20 May 2022

How to vote today, plus nuclear subs and general practice

Comment KnowCents TheHill

If you want the best deal for GPs, here’s who should get your vote. And why a big Defence contract matters to you.

You can probably tell from today’s First Draft topic that I was pretty stuck for things to write about this week. Hence the nuclear submarine thing, just in case you are sick of hearing about politics, policies and elections. You’re going to have to read down a bit to get to that though. 

If you’ve been following the federal election and healthcare policy announcements, your first question about today’s topic should probably be: how do you make a judgment on whom to vote for, based on healthcare offerings, when neither party seemed to give a toss about healthcare at all?  

Which should lead to the question: why do both major parties think it’s OK to ignore a couple of fairly obvious crises unfolding in healthcare around the country, the most visible during the election being the rural doctor shortage?  

Not a night seems to have gone by during this election, even on the commercial TV channels, when a reporter asking random questions in rural marginal electorates didn’t have some punter quickly complain that they couldn’t see a doctor in their town, GP or specialist, and their hospital never had doctors on staff.  

OK, the Coalition came out early with a policy that they claimed would help solve the rural doctor crisis. But they announced only $146 million with which to do it, and the detail was a random selection of services they were going to throw money at, the way they have with car parks and sporting facilities in marginal electorates – not a cohesive, reasoned approach to the problem.  

With only $146 million, you don’t need any detail. You aren’t going to scratch the surface of this problem.  

Essentially, we don’t have any GPs left in rural towns, which means we don’t have any doctors to man small to mid-sized regional hospitals. If you go west of the Great Dividing Range (sorry, Western Australia – not sure what the analogy is over there), you don’t run into a town that isn’t in some sort of trouble.  

We are plugging the problem by paying VMOs vast sums to fly in and out of the regions at massive expense to the system overall (on average, we might be paying more than $4,000 a day plus expenses per VMO). Obviously, it’s not a long-term answer. And obviously $146 million is a dumb amount of money to offer up if you were serious about fixing it. 

So, the Coalition weren’t in the least bit serious in making the offer and policy, and neither was Labor, when they matched it. As they did, as some sort of mimicking-bird-like behaviour, with just about every other new policy the Coalition came out with during the campaign. 

Labor then announced their Urgent Care Centre policy, which was a clear indicator that they had even less of a clue about anything healthcare (I normally vote Labor, by the way).  

The policy failed when first tried with super centres 40 years ago. What was different about this new offering that was going to make it work now? Nothing. Just weird, but certainly an indicator of interest levels and ignorance. 

Oh and by the way, we didn’t get the chance to ask – we’ve been asking Labor’s Mark Butler for an interview for three months now.

The AMA quickly came out and put paid to the Urgent Care Centre idea and gave Labor and its leadership a bollocking over their attempt at getting voter attention with such a lame policy. Other than pointing out that their token healthcare policy would not do a thing to ease the burden on emergency departments, AMA president Dr Omar Khorshid urged Labor to leave healthcare out of its key election strategy of presenting a “small target”. It is just too important, he told the Opposition Leader, Anthony Albanese, in a one-on-one meeting. He needed to “go big” instead. 

The problem, of course, is that if you are already this clueless in the run-up to an election, this late in the game, and you don’t want to present your competitor with any opportunities to bring you down at all, you have very little space to work with. 

So, some kudos I guess to Labor for edging themselves out onto a very sturdy and small limb, and stating that, on reflection (they didn’t say “on reflection” of course, but they should have) primary care is a lot of trouble so they are going to pull out the B-dollar word and throw it general practice’s way.  

But not much kudos, sorry.  

It was very late in the day and probably approved only as a disruption tactic for the Coalition campaign launch, which was happening the next day. And although obviously someone had given them some lines to run that were reasonably accurate about why general practice is in trouble, the detail was so light and high level that we all knew it was tactical, not a commitment that emerged from any serious understanding of what is actually going on. 

But as we wrote last week, a billion dollars is a billion dollars, and a lot more than any other healthcare policy offering in the election (except the United Australia Party, which we will get to). 

Dr Khorshid labelled it a “down payment” only on the unfunded Primary Health Care 10-Year Plan developed under the Coalition. Perhaps more important than the money at this stage was a commitment by Labor to actually bring all the key doctor and consumer groups together after the election to work on the detail on how the money would be spent. 

This, at least, was an offer of an opportunity for various groups to put their case and help Labor understand better the trouble general practice is in. Perhaps with such a meeting, or a series of meetings, someone would be able to secure some more meaningful long-term funding for the sector. 

With this late addition to the race from Labor, as far as scoreboards go, if you are a swinging GP (voter), in a marginal electorate, who is most concerned about healthcare in this election, then Labor is the marginal winner for your voting intention between the major parties.  

At least there’s a sure $1 billion (hmm?) coming to general practice, and a promise of meeting everyone in Canberra to talk about it all.  

The Coalition doesn’t seem to care at all.  

Maybe they think that their pandemic healthcare spending is their credentials (it isn’t). They list all the pandemic spending under their policy offerings on their election site.  

Defunding the Primary Health Care 10-Year Plan at the start of the election was a very bad look that they should have tried to address, especially after Labor upped the ante last week with their offer.  

Dr Khorshid said it all last week after Labor came out with their $1 billion when he stated: 

“It was very disappointing to the medical profession that, having had a commitment for this sort of spend from the government at the last election – the medical profession engaged with government over the full term of this government, to the point where a 10-year primary healthcare plan was released at the last budget. 

“But this was a plan that was unfunded, and the money that Scott Morrison had put on the table back at the last election has vanished into thin air, meaning that it was an unfunded plan that was likely to sit on the shelf no matter how hard the medical profession and others had fought for it.” 

I would be remiss, of course, not to mention the policy of the UAP here. If we do vote them in, they have promised to spend an additional $40 billion in the next few years in healthcare, which seems like it would be good and a winner.  

But in an 11-line healthcare policy, it is apparent that UAP doesn’t understand anything either, and almost all that spend would be on hospitals, which sort of fits in with their “bigger and shinier is better” (aka let’s rebuild the Titanic) philosophy. Also, they might not have any money left if they have to fund everyone’s mortgage once interest rates go above 3%. 

Anyway, good luck today, everyone, for whomever you want to win. I’m in Warringah, which has the original teal independent and prime minister killer, Zali Stegall (climate change closely followed by a real federal ICAC), against a Liberal who has openly stated that transgender people are fooled into being mutilated and sterilised, and who likens herself to the French resistance fighting the Nazis. I’m not entirely sure who the Nazis are in her analogy, though. I’m thinking it might be the coach of the opposition netball team her kids play against.  

Deves a few years back

Why nuclear submarines are relevant to general practice 

In GP-land, an announcement last week by the Department of Defence (DoD) on a contract to build a whole new health ecosystem for the Australian defence force would mostly have gone through to the keeper, is my guess. 

How would such a contract be relevant to general practice? 

If you want the gory detail on the reasoning why, you can read the logic here on our sister digital health newsletter, Wild Health.  

The short version is this: Defence is building the perfect interoperable healthcare ecosystem for all its personnel that will be fully cloud enabled (and able to work offline when needed), be able to share healthcare data seamlessly between its hospitals, GP services and all its allied health services such as dental and pharmacy, and use all the data available to optimise the health of its workforce over time. 

Which is just like nuclear submarines, right? 

OK, put another way: 

Why buy a diesel sub when the future strategic environment clearly points to nuclear being the required option, even if you have no nuclear capability or expertise on hand? Well, you do what you have to do to have the best for your citizens’ defence. 

So why deploy a healthcare solution that isn’t interoperable in the manner that is optimised via FHIR, the cloud and fast-evolving standards for seamlessly and securely sharing healthcare data in real time over the web, so all points of the system talk to each other, and patients, wherever they are?  

It’s the DoD nuclear sub principle. Build for the future. 

DoD is going to attempt to build the perfect healthcare interoperable future. And when it does, it will be there for us all to see in a closed ecosystem bubble. No messy payment funding paradigms to adjust or change, or politics between the federal and state governments on making tertiary care talk better to primary care to prepare for the oncoming chronic care tsunami. Your very own closed-loop healthcare system that you can start from scratch and do as something perfect, undisturbed by the not-so-subtle nuances of the outside healthcare world. 

If it works, we should get a good look at the future of healthcare efficiency for things such as distributed patient data access, seamless sharing of information between tertiary, primary and allied care, and perhaps even more importantly, collection and analysis of clinically meaningful, population health data – everything in the system will be SNOMED coded, compared with the outside world where our primary care patient management systems each use bespoke coding, and our hospitals still use a variety of systems. 

But it’s the DoD and submarines, I hear some of the more astute observers saying; nothing will come of it. It will run over time, over cost, and will probably be abandoned down the track as the failure of a past government. 

Actually, none of that is going to happen in this contract. 

It is being run by US-based engineering and IT integration firm Leidos, which is already the major integrator for the US defence forces’ healthcare systems, and which operates primarily in the US, where standards for healthcare data sharing, and technology, are now far advanced compared with Australia. 

That, and the project is already well under way, and so far, everything in test environments is working pretty well. 

An interesting pointer for GPs and the future in this project might be that the main local technology vendor partner is MediRecords. 

MediRecords was originally built more than five years ago as a cloud-only challenger to the major patient management system vendors, Medical Director and Best Practice. 

Its founders had the goal of being what Xero has been to the accounting market (Xero’s cloud accounting offering rapidly gazumped MYOB, the market-leading software provider to the sector). 

But that never happened. Perhaps it just hasn’t happened yet. 

When it was first launched, MediRecords suffered significantly from having to backwards integrate from its modern cloud-sharing architecture to so many legacy server-based systems in order to meet the expectations of doctors.  

Today, both primary care and specialist patient-management systems remain mired in the past of on-premise, server-bound technology stacks, to the point where government contracts will often specify integrations for patient-management systems which do not talk to cloud systems at all.  

A recent tender for supply of deidentified patient data to the government via PHNs and GP practices actually specified that only legacy PMS systems could be used. This is a great way to keep your healthcare system anchored in the past. 

Our current key patient-management systems include Best Practice and Medical Director for general practice and Genie for specialists. All these vendors have either developed a cloud version of their product (Medical Director has Helix and Genie has Gentu) or are saying they are deep in development of their cloud versions (Best Practice). 

But without other key parts of the healthcare system moving to cloud at the same time, the practicality and cost for the patient-management vendors of moving their customers over just isn’t there. There are just too many integrations these systems are still talking to – payments, patient bookings, secure messaging, referrals, data capture and download, et al – that are still using legacy technology. 

That the major access points to all our doctors in Australia are legacy-bound, server-based systems means that anyone building new applications that require doctor or patient access are usually building its integrations in a legacy manner. It is sort of the opposite of a virtual circle. The more you build to the older systems, the deeper the hole you dig for the overall future of the system. 

Even though we think of the patient-booking systems as modern and largely web based, their integrations to the patient-management vendors lock their technology in the past to some degree. 

How do you escape this bad paradigm? 

One thing The Department of Health could try is mandating that within a certain period of time all software vendors and healthcare providers in the country upgrade their tech to modern and common web based information sharing standards. This happened in the US five years ago and it is fundamentally why, in terms of technology on data sharing and patient access, they are streets ahead of Australia nowadays.

Interestingly, both Medical Director and Best Practice were in consortiums that tendered for JP2060 and lost out to Leidos and MediRecords.  

That each lost out to the much less visible and cloud-first MediRecords outfit isn’t necessarily that MediRecords was the best or only cloud-technology offering. The integrator is probably as important in the selection on a contract such as this as the partner vendors and their technology are.  

But at the start Leidos, which was always the frontrunner in the integration stakes given its US track record, probably had its pick of PMS vendors to partner with, and MediRecords was the vendor it ended up going with for the core of the project.  

What do we think that says about the future of patient-management systems for GPs? 

Notably, Alcidion, Coviu and Fred IT, also part of the project, are clearly the leading local vendors for the technology roles they are playing in the project.  

After MediRecords, a key role in JP2060 will be played by Alcidion’s knowledge-management products, in tying together and then analysing all the patient data being generated by the project. 

Seamless and meaningful data sharing are a key part of the project, and a key issue for Australian healthcare departments, which currently rely on disjointed de-identified patient data feeds from hospitals, PHNs and other sources, all of which are dragging data out of systems that code the data differently from a clinical perspective and are ad hoc at best in how they manage data.  

Twenty-seven of the country’s 31 PHNs have recently formed an alliance to manage data out of one modern cloud-based service that they developed out of Western Australia. However, from a population health perspective, this group still faces the huge issue of how they centralise and share this data, how they equalise data sourced from different PMS systems that code data differently clinically, and if the data, which is effectively hacked out of GP patient-management systems, is really cohesive enough to create meaningful population models from. 

The new ADF system will be the first closed health ecosystem in Australia with data coded all via SNOMED, and shared seamlessly between every key health service in the system, and which will have an Alcidion AI technology overlay eventually applied to the data. 

So, nuclear submarines are important and relevant to general practice, then?  

Sort of. 

Declaration of Interest 

Jeremy Knibbs is the publisher of The Medical Republic and a technology and business writer for the group. Among some other interests in healthcare start-ups, he is a non-executive director of MediRecords, mentioned in this article.