Pathfinders - Aboriginal Health Informatics

It’s a big call! Trevor Lord thinks Aboriginal Health in Australia may be one of the most successful areas of development in Health Informatics. He shares the basis for his view with Australian Hospital and Healthcare Bulletin.
Firstly, we need to look at the big issue for Healthcare delivery: 9.5% of GDP and rising at twice times the rate of real growth in our economy. That is unsustainable. We need a major shift in productivity; essentially a revolution in how we deliver health and how we stay healthy.
Health Informatics offers the tools for that revolution. It delivers a new world of communication between Patient Consumers and carers. We have the capacity to share key health information at any time and any place. For the first time we can support health care teams all sharing the same health record and health management plans. We can provide detailed data analysis of health information to refine and support evidence based Health Care. We can do this at the level of an individual, a provider, a region or an entire population.
The most important tool is the capacity to provide an individual with the information and knowledge platform that allows them to take responsibility for their own care.
Take a look at Aboriginal Health and it is all there. They lead in tele-health applications. See Case Study at right.
Share health care information started in Katherine in the NT in 2002. This was part of the Australian Governments HealthConnect trials. Whilst the trial finished in 2005 it was so successful that in 2005 it expanded to be the Shared Electronic Health Record Service. This expanded to eHealthNT in 2008 and included a Secure Electronic Messaging Service. “Easy fast and secure method of communicating clinical information between health care providers including NT Public Hospitals” (NT Health).
In 2011 NT Health with support from the National Electronic Health Transition Authority (NEHTA) converted this to an Ocean EHR platform. This was called MyEHR. The conversion included fifty thousand patients with four million documents. This shared EHR was the first step in preparing for the Personally Controlled EHR. It interfaced with many disparate systems. Acute care hospitals, GP systems and Community Care. The result; a shared Health information system for the whole health care team servicing remote and predominantly Aboriginal Communities across the Northern Territory.
The final step in this path is the full transition to the Personally Controlled EHR (PCEHR). This will be Version 5 of the PCEHR and will bring nearly 100,000 full shared NT records into the PCEHR. Due for implementation mid year (depending on the outcome of the review) there are a number of very significant changes that take advantage of clinical experience from the MyEHR. Carers in the NT will have additional clinical function with links to the National Health Information network and the patient/consumers will get the advantage of personal control and access that underpins the PCEHR.
Consider the experience that the NT offers us at a National level. The have more than a decade of experience with shared health record information. This is predominantly in Aboriginal Health and remote communities. Not just GPs but the whole range of health care providers through out the Northern Territory, Aboriginal Health Workers, nurses, GPs, Specialists, Hospital Emergency Rooms, Community Health Workers, mental health teams, all from a vast range of organisations private, public, non Government. Clinicians who have moved on from who owns the information to understanding how important quality health records are to providing efficient health delivery.
At the Primary care level Aboriginal Health Informatics is very different. There is a limited range of Clinical Information system providers. Communicare (now owned by Telstra) has most of the Northern Territory to itself. In Western Australia there is one of the first true Internet based EHRs in Australia. Assoc/Prof David Glance (ex Microsoft) UWA centre for Software Development took a secure messaging application and built it into a full Internet EHR MMex. This application covers the Aboriginal Communities of the Kimberley and Brisbane Urban Aboriginal Health Region. Recently taken over by ISA Technologies Mmex reflects a massive amount of clinical input into development and like Commmunicare is geared heavily to Aboriginal Health needs.
So, in Aboriginal Health we have the opportunity to see and contrast two solutions to share health information; a full regional internet electronic Health Record application MMex, and more traditional practice based clinical information system using the National Shared Electronic Health Record to provide access to key information beyond the practice.
Best Practice and Medical Directors also play important roles in Aboriginal Health in the other states. What will be most interesting is what Telstra now does with Communicare. Will it move it to an Internet based record system or will it focus on the PCEHR as the sharing interface? Certainly present indications is that Communicare is well ahead in its PCEHR interface and is taking real advantage of the metadata capacity within the PCEHR. One suspects that they will look at both approaches over time. Internet based Communicare will allow a regional approach to a full shared electronic record with the PCEHR offering sharing when a patient leaves the region or needs care outside Primary Care. Essentially - the best of both worlds.
Dr Angus Turner, opthalmologist.
Dr Angus Turner, a young opthalmologist, has worked with remote Aboriginal communities to develop tele-health eye screening.
The process he undertakes includes a trained Aboriginal health worker taking a portable retinal scanner to a remote community and completing retinal scans on all the diabetics in that community. Each scan is then uploaded to an iPad with an inbuilt link to the Electronic Health Record. The health worker returns to centre and links the iPad to the internet based Electronic Health Record. The scans are uploaded to the individual patient’s record. Secure Email notification of the scan is sent to Dr Turner. Turner reads and reports on the scans in the patient record. A secure email then alerts the health worker on the need for full review, early repeats scan or routine follow up.
These patients live in locations that are further than Perth to Melbourne. Even the cost of flying a patient to the regional centre in Broome for a routine scan is more than $1000. For Indigenous diabetics, this screening should be performed annually.

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“Understanding clinical care is a real problem for analysts and developers. Understanding software design is worse than a foreign language for Clinicians. When the two groups meet they may as well be conversing in totally different languages.”
DR TREVOR LORD

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What will be most interesting is what Telstra now does with Communicare. Will it move it to an Internet based record system or will it focus on the PCEHR as the sharing interface? Certainly present indications is that Communicare is well ahead in its PCEHR interface and is taking real advantage of the metadata capacity within the PCEHR. One suspects that they will look at both approaches over time. Internet based Communicare will allow a regional approach to a full shared electronic record with the PCEHR offering sharing when a patient leaves the region or needs care outside Primary Care. Essentially - the best of both worlds.
Where Aboriginal Health Informatics is truly exceptional is in the area of population health. A New Zealand GP, Graham Simpson, migrated to the hills of Perth. Simpson was involved in the RACGP in the early 1980s when it produced the paper-based Problem Orientated Record System. Simpson decided to build an electronic Version. Medrecord was built early in the 1980s using the Pick operating system. Graeme could program in Pick Basic. Although not a true relational database Pick offered the capacity to build a range of relationships between data fields.
Medrecord had the optimum clinical input. It was built on the fly in a GP surgery. Graeme had a partner Jan Ravet. Jan was a great IT enthusiast and also learned to program in Basic. Jan was the first to try voice activation in clinical practice in Australia. Sadly the young patients laughing at his strange earphones and microphone made this form of input more than difficult in a live consultation.
Basys Gary And Karen Back with Ross Davies took on Medrecord as a commercial product. In fairness to the East Coast, Frank Fry was developing a very special prescribing package in his practice in Queensland. The progeny of this was Medical Director and now Best Practice. These are both are still alive and well, sadly Medrecord followed the path to demise of most Australian Medical Practice software.
Whilst the GPs had done a reasonable job it took a now well-known Trish Williams to come from the UK and produce the first full function EMR in Australia for GPs. At one million dollars and with an initial Commonwealth Project (Computer Assisted Practice Project 1986) with only 20 sites one can see t at cash flow was always going to become an issue for this first real player.
In the Kimberly an Aboriginal Health Doctor Ian Wronski (now Professor Wronski and Pro Vice Chancellor, Faculty of Medicine James Cook University) had the vision to see how computers could make a major difference to public health in Aboriginal communities. He went to Medrecord and commissioned them to build a special cut down version of Medrecord. Essentially this was a patient public health database. Health planner allowed Ian and his team to track the health care needs particularly in health prevention and health promotion of the Aboriginal people of the Kimberley.
In about 1997, Health Planner was replaced by the Primary Care Information System (PCIS). PCIS was a new version of Health Planner to move on from the demise of Medrecord. In the NT the extensive use of Communicare and the development of the Shared record PCIS is gradually reaching the end of its life. In the Kimberley PCIS has been replaced my MMex.
What Wronski started has progressed to the development of the sophisticated Chronic Disease Management modules within the Clinical Information systems used in Aboriginal Health.
For those looking at how we will address Chronic Disease information in the PCEHR these modules used in Aboriginal Health for more than two decades will be a very good starting point.
Aboriginal Health is also leading the way in data analysis. Tell me for your practice or health region how many of your regular female indigenous patients with diabetes and aged between 45 to 54 had a HBA1C (longer term measure of average blood sugar) of less than 7% (reasonable control)? Well, most Aboriginal community clinics, clinic networks and even regions can.
That and 378 other detailed questions on clinical performance in the management of chronic care, children and mothers forms the OCHRE Streams report. On Line Community Health Reporting Environment is compulsory for all Aboriginal Controlled Health Organisations in order to obtain funding.
In the Kimberly, using a full Internet record system one could look at the prevalence of any major health problem on 30,000 aboriginal people scattered across more than twice the area of Victoria. One can compare data from different communities.
Dr Trevor Lord
Dr Trevor Lord is clinical governance advisor and clinical lead of the National Electronic Health Transition Authority as well as being a member of the Royal Health West and RACGP Tele-heath Group and adjunct senior lecturer at the School of Medicine at the University of Notre Dame. He recently retired as senior medical officer of the Kimberly Aboriginal Medical Service responsible for chronic disease. He has served on many committees, including the 2011-2013 State Tele-health Advisory Group and 2012 National Tele-health conference.
Dr Lord has been published in numerous journals and publications on health informatics, and also presented at conferences on rural and remote health and telehealth

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“Aboriginal Health and its leadership has the capacity to show Australia the path to the health revolution and the amazing productivity gains that health informatics has to offer.”
DR TREVOR LORD

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One can compare data by age and sex as well as against National Data.
Not only can we examine the data but Aboriginal Community networks use it to guide efficient health delivery. Setting up smoking cessation program priorities, which communities are targeted first and which age group, is guided by actual numbers on live data. Try doing that in your local suburb.
So why has Aboriginal Health been so successful in delivering Health Informatics. When we look at most Health Informatics projects outside the Aboriginal Health sector, we often see failure. Health Care is complex. There is never black and white, it is all shades of grey.
Understanding clinical care is a real problem for analysts and developers. Understanding software design is worse than a foreign language for Clinicians. When the two groups meet they may as well be conversing in totally different languages.
Aboriginal Health Informatics started with the clinicians. Clinical input is still having an enormous impact on development. In Aboriginal health we see decades of experience. We now have a cohort of health Informatics experts in Aboriginal Health. These include nurses, health workers, doctors and a number of highly experience health informaticians. There are clinical leaders with Aboriginal health backgrounds and enormous experience in what health informatics can deliver.
We are now seeing young Aboriginal doctors who have past IT backgrounds and some Aboriginal health software developers entering post graduate medicine.
In Aboriginal Health we have already started that health revolution Australia desperately needs to improve the productivity of health care delivery. This started a long time ago.
Prior to the 1980s Aboriginal health was delivered by public hospitals and some general community services. Aboriginal people did not feel comfortable entering normal general practices. Sadly, they were often made to feel quite unwelcome. Key Aboriginal leaders drove the concept of Aboriginal controlled health services and throughout Australia Aboriginal controlled community clinics developed. Dr Puggy Hunter was one of many key players. Originally from Darwin he developed the East Kimberley Aboriginal Medical Service in Kununurra then played a key role in the Broome Aboriginal Service. He went on to chair the Regional Kimberly Aboriginal Health Services Council. This brought together all the Aboriginal Community Health Services in the whole Kimberly Region.
Aboriginal people appreciated that health care was a lot more than a visit to the doctor. They appreciated the devastating effect of chronic disease well before the white community. They wanted to prevent these diseases in their children. So their focus was always on prevention and public health.
In addition they wanted the care to be sensitive to their culture. That meant Aboriginal people delivering health care. The concept of the Aboriginal health worker was developed. Bright people with an interest in health were identified in their communities and trained to be local health workers. Their understanding of their community more than compensates for their lack of educational opportunity. Gradually, we saw Aboriginal nurses develop in the younger generation.
So the initial focus of Aboriginal health was about the community and the health care team. It was about patient centred public health, prevention and not about the doctor. When a patient presents with a problem the clinical team is always focussed on the opportunity to look at the whole health profile not just the one problem.
[caption id="attachment_8304" align="alignright" width="133"] Pro Vice Chancellor Ian Wronski[/caption]
Aboriginal Health had this as the focus when looking for the tools to support care delivery. This, well before the technology was available. This focus enabled their health leaders to better inform the Health informatics community on the real needs.
As a result, their development projects all had a high level of success. Their small HealthConnect Project became an entire Northern Territory Shared Record System. Now it will be an important part of the PCEHR. A small project with UWA and the Kimberley has seen Australia’s first regional Internet based Electronic Health Record.
So, in Australia, the Aboriginal health community now stands ready to go forward in health informatics. They have more than a decade of experience in shared health information. They have demonstrated the capacity to deliver highly sophisticated data across a community, a region and a nation to enable identification of health care needs and priorities. They have the most experience with tele-health, satellite communication and remote monitoring tools.
I would argue that Aboriginal health leads Australia in community based eHealth and health informatics. There is a proven capacity to efficiently deliver innovation and effective change. The future is bright. Aboriginal Health and its leadership has the capacity to show Australia the path to the health revolution and the amazing productivity gains that health informatics has to offer.