Health Technology –opportunities and challenges during major system change

New Fiona Stanley Hospital Dr Simon Towler Health Technology 2013

What is your view of the world?

Reform in health care and technology

Change in the Australian Health System

– National – NHRA

– IHPA – NEP

– NHPA – performance assessment

– State health reform – WA

– Workforce changes

On background of constantly changing health care

Health Reform Committee Report (2004)

Key challenges include:

– A growing and aging population

– Widening gap in health status between the rich and poor

– Escalating demand for services

– Substantial emphasis on tertiary hospital care

– Workforce shortages

– Increasing difficulty in funding growing health costs

Health Care Framework

Research

Epidemiology

Quality & Safety

Information/Data

Performance Measures

Health Outcomes

Planning-strategic

Philosophy of Care

Population Health

Policy & Protocol

Performance

Operational planning

Health service delivery

Infrastructure

Resources

Interventions/Programs

Partnerships

• Safe: avoid preventable injury from care

• Effective: services based on scientific knowledge

(underuse/overuse)

• Patient centered: respectful, responsive care

• Timely: reducing waiting and harmful delays

• Efficient: avoid waste

(equipment, supplies, ideas, energy)

• Equitable: no variation due to ethnicity, gender,

age, location, socio-economic status

Improving 21st Century

Health Systems

Institute of Medicine

70% Proportion of Australia’s

$100 billion-a-year

healthcare costs for which

governments foot the bill

Source: Australia's health 2010, a report by the Australian Institute of Health and

Welfare

5.2% Average annual increase in

recurrent expenditure on

public hospitals in Australia

Source: Australian Institute of Health and Welfare, between 2005-06 and 2009-10

(after adjustment for inflation)

19% The average proportion of

time a nurse spends on

direct patient care on the

active nursing part of a

shift

Source: The Permanente Journal Summer 2008: ‘A 36-Hospital Time and Motion

Study: How Do Medical-Surgical Nurses Spend Their Time?’

20 to 40% World Health Organisation

estimate of all health

spending wasted through

inefficiency in the system

Source: The World Health Organization’s 2010 World Health Report: Health Systems

Financing – the path to universal coverage

NHHRC 2007

• People and family centered

• Equity

• Shared responsibility

• Strengthening prevention and wellness

• Comprehensive

• Value for money

• Providing for future generations

• Recognising that broader environmental influences that shape

our health

Health expenditure

• This report identified that advances in medical

technology have been a major driver of the growth in real

health care expenditure and estimated that the cost of

technological change contributed 1.9 per cent to the

annual growth in real health care expenditure of 5.3 per

cent, or 36 per cent of the annual growth in real health

care expenditure from 1992-93 to 2002-03.

Productivity Commission Report

Productivity Commission Report

Overall, advances in medical technology arguably have

provided value for money — particularly as people

highly value improvements in the quality and length of

life — but the cost effectiveness of individual

technologies in practice varies widely and for some is

simply unknown

Productivity Commission Report

• Evidence and needs based access to new technologies is

preferable to existing, often blunt, rationing mechanisms.

• Systematic reviews of efficacy and cost effectiveness of new

technologies once they are in use could promote overall cost

effectiveness of healthcare, without unduly delaying their

introduction.

• Greater procedural transparency and community involvement in

HTA have the potential to foster greater acceptance of technology

funding decisions and to help ensure that HTA is not used simply

to restrain expenditure.

KEY

REFORMS

If governments, the professions and the community really

want and expect a “better” health system, then it is time to

start asking questions about resource allocation, in a spirit of

transparency, with an explicit statement of values, and

supported by a systematic and evidence-based framework.

The answers have the potential to enhance the sustainability

and quality of health care.”

Title:Identifying existing health care services that do not

provide value for money

MJA Volume 190 March 2009 Elshaug et al

Technology – not just devices (2004)

– Drugs

– Devices

– Diagnostics

– Information and communication technology

– Interface technologies

– Genetics in health care – the molecular revolution

– Personalized medicine

– Metadata – derived information

Managing Healthcare

McGLYNN, E A et al

NEJM 348;26 June 26, 2003

“Care requiring an encounter or other

intervention had the highest rates of

adherence (73.4%), and processes involving

counseling and education (e.g., advising

smokers to quit smoking) had the lowest rates

of adherence (18.3%)”

Transfusion Variability in Austria

1,401 THR - patients transfused

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

15 12 13 16 9 3 1 7 2 11 4 6 5 8 14 10

Center No.

Huge inter-hospital variability of

RBC transfusion rate for matched pts:

16 – 84%

Gombotz H, Rehak P, Shander A, Hofmann A.

Blood use in elective surgery: the Austrian benchmark study.

Accepted for publication February 14, 2007 in Transfusion

NHMRC

Serving the Australian Population

• Health service research

• Research translation

• Population health research

• Aboriginal health research

• Ethics

Therapeutic reviews

Prevention Evidence

implementati

on

Innovative

industries

Conversion of research findings into:

• Effective policy

• Improved practice

• New products

Research Translation

5 December 2013 Slide 32

“9 Steps”

Guideline development: 1. Committee established consistent with NHMRC Act

2. Specialists in evaluating medical evidence undertake a systematic literature review.

3. Professional, technical and scientific writers turn evidence into draft guidelines.

4. Guidelines are put out for public consultation

5. Review submissions and re-draft guidelines

5 December 2013 Slide 33

“9 Steps”

Guideline development: 6. Redrafted guidelines are referred to independent reviewers

to assess the process of their development.

7. Peer reviewers invited to review guidelines.

8. NHMRC Council considers all material and recommends further changes if required and finally advises CEO to refer guidelines to Minister for Health for endorsement.

9. Guidelines are publicly released.

( It takes 18 months - current for 5 years )

Cutler Report 2008

“We have known for generations that

innovation pre-eminently determines our

prosperity.”

Innovation

Cutler, 2008.

“Firstly, the architecture of Australia’s existing national

innovation system is now a generation old. It requires

reappraisal and the policies it comprises require

renewal, refurbishment, recasting and in some cases

re-imaging.”

Investment in innovation

What evidence-based medicine is:

“Evidence-based medicine is the integration of best research evidence with clinical expertise and patient values” - Sackett, et al 2001

Rule 31 –

Review the World Literature Fortnightly*

*"Kill as Few Patients as Possible" - Oscar London

0

500000

1000000

1500000

2000000

2500000

Trials MEDLINE BioMedical

Med

ical

Art

icle

s p

er Y

ear

5,000?

per day

1,400 per

day 55 per

day

From “Introduction to EBM – Paul Glasziou – 2003”

Questions

• Can it work?

• Efficacy

• Does it work?

• Effectiveness

• Should it be used, given other calls on a fixed budget?

• Economics

• Is it reaching those whom it should?

• Availability

EBM

Policy

Audit

Development

From “Economic analysis” – Ken Stein - CEBM

PBAC/MSAC

Advising Australian Government

on which new technologies to fund

Reviewing currently funded items

HealthPACT

HORIZON SCANNING

Prioritising summaries

Horizon scan

HTA

Nationally Funded Centres

• Limited sites for therapy/service - not in every jurisdiction

• Funded through AHMAC cost-sharing formula

• Available to all Australians on referral

• Final cost based on number of patients treated

NHMRC BUILDING A SELF IMPROVING SYSTEM:

We will focus on supporting the most valuable health and medical research.

NHMRC will broaden and build Australia’s capacity for research.

Facilitating the process of research translation

Improving evidence-based guideline development

Assisting health decision makers to implement evidence from research

Improving the integration of research, professional education and patient care

Information as a resource

•Informing change

• Foundation for policy development

• Underpinning innovation with data

• Evaluating healthcare and health services

• Developing expertise in using information resources

• Basis for health technology assessment

• Developing workforce

Technology and Resource allocation in WA

• Information management is the key to better planning and policy development

• Health Networks to take a lead on technology for WA

• Develop WA Policy Advisory Committee on Technology

• WA Therapeutics Advisory Group

WAPACT – role and function

• Mechanisms for early identification of new technology/clinical practice with potential implications for public health services.

• Assessment of clinical and cost effectiveness of new and existing technology/clinical practice.

• Priorities for the introduction and use of new technology/clinical practice. • Policies and procedures for best practice and service delivery for

introduction and use of new and existing technology/clinical practice in public health services.

• Requirements for evaluating and monitoring the introduction and use of new technology/clinical practice in public health services.

• Dissemination of information on the introduction and use of new and existing technology/clinical practice to key stakeholders.

• Represent the interests of Western Australia at a national level and ensure that its requirements in relation to technology assessment are considered on the national agenda.

Resource Allocation Model - ABF

• Change from historical funding

• Align health resources with outcomes

• Promote innovation

• Develop information resources

• Embed evaluation in health services

• Evidence based introduction of technology (HTA)

• Align with National Health priorities

• Understand unique WA requirements

©2011 Hewlett-Packard Development Company, L.P.

The information contained herein is subject to change without notice

©2011 Hewlett-Packard Development Company, L.P.

The information contained herein is subject to change without

notice

Peter McMahon

Client Sales Executive

HP Digital Hospital

Mob: +61 437 078 137

ICT: a small but critical

piece to enable the

hospital of the future

Healthcare

Reform

“The hospital is altogether the most complex

human organisation ever devised”

Peter Drucker (November 19, 1909 – November 11, 2005)

Writer, management consultant, and self-described “social ecologist”

HP Confidential

51

A Tale of Two Hospitals

51 HP Confidential

• St. Olavs Hospital Trondheim Norway Implementation

–2002-2005 Phase 1 –2006-2010 (2013) Phase 2

HP part of a consortium

• AHUS outside of Oslo Norway

Implementation –2004-2009 Phase 1 –2009-2010 (2011) Phase 2

HP co-Prime with Telenor

52

Functional silos

Traditional ICT Infrastructure

Nurse Call

Phone

Systems

(PBX)

Telephones

DECT/Pager

Door Opener

Intercom

CCTV

AGV (Robot)

Light

Blinds

Heating

Facility

Control

Mobile ward

round

Wireless LAN

WiFi

Client PC

Hospital

Applications

Paper

Medical Devices

EPR PACS HIS LAB EHC

RFID

Patient TV

HP Confidential

53

IP everywhere - everything on IP

St. Olavs IP Infrastructure

IP everywhere – everything on IP : Unified Communication

Nursing

portal

Patient terminal

LAN/WLAN

IP converter

ESPA 4.4.4

MDA/

PDA PC

Mobile

phones

(SMS)

Wireless IP phones

OPC, SMTP, SMNP

I/O signal

converter

HP

digital pen

Patent monitoring

Medical equipment

WiFi tags Facility

control

IMATIS® Middleware PACS EPR EHC Laboratory etc.

GSM

Nurse call

Pock.pager IP telephones

HP Confidential

54

Experienced results at St. Olavs after

completion of Phase 1

treated more patients in 2007 than 2006 with

400 fewer staff

improved patient care with better access to data

patients stays are shorter, less inpatients

staff productivity increased through better

collaboration

reduction of annual workload 2006/2007

St Olavs New Hospital Facts

Delivering outcomes that matter

30% 20% 6%

Outpatient

capacity

Length of

stay

Productivity

improvement (per year)

..while reducing overall operating expenses..

..while improving patient satisfaction..

HP Confidential

55

ICT: a small cost centre

• The bulk of costs are

salaries (66%)

• Goods supplies 14%

• ICT is a small part

• ICT is the KEY to

making personnel

more efficient

• Why ”save” ICT costs?

Pay cents to save dollars

Source: Australian Institute of Health and Welfare, Recurrent expenditure, public hospitals, 2009–10

ICT: a component of

Administrative expenses

56 56 HP Confidential

Integrated Digital Healthcare Community – “Strategic Themes”

What’s next?

Improve Operational Efficiencies

Velocity of Care Performance Metrics

Personalised

Medicine

Evidence

based

Medicine

Future

Ready

Patient-

centric Care

Real-time

Care

Remote

Medicine Sp

ee

d I

nnova

tio

n to

Pra

ctice

Imp

rove

Qu

alit

y o

f C

are

Colla

bora

tive

Tre

atm

ent

Integrated Care

Environment

Frictionless

Workflow

Invisible “Intuitive”

Technology

Opportunity of Health Reform Committee Report

(2004)

– Capital program - $7 billion dollars

– Models of care

– Organisational change

– Focus on ICT

– Bringing the system together

– Changing tertiary education in health – national registration

– International technology partnership

London Healthcare “A Framework for Action”

Localise where possible, centralise where necessary

Routine healthcare should take place as close to home as possible.

More complex care should be centralised to ensure it is carried out by

the most skilled professionals with the most cutting edge technology.

Capital program – platform for technology change

– New hospitals

– Emergent national hospital construction standards

– Major equipment budget

– Technology mapping

– Need for additional expertise - SG 2

– Major opportunity to ICT upgrade and development

– Don’t forget the challenge of effective implementation

BURNS Service FSH

6 month commissioning delay

New Models Today

Sufficient funding and efficacious technology may be

necessary conditions for achieving health gains, but

experience in many countries confirms that they are not

sufficient.

Effective and efficient service delivery is the point at which the

potential of the health system to improve lives meets the

opportunity to realise health gains.

New Models Today

How to make it better?

New Models Today

Environmental conditions… Can promote or support better performance whether at the general

societal of health service level

Other environmental conditions may inhibit efforts to improve

performance of even make it worse

At times an organisation must simply adjust to prevailing environmental

circumstances, or

Act to change the environment in which they find themselves

New Models Today

Implementation capabilities

Assessment of implementation capability must be

undertaken whether the strategy will effect many services

or just a single site

Ascertaining that current capabilities are adequate or could

be sufficiently enhanced is essential to success regardless

of the scope chosen.

New Models Today

Other considerations..

- Flexibility

- Data

- Evaluation

- Stakeholder engagement

- Things change so programs may have to change

Deloite Ross Tohmatsu 1991

• The major weakness evident in the Western Australian health system is a lack of integration across its component agencies.

• Planning has been isolated from clinical expertise and consequently implementation of plans and recommendations

has been difficult.

Alignment

Purpose

Partnership Applied wisdom

Sir Liam Donaldson

Chief Medical Officer

UK Health

Our challenge

Relatively, little progress has been made in developing

routinely available measures of health care quality. Waiting

times for surgical operations and outpatient consultation is

an important measure of a health service's performance but

it gives no insight into more fundamental aspects of

quality.

Health workforce of the future

1. Will need new and strengthened skills &

competencies to respond to current and emerging

health challenges

2. The context in which these skills are learnt and

developed will significantly change

Durham and Plant, 2005

Sir William Osler

• The hardest conviction to get into the mind of the beginner is

that the education upon which he is engaged is not a college

course, not a medical course, but a life course…for which the

work of a few years under teachers is but a preparation.

Sir William Osler

• It is, I think, safe to say that in a hospital with students in the

wards the patients are more carefully looked after, their

diseases are more fully studied and fewer mistakes are made.

‘If you don’t like change,

you’re going to like

irrelevance even less’

General Eric Shinseki

Chief of Staff US Army

U.S. Saved 135,000 Lives, $810 Billion

Using Polio Vaccines

By Vivek Shankar

Jan. 23 (Bloomberg) – The U.S. in the past 50 years saved about

135,000 lives and $810 billion in health-care costs by using polio

vaccines, a study found.

An additional 25,000 lives will be saved by 2015, said lead author Kim

Thompson, an associate professor at the Harvard School of Public

Health, in an e-mail yesterday. By 2015, health-care savings will

top $1 trillion, she said.

“Developing capable, motivated and supported health workers is

essential for overcoming bottlenecks to achieve national and

global health goals. Health care is a labour-intensive service

industry. Health services providers are the personification of a

system’s core values – they heal and care for people, ease pain

and suffering, prevent disease and mitigate risk – the human link

that connects knowledge to health action.”

Working Together for Health. The World Health Report 2006. WHO

Thankyou

New Fiona Stanley Hospital