  Many are poorly placed to respond to this due to the state of their corporate IT systems.  "Significant investment is likely to go into addressing for example upgrading HR/Payroll and Finance systems."

This is hardly a trivial exercise in itself as the recent problems in the Queensland Health payroll system sadly demonstrated.

Mobile apps are  the other significant emerging opportunity identified by Accenture. "Mobile apps, specifically the development and operation of consumer and provider apps to enable new models of service delivery.  We expect to see significant innovation in this area; what’s less clear at this stage is how suppliers will make money in this space."

Digitizing the patient

A cross cultural study of doctors and digitization by Accenture found Australia lagging many advanced markets in the uptake of digitized medicine, although the same study found areas of significant improvement.

According to Accenture Partner Lee Donoghue, “We haven’t seen a huge shift in adoption particularly in secondary care. We have pretty high usage of EMR in GP practices but only 28 per cent of secondary care doctors are users of EMR

As noted earlier  hospitals are a major gap in terms of information capture and sharing across the health system. " That has not changed a great deal, however what we did see an increase in the number of doctors who are entering patient notes - up by about 25 per cent over the last year."

That is consistent with the global pattern where the general trend is for more doctors to use EMRs and to contribute to them, says Donoghue.

On the upside in its study Accenture identified  an increase in access to clinical data in Australia and the increase was above the global trend. "Also access to data produced by other care providers outside of the individual doctor saw an increase."

But weighed  against that, Australia is a genuine laggard when it comes to GPs sharing  electronic communications with patients."

 Less than two per cent of GPs sent e-communications to patients and slightly higher in secondary care. "There is an expectation this will increase but we are not seeing a great shift."

Quite apart from significant cultural resistance to sharing, which the evidence suggest is breaking down over time, there remain technical and structural impediments to building a genuine national digital health infrastructure, starting with the issues of attending to legacy systems.

According to business intelligence specialist and QlikTech Regional Vice President for Asia Pacific, Phillip Beniac, " There is a lot of information within the healthcare sector that is tied up in silos." He says the  trick is to bring in all the information about a patients out of  the silos and into an environment where it can be managed within the context of the overall eco-system.

"As the health care sector shifts towards evidence massed medicine  and things like pay for performance diagnosis  there are many initiatives around bringing in data from disparate systems that historically where more or less managed in silos. And that allows for a more comprehensive overview." says Beniac

James Brennan, Unified Communications Director, ANZ at Polycom  is another with first hand insights into the challenges for health IT development in locally.

"In Australia you have a number of factors working against the healthcare industry such as an aging population, and  remote and regional communities who are looking for equivalency of health care. Then of course there is the perennial issue of doing more with less."

Standards setting and agreed operating principles are other issues which Polycom and other providers have to deal with. The IT industry has a long heritage of setting standard, however the issue in Australia is that there are other agencies involved in the debate.

"The lack of standardization across all technologies is a huge issue, not just for our technology. Governments have firm ideas about what they want implemented and everyone is in agreement that there needs to be a better way to do it."

"But everyone is driving their own agenda," says Brennan. "Even within a state like Victoria you have seven regions each driving their  own plans and often within a state there might not be a centralized department to bring all of this together."

"In the technology  sector there are dozens of these industry bodies or agency bodies trying to make recommendations but the problem is there is no one single owner of it, according to Brennan.

"In our industry in particular with telemedicine and video collaboration and health there are half a dozen small bodies - that is a key issue."

This compares unfavorably with the Canadian and US experience.

"If you look at the American Telemedicine Association or the Canadian Telemedicine Association  they have been long standing leaders in the industry and they set very clear recommendations around how you should and shouldn’t use the technology."

According to David McGrath, head of sales and marketing at ASE IT Networks "Connectivity is another key issue in Australia where outcomes are compromised by too much bureaucracy and too little decision making.

"It is difficult when you take a government lead approach to something like health because you get bogged down on the  other side (regulation) and the tech or innovation piece isn’t allowed to flourish."

"For instance we have a large amount of storage on our store cloud infrastructure which is perfect for health records its a solution built on Netapp which has  a very good reputation in the health space in the US.

But getting the conversation going generally starts with the regulation and compliance issues rather than what can be achieved as an outcome."

Instead, says McGrath, health leaders should start with what's possible and work backwards, "...rather than trying to find roadblocks all the time."

To get a sense of the current state of play in the health IT sector locally, CRN spoke to industry leaders about four areas of current development including personally controlled electronic  health records, telemedicine, and mobility.

PCEHR

The personally controlled electronic health records (PCEHR) initiative has been subject to plenty of debate, particularly as it relates to getting the various  health operators.

Now however, Accenture's Donoghue at least believes progress is being made.

" PCEHR provides a platform to grow and in many ways it is providing visible progress which is creating its own momentum."

A reason for the delays, he says is that Australia pursued an opt-in system, where as many other countries operate opt out schemes.

"By  its nature this means it requires consumer campaigns and it will be a measured adoption.

Donoghue says the last year has seen an acceleration. "We have just gone past 500000 consumers registered."

"That pattern is also visible with provider registrations and we are seeing it flow though to usage with the generation of shared health summaries and event summaries."

Donoghue  says  as areas connect some of the more  advanced groups  are starting to stretch the service in new and creative ways.

"This speaks to momentum in the ehealth market compared to two years ago."

Hospitals are a major gap, allied health specialist ,aged care generally the coverage of EMR is still quite and some of those gaps with become critical priorities, according to Donoghue.

X-HEAD] Telemedicine

Telemedicine in Australia is often discussed in terms of regional health but there is much  more to it than that these days.

Industry leader Polycom breaks the market into three sectors; general and administrative, clinician to clinician, and finally direct patient/clinician interaction.

Brennansays currently the administrative piece is the dominant application for telemedicine although the clinician to clinical market is quite mature.

" So if we look at new hospitals being built in WA and SA they are starting to plan those facilities into the hospitals with video collaboration capabilities built into the emergency rooms and the operating rooms."

The direct patient to clinician applications – which is how most non health professionals consider these systems. is still relatively young.

" There are some excellent early adopter case studies in Australia of people reaching out to the end patient, " says Brennan, "The longest standing end patient clinical work we have been doing is in Victoria where we are  working with the Victorian Stroke Telemedicine Project."

In that instance Polycom is working with the Benito Health and Lodden Mallee regions which have been working  on the immediate diagnosis of stroke patients in rural areas and while this is a rural application but it could just as easily apply to less rural areas, says Brennan.

"Within the first few hours of someone having a stroke - if it's a particular type of stroke - there is a medication that can be provided that greatly enhances outcomes for the patient.

There are some very specific things a neurologist can look when a patient presents such as  eye movements, lip movements, ticks in the mouths, and eye/hand coordination and it is in these kinds of areas that telemedicine excels.

"Using high definition technology, specialists can literally do that work from thousands of miles away.

In terms of Patient to clinician systems, Accenture agrees that Australia is still in early adopter mode.

"We’ve moved beyond the pure innovators, like Queensland where there was early interest due to a significant proportion of the population living away from the major cities where specialist services are concentrated."

  There are some great examples of innovative service delivery in Queensland, such as telepaediatrics and telepsychiatry, where incentives have existed for almost a decade according to Donoghue, however, adoption has been very slow notwithstanding the positive response from patients.

Government policies have helped, to an extent.  The Federal Government introduced new Medicare items for online consultations in mid 2011 and these payments cover a range of medical specialties but are restricted to people living outside major cities or residential care facilities.

Lump sum payments are provided to cover set-up costs as well as ongoing consultation charges however, there are restrictions on the payments, as well as significant change management challenges  have meant that only a limited number of doctors have been willing to take this on at the present time, say Accenture. 

"Accordingly, we still see pockets of innovation around telemedicine and moderate growth rather than widespread, large-scale adoption, " notes Donoghue

That said, he remains optimistic. "Faster broadband, new communication technologies (like WebRTC), the proliferation of mobile devices and the PCEHR system are all further triggers for changing the way that care is delivered.  These factors, combined with payment incentives and rising acceptance of video consultations, are likely to increase take-up."

MOBILE

The emergence of services like Skype has not  just trained consumers to be more comfortable with the idea of telemedicine. It is helping to deliver a cultural change around mobility.

"Something like Skype has been a huge overall benefit to our industry because it has made people comfortable with the video collaboration." says Brennan. "If you have elderly patients they are probably talking to their Grandchildren on Skype.

In another example, the  PCEHR has been extended to start to support mobile devices, according to Accenture's' Donoghue .  A mobile gateway has been established and the  first mobile app -  child EMR or an electronic blue book - and been delivered .

"And this is the trend we are seeing in other countries - it’s the integrated of ehealth  and telehealth."

Given were the Australian market is in terms of smartphone adoption, and supported by the rollout of faster broadband  Donoghue sees real potential for convergence between these discrete technologies for new care models.

"That is an interesting development given how some of the health initiatives are starting to come together."

"We are seeing explosive growth in the development of mobile applications - this is a part of the broader consumer revolution."

Many of these mobile apps provide features and functionality to give consumers greater involvement and control over their own health.

"And as you start reorienting your health system from dealing with acutely sick people to dealing with a health management focus mobile apps are going to play a key role."

Part of the interest, he says, will relate to integrating those with ehealth records which the primary care physicians use.

"That's why the intersection of public sector health infrastructure  investment and consumer lead mobile applications will be a really interesting space to watch."