Webdiary - Founded and Inspired by Margo Kingston

This is Trevor Kerr's second piece for Webdiary. His first was A desalination plant for Wonthaggi? Thank you, Trevor for raising some important - and controversial - matters.

In $100m to break through waiting lists the suggestion is made that Labor will move to open some surgical waiting lists in public hospitals to contracts (presumably via competitive tendering) from private hospitals. I wonder if service providers in New Zealand, Singapore and Mumbai will be able to bid? Be warned, though, this little hypothetical will end up with a strong set of arguments for a National Identifier.

The business of private (for profit) facilities is very different from fully subsidised health care. If private hospitals are going to bid for public work, it could be instructive to consider how they function. So, let's take a fictitious surgical clinic somewhere in the Gulf States. This facility was built inside one of the hotels for the super-rich, specifically to cater for a small range of surgery. The Gulf State Orthopedics clinic specialises in joint replacements. At the outset, the owners of GSO knew very well the nature of the clientele from which they would draw their business. Staff are recruited from anywhere and the surgeons can make as much there in a two week contract as they would in three months at a UK hospital.

Apart from creature comforts, clients expect the highest quality treatment and perfect outcomes. They also require tight security. But while clients have to leave their passports at the desk, there are no other identity checks. It is well known that people can book in under assumed names. At reception, each new client submits to a range of biometric measures, including fingerprinting and iris scans. They also deposit a sample of blood for the DNA bank, in case there is a tragedy and identities have to proven. They are then issued with small radio-emitting trackers that are worn on the wrist at all times: these are needed for access to the areas that require authorisation. All of the staff are tracked electronically and have undergone rigorous, pre-employment proofs of identity (see A European identity card for health professionals) and police checks in their countries of origin.

On discharge every client is issued with printed summaries of all results and procedures. They are also given a DVD which has all data in common readable electronic format for easy transfer to databases at home. The disc also contains relevant images and the CVs and contact numbers of the principal medical personnel on their case.
The original clinic, the GSO, has been so successful that competitors have sprung up to cater for the rich and powerful who cannot trust the competence or the security of their own state's facilities. The competition for big money is intense, so comparators are used in the advertising brochures. Since Quality and Safety feature highly in the mission statements of the clinics, and some prospective clients have doubts about institutional self-promotion, an independent international auditor has been established. The best clinics submit verifiable data on quality and safety, and the rankings are freely available. These are add-on costs to the consumer, initially, but the competitive culture drives the search for continuous improvements and innovations that cut costs while lifting Q&S standards.

The common thread in this, all of which should be transferable to the publicly funded sector, is sharing of data. One way of critiquing the current situation of health data in Australia is to try and imagine how far we will be behind Singapore in 10 years, after they have their superfast broadband (Race on to build ultra-fast broadband). We can use the example of the Labor government's plan for preventing obesity in childhood, a Weight check at four years. Where will this data be held, who will have access to it and how will it be integrated with other data that has been collected, such as immunisations?

At the root of all questions about health informatics is the ability to assign data with supreme and incorruptible accuracy to the correct individual. In order to cut short any notion that the Medicare Number fulfils the criteria as an identifier, see the glossary at Australian Institute of Health and Welfare (AIHW). Medicare card number identifier N(11) - "As a person can be identified on more than one Medicare card this is not a unique identifier for a person." In regard to information held by governments on children, there have been notable problems. From Data integrity in the Child Support Agency (pdf):

12. While relatively few in number compared to the entire record set, the presence of erroneous records in the database indicates a weakness in effective control systems for data entry and recording. The CSA has recently introduced a Data Quality Improvement Programme, including a series of activities designed to test specific aspects of data quality in Cuba. The CSA will benefit from extending this programme to incorporate a comprehensive check of the application of all relevant business rules within the database.
13. Furthermore, the CSA should draw on the findings of this audit, and the information obtained through its Data Quality Improvement Programme, to identify and address weaknesses in data quality control systems. The inclusion of some controls should be relatively straightforward—such as a technical level control to ensure that an ‘end date’ does not precede a ‘start date’, within a line of data. Other controls, such as enforcing a standardised approach to recording names and addresses, may present more of a challenge, yet are essential to improving the overall quality of customer data in Cuba.
14. Most of the errors and weaknesses identified in this audit pose a minimal risk to the CSA’s overall administration of the Child Support Scheme. However, particular errors or anomalies on individual records can result in an inaccurate calculation of child support liability. For the families involved, the effects can be significant. One of the objectives of the Child Support Scheme is that ‘parents share in the cost of supporting their children according to their capacity’. Incorrect child support liability calculations, resulting from errors on customer records, pose a risk to the achievement of this objective. 

The UK has, or has had, more than one scheme to keep records of every child. In Children’s database delayed to review security:

The security review follows the news last week of a security failure by HM Revenue and Customs (HRMC) on child benefit data, resulting in the loss of two discs containing the personal details of 25m UK citizens, including bank details and addresses.

From the US, (in Harvard Study Confirms LMN Conjecture):

Our findings raise concerns about the ability of the current approach to achieve widespread electronic clinical data exchange.

Also in the US, from Veterans Affairs Healthcare:

Experts generally agree that electronic records are absolutely essential to significant health care reform. However, only about 5 percent of the nation's hospitals now have them. That means, for example, that in most private hospitals 20 percent of lab tests are repeated simply because doctors can't find a patient's results.

How is pathology in Australia? Do we have a national provider? No. There are many, both private and public, and each more or less restricted in scope and access. They do not communicate with each other, and send only limited subsets of data out to bodies like Medicare. Symbion's latest advertisement for their pathology section claims "our national network of pathology providers", but each of its individual laboratories is a discrete entity. There is no exchange of data, so that a client at Symbion's Melbourne branch would have to take his results on paper if he moved to Sydney. One of the results of this self-imposed insulation is that a lot of repeat testing goes on, which is not a bad thing for a business taking profit from transactions.

The pathology business is complex, but the current negotiations between Symbion, Healthscope and Primary seem to be overlooking one of the critical aspects. This is the matter of information systems. Pathology has been computerised for decades, and every practice stores millions of individual laboratory results. These databanks are important for tracking a person's health over time, and the aggregated data have immense value for public health and for research into new pharmaceuticals. However, each pathology company locks away its data so that they cannot be compared easily with the values in another provider's computer system.

Suppose my GP sent me to spend a few days in a major teaching hospital for an acute medical condition. One would think that, in 2007, I would be able to carry an electronic summary of my test results and the specialists' conclusions with me when I went home. Or, it ought to be possible for each and every one of my chosen health care providers to get access to the information, the hard facts, via the Internet. None of this happens, though.

Taking a simpler example, suppose I have a chronic condition like diabetes and I have had all of my tests done with the same pathology provider. If I am referred to a specialist, and more tests are done with a different pathology company, will all of my results become available on my GP's computer? Or, if I travel interstate, and have tests done by another pathology provider who is part of the same corporate empire, will any of my doctors be able to view all of my results in sequence so they can be compared? Not likely.

I am willing to guess, in the case of likely mergers or buy-outs between the pathology elements of Symbion, Healthscope and Primary, that it is impossible to merge the laboratory databanks without risk of loss or corruption and without huge expense. All parties involved in the negotiations, not least the shareholders, ought to be asking how they can get an objective analysis of the implications. Further than that, several national regulatory bodies ought to be looking very closely at what impact the deals may have on the integrity of essential health data. That integrity rests on the creation of a National Identifier; there is a risk that further consolidation of health records into non-standard, proprietary formats will hinder the process of standardisation. That is, if major pathology providers who own and maintain vast collections of data are occupied in pursuing their own business goals, they will not be inclined to devote their own resources to collaboration on the national electronic health record project. NEHTA (National E-Health Transition Authority) was set up as an incorporated body during the previous government, and its status under Labor is probably under review.

Since Labor took over, we have gone from Labor swift to dump Access Card to Rebirth of the Access Card?:

Labor kept its election promise by scrapping the controversial $1.1 billion program. The card was intended to provide every Australian with a unique health and welfare number and biometric photo on a smartcard. Mr Hayes said while the Coalition went too far with the Access Card, he believes Labor would, in future, have to introduce a more secure way for people and the federal Government to access e-health records.

A national identity management program will be expensive, and not only because of the bandwidth required to disperse it all over the country. A research paper on the subject, Identity management in the UK public sector to 2011, costs nearly one thousand pounds to purchase. Singapore has just announced a radical departure from previous models of access to information (Singapore split a lesson to Telstra) including catering for telemedicine. That last point is vital, because health professionals will need real-time, high quality video to be able to take part in remote consultations. 

In summary, e-health requires both a national identification scheme (for patients, clients and service providers) and superfast broadband. More important, though, is the need for oversight from a government commission charged to preserve the public interest against the ravages of commercial cartels.