There is a twilight zone between the promise and the reality of new digital systems in healthcare
Something is going wrong when a manager running a major Australian hospital information systems looks at buying a hospital-wide electronic medical records (EMR) system then decides instead to buy a surgical robot for one of their busy theatres.
Why is that the robot is winning in the return on investment stakes against an EMR.
You might question the competence of such a manager given the supposedly vital role EMRs promise in terms of both both safety and hospital efficiency.
But you’d have to think again.
For one thing, hospital EMRs are inordinately expensive. You won’t get a decent installation for under $250 million, and that’s talking bargain basement prices. Most major LHNs that are heading down a path of a modern multi-hospital installation are looking at $1 billion plus contracts.
And that will often be only the start. Oh, you wanted fries with that? You needed to say at the start. No problem, we can add that ICU module for another $20 million. For three hospitals you’ll get a discount though, so let’s say $50 million all up. What, you wanted an integrated payment and scheduling system for your surgeons? You should have said.
And so on.
Although some of our hospitals have had EMRs for a long time, the terrible truth seems to be that, in most circumstances, the installation of an EMR, or a modern replacement of an existing one, is creating enormous issues.
And cost isn’t the only problem. Talk to any head of ED or ICU and you’re likely, off the record, to get a diatribe about: how the new system has turned all the doctors in their unit into data entry robots; how no-one in management actually understands how their unit works; how clinicians weren’t included in the design and installation process; how the shiny new $300 million EMR simply doesn’t work properly (when it probably could): and, how, mostly, what seems to have been achieved is that the unit manager is spending all their time on new reports to hospital managers, which are mostly about performance and cost, not about better clinical outcomes.
It is well known among most EMR professionals now that installing a new system is not going to save time, and possibly not money either. At least not to start with. But, if done reasonably, most will tell you safety will be improved.
Having said this, one professional was quoted in our last Wild Health Summit on interoperability in Melbourne as saying, “sometimes all you achieve with your new EMR is to kill your patients more efficiently”. To be clear, we think this professional meant they weren’t saving any more lives, but they were saving money.
Who is auditing these new installations around the country to make certain these issues aren’t occurring? If you go to Victoria now, for better or for worse, each hospital is run more or less like its own business. That has advantages. Market forces create a certain amount of efficiency. But it does mean some get it right and some get it wrong. Awfully wrong.
In the case of the manager and the hospital mentioned above, there was a lot of due diligence and thought, and, in the end, they decided to persist with paper – for reasons of safety, cost and doctor sanity. And they then spent what little money they had on a neat new robot.
In a private briefing following Melbourne’s Wild Health in April to key Victorian Hospital clinicians and managers, it became clear that we are in the twilight zone of Australian EMRs. A zone where we are learning and failing. A zone where the sales hype of the big global vendors is only just starting to be disassembled into its component implications – which might all be summarised as “our system does actually do all we promised, it’s just that we didn’t quite tell you how much it would cost if you take into account that you will need to train and teach all your staff to do everything completely differently, that they will all need to spend a ton of their time data inputting. So you’d better warn them and get them culturally into the idea that being a healthcare professional now involves data entry too, and that, hey, we just sold you guys the best bits. We’re sales people, after all. It is actually going to take a lot more money, a lot more learning and people change, and a lot more time. And that is all going to cost”.
Potentially, according to some high-level experts attending this private briefing, it might require some sort of mega healthcare disaster incident, to prompt both state and federal governments to realise that not funding the proper installation of more EMRs is going to cost a lot of lives, and there will be an awful realisation that our current penny-pinching ways will end up costing us pounds because we waited. And if such an incident occurs, it will likely be clear that our efforts to rein-in healthcare costs and be responsible, by keeping EMR installation under control, are, in retrospect, negligent.
You would assume that most hospitals would be reasonably well served by digital medical systems by now. After all, if such systems are so thoroughly ensconced in sectors such as banking and travel, we would make sure the health of our nation was equally well served. Wouldn’t we?
Apparently not.
In Australia, we have a grand total of only three HIMMS 6 rated hospitals. HIMMS, or Healthcare Information and Management Systems Society, is a huge global group which has a rating system of 0-7 for how good your hospital is at its digital systems, of which EMRs are a major component.
To give you some idea of how bad that number is for Australia, the US has about 2300 hospitals rated at either 6 or 7. We don’t have one yet that has managed 7. If you convert the US number to Australia on a per capita basis, it would mean that if we were on par with the US, we would should be approaching 50 hospitals around the country with either a 6 or 7 rating. I think the comparison to some European and especially Scandinavian systems is much worse. We are really bad.
Where do we go from here?
Well, for one thing, it’s not the technology, stupid. Not entirely, anyway. The technology exists for Australia to get a lot better. And our global EMR vendors have been in this country for many years, mostly dealing with state government health departments.
It has a lot to do with funding and our attitude towards safety, and eventually efficiency, in health.
OK these systems can cost the price of a small island nation, but we are in a digital age where eventually we know data is going to provide us with massive step changes in efficiency. When was the last time you even went inside a bank? And where is that sort of upgrade in health in Australia so far?
One clinician I spoke to last week who was running major hospital ICU described how they had settled on the safest system to use in their hospital – butcher’s paper with colour markers blu-tacked up everwhere! Such a system, well organised, might actually be safe. But once these patients are out of this unit what happens? Roll up the butcher’s paper and courier it to all the other touch points for each patient as they travel on their healthcare journey? OK, let’s be digital and practical then. Photograph the butcher’s paper on your iphone and text it? Hmmmm … not entirely secure.
But then apparently many junior doctors working in our hospitals are turning to WhatsApp for its communication utility. That’s another problem with complex technology such as EMRs. When it gets too complex, humans take shortcuts.
One massive trick that Australian governments seem to be missing in not funding more EMRs is the power that both primary and secondary data will one day provide to a spectrum of healthcare services using data analytics.
Data analytics, done well in a healthcare environment, will one day be truly revolutionary.
Even if that healthcare disaster never happens, future royal commissions are surely going to look back and censure our past governments (today’s governments) for not having the foresight to get this EMR infrastructure installed much earlier so the benefits of both primary and secondary data mashed with lots of other external patient data.
What benefits?
Suicide prediction, readmission avoidance, significantly faster and more accurate diagnosis in all sorts of fields, far better interoperability between tertiary and primary healthcare, vital population health analysis, early prediction of pandemic incidents, and so on. And that’s not even touching on the potential of machine and deep learning in some of our new hospital systems, which will never be realised without such data.
There is no question that we are at the cusp of a healthcare revolution in both safety, clinical effectiveness and returns on our investments in technology. But, the fuel of that revolution will be data.
And the engine will be well applied human capital. But we do not have even the most basic of systems in place to collect that data. And our healthcare professionals aren’t being prepared properly for the change.
Apparently, that we kill around 23,000 patients each year through medical error of some sort, most often caused by a lack of, or very poor, information and or communication, is no big deal.
Most of this issue can be sorted with a well-coordinated network of EMRs and decent interoperability between tertiary and primary care EMRs.
What is it going to take to get us out of this mad lethargy?
