Inner Melbourne Medicare Urgent Care Clinic Worked Well With No Charge

A week after I had a minor health problem looked at by a Canberra Health Walk-in Centre, I had a recurrence and needed more treatment. I was visiting another city on Saturday night. Not knowing what else to do I went to the emergency department of the relevant specialist public hospital, where I had been treated 40 years before. I was promptly seen by a triage nurse who took a few details. About twenty minutes later I was examined and told the doctor would likely prescribe what the nurse practitioner did in Canberra. However I then sat for an hour and half waiting to be seen by a doctor. From the number of people waiting I estimated I would not be seen for another ten hours. So I apologized to the nurse at the desk & left.

In the interim I discovered there was a Inner Melbourne Medicare Urgent Care Clinic, which opened 8am Sunday. So I would be able to be seen there, before it was likely the emergency staff of the hospital would get to me. At exactly 8am the next day the door opened at the clinic. There was more admin, thanin Canberra, having to fill in a HotDoc based form, but not too hard. About ten minutes later I was examined by a doctor and prescribed what I had previously taken. In Canberra I had been simply handed medicine, but here I had to find a pharmacist in a strange city on a Sunday morning (difficult, but not impossible). 

I continue to be impressed with Medicare Urgent Care Clinics. They do what they are designed for: to divert people who do not have life threatening conditions from hospital emergency departments. It is not that these people, including me, are turing up at hospital for the fun of it, we just don't have anywhere else to go. 

One aspect which needs work is electronic medical records. The Canberra clinic apparently did not have my hospital records despite being in the same hospital system. The Melbourne hospital had my name and address on file, but had retained no details of my previous treatment. The Melbourne clinic had none of my medical details, despite my approving they have access to my digital health record and Medicare details.

Canberra Health Walk-in Centre Worked Well and is Free

I needed a minor health problem looked at and my doctor was busy, so I went to one of  Canberra Health's five Walk-in Centres. Normally I would have gone to one in Belconnen, but the website showed they had five people waiting for treatment, so I went to Dickson, which had only two. The Dickson Center looks like any large medical practice. The difference is the lack of paperwork, the speed, and nothing to pay. I only had to give my name and confirm my phone number, for the receptionist to find my medical record. After a few minutes a nurse practitioner showed me into a very well equipped examination room. After some questions, examination and diagnosis, I was handed medicine, told how to take it and was out the door. The clinics are part of a national system of Urgent Care Clinics and designed to take the load off public hospital emergency departments, by diverting non-urgent cases.

Improved ACT Health COVID-19 Vaccination Booking System

To make an online booking at ACT Government COVID-19 vaccination clinics, clients are required to use the MyDHR system. Previously when I tried to register I found the process confusing and was not able to register. When I tried today, I found the process had improved and I was able to register, but it appears it is still not possible to use this system to book a vaccination online. This differs from private vaccinations clinics, where the patient is shown dates and times they can select from, online, as soon as they are registered in the system. 

Medicare Number Format

A problem still exists with the way the patient has to enter the Medicare number on the ACT Government system. This differs from the format used by Federal Government and private providers. It will only be a problem the first time the patient registers with the system. For someone who will regularly attend a clinic for medical treatments, that is not a major problem. But for an emergency vaccination campaign, where each patient will attend only two or three times, difficulties in initially registering are more significant. 

Registration 

The ACT Government page on vaccinations has a link for patients to register. However, that link doesn't take the patient to the registration screen, but to the login screen. The patient is then asked for their user ID and password they have not yet been issued with, which is confusing. There is a link for registering, but patients are may be confused at this point and never see the link.

MyDHR One Time Security Code,
ACT Health, 3 July 2021

Once the link is found, registering is not too complex. The patient is asked to enter a code sent by email or SMS. This is described as a "one time security code". If this process only applies during signup it is not clear how this authenticates the person, as neither the email address or telephone number have been separately authenticated (unless perhaps this information is obtained from Medicare). 

Secure Username?

MyDHR Choose User name,
ACT Health, 3 July 2021

After entering the security code (which arrived promptly by SMS), I was asked to create a user name. Confusingly, the instructions were to "think of one that is secure and easy to remember". It is not clear why the user name has to be "secure", as there is a separate password to be entered. The instruction to make the user name secure contradicts the one to have it easy to remember. Also the indication that this username can never be changed would add to the stress for the patient. Also it is a flaw in the security of the system to have a code which must be secure and cannot be regularly changed.

MyDHR Main Screen

MyDHR Main Screen,

ACT Health, 3 July 2021

After choosing a username and password, I was presented with a reasonably easy to read main screen. However, the first item listed was not booking a COVID-19 Vaccination, but checking eligibility. I suggest this be changed, s the purpose of the exercise is to book a vaccination. 

MyDHR Vaccine Eligibility,
ACT Health, 3 July 2021

After answering a short list of questions about eligibility, I expected to be told I was eligible. However, instead the message was that if I was eligible, I would be contacted withing 24 hours to let me know when an appointment was available.  This is not a good systems design, as first of all the patient has to wait 24 hours, for no good reason. Secondly, a patient who hears nothing doesn't know if they have been placed in a lower priority category, or missed the message. Thirdly, it is not clear to the patient how they actually book a vaccination.

No Medical Records on System

The ACT Government system is intended to provide a comprehensive system for patients of ACT Health, not just vaccinations. So I looked to see what records were recorded. There was not record of my ever being a patient, although I had spent a night in the ICU and received numerous tests. It may be my treatment was too long ago to be worth loading into the new system, but patients will not feel reassured about receiving further treatment, if there is no record of their previous treatment.

Confusing Email

After registering, I received an email with the subject line "Please check your MyDHR account". However, the body of the message said "... you have new information in MyChart.". But what is MyChart? There was no signature block to indicate this message was from the ACT Government, and no contact details to reassure the patient this was a genuine message and help the patient seek further information (the message had a "no reply" address). 

Why Are the Federal & ACT COVID-19 Vaccination Booking Websites So Difficult to Use?

WHO Digital Vaccination Certificate

This is to suggest improvements in the COVID-19 vaccination websites of the Federal and ACT Governments. In contrast to those of a private medial provider, the government sites do not appear to have been designed to prioritize vaccination of the general public. It is suggested a booking link be added to the top of the federal and ACT pages, and the ACT use the same Medicare number format as other providers, and not limit online booking at its clinics to existing patients. This is based on my experience helping design emergency websites and teaching how to do this. 

Below I detail some changes, and why they are needed. Australia's vaccination rate is currently far below that needed to have everyone eligible offered at least one dose buy the end of the year. There are obvious flaws in the federal and ACT vaccination websites, including incorrect, and misleading formation. By making it harder for the public to get vaccinated, are placing lives, and the economy, at risk. It is suggested changing the government sites to make it easier for the bulk of the population to book a vaccination. It would also be useful to offer something tangible, such as a vaccination certificate, with a QR code.

Suggested Changes

1. Booking Link at Top of Page: Both federal and ACT governments should have a line at the top of their main COVID-19 web pages for booking:

• Fifty or over? Book your COVID-19 vaccination now:  50+ Book! 

2. Show online booking sites first: The federal government page should display vaccination centers which have online booking first. Public high capacity clinics should be displayed first, followed by GP clinics, and GPs last.

3. Allow ACT residents to register online with ACT Health: The ACT Government should delete the map from their page until there are more ACT centers for the public to choose from. The Medicare number entry field on the MyDHR registration page should be changed to use the same format as federal government and private medical sites. The restriction that only existing patients can register should be lifted. 

Finding Where to Get Vaccinated

A web search using Google for "covid19 vaccine booking", has as the first four responses:

1. COVID-19 Vaccine Booking - Book An Appointment (Ad) https://www.health.gov.au/
2. COVID-19 vaccinations - Available now in Canberra (Ad) https://www.nhc.coop/
3. How will I get my COVID-19 vaccine? | Australian Government ...www.health.gov.au 
4. Booking your COVID-19 vaccination - COVID-19 - ACT Health www.covid19.act.gov.au

The first two of these are paid advertisements and the next two native responses. The first is to the federal health website, the next a private clinic in Canberra, then a different Federal Government page and lastly the ACT Government. That there are two different federal government pages resulting from the one search is confusing. 

Federal Health Website

The first Federal Government page says "... book an appointment if you are eligible ...", but this is below the fold, below the first screen of information, in the middle of a sentence and thus very difficult to see. 

From: COVID-19 vaccines, Australian Government Department of Health, 17 May 2021 (detail). https://www.health.gov.au/initiatives-and-programs/covid-19-vaccines

The priority in the design of this page appears to be to educate the public as to who is eligible, so as not to overload the system. With the decision to permit all over 50s to book, I suggest this is misplaced. The priority should be on getting people vaccinated and saying "book vaccination".

After three screens the federal system displays the nearest vaccination centers. Here they are for O'Connor, ACT:

Vaccination centers suggested for O'Connor ACT.

The screen is headed with "Please use online appointments where available to reduce call volumes to clinics. If you can’t find an appointment or a clinic in your location, please check back in a week.". However, four of the five entries displays are for phone bookings only. Following the instructions given, the user would select the one and only clinic which takes online bookings.

The only entry which has a link for online booking is to the ACT Government clinic. However, this only accepts online booking from previous patents of ACT Heath (and I was unable to make a booking even though I had been a patient). 

National Health Co-op

National Health Co-op is a non-government, not-for-profit health service. The web link leads to a vaccinations page, with two buttons, for "Covid 19" and "Flu Shot". This then shows the six locations where a shot can be booked. The details of how to registered and book are left until later.

National Health Co-op COVID-19 Booking details

This is a good design, the user gets to see where they could go, without having to enter a lot of personal details first. However, the information presented contradicts that on the Federal Health web site. The Federal site lists the Co-op's ANU clinic as available for phone bookings only. That clinic is not listed by the Co-op's website and all of those listed can be booked online. It appears the Federal government site is incorrect, listing a clinic which is not available and also not listing those which are. 

Second Federal Government Web Page

The second federal government page to appear in the web search results is "How will I get my COVID-19 vaccine?". This has a link for "Book or register for COVID-19 vaccination", but below the fold, so the user has to scroll down to find it. This then links to the COVID-19 Vaccine Eligibility Checker, discussed above. Again the booking link is not prominent, and the page does not appear to be designed to have vaccination booking as a priority.

Federal how will I get my vaccine page.

This is not a good design, as the link for booking a vaccination is not prominent. 

ACT Health

The ACT Health Booking your COVID-19 vaccination page, has the link "How to book your COVID-19 vaccination" above the fold. 

ACT Health Booking your COVID-19 vaccination page

This then displays a map showing the clinics:

ACT clinics map

However, only one of three of the clinics shown are for the general public. As a result showing a map is misleading, not useful. The one clinic shown requires online booking via the ACT Government booking system "MyDHR". This system requires entry of the Medicare number in a format different to that used by the federal government and private providers, and the number is not displayed as it is entered. Also online registration is only available to those who are already patients in the ACT health system (and in some chases even not then). 

MyDHR Registration screen obscuring Medicare number.

Previously I provided some "Suggested Improvements to ACT Health COVID-19 Vaccination Booking System". Unfortunately so far the ACT Government has not made the suggested improvements. The only response received is a Tweet (3:01 PM · May 14, 2021) from ACT Health: 

"Hi, if you have any technical issues when using MyDHR, please call 02 5124 5000 (24 hours a day, 7 days a week). Please refer to our FAQ 'I'm having issues signing up to MyDHR' for other reasons you may be having issues"

While this doesn't address any of the issues, it at least indicates the suggestions have been received by the ACT Government.

Suggested Improvements to ACT Health COVID-19 Vaccination Booking System

To make an online booking at ACT Government COVID-19 vaccination clinics, clients are required to use the MyDHR system. However, the way the client enters their Medicare number is very confusing and only those who have already been clients of ACT Health can make a booking. I suggest the way the Medicare number is entered is made easier, in line with other online systems. Also I suggest the requirement that only existing clients can book be lifted.

The page with information on bookings has an explanation of how to enter the  number. However, this is down on the page, below where the user is invited to click to make a booking. As a result it is likely most users will never see the instructions on entering the Medicare number, particularly when using a smart phone. 

Medicare Number Problem

The ACT Government instructions on how to enter the Medicare number contradict those of the Federal government. The Federal government says:

"Enter your Medicare card number, followed by your Individual Reference Number"

But the ACT Government says: 

"When filling out the Medicare number, please note the format needs to be XXXXXXXXXX-X where the last digit (IRN) is what appears next to your first name on your Medicare card".

Compounding the problem is that the MyHDR registration screen does not display the Medicare number as it is entered.

I suggest the Medicare number be displayed and be entered in two parts: the Medicare number itself, and the IRN.

MyDHR Registration screen obscuring Medicare number.

Registration Problem

The MyDHR login page has a "Sign up for MyDHR" button. This then requested the client's name, date of birth and Medicare number.However, registration is not accepted from new clients. The person registering has to have already been to ACT Health. I suggest this be changed to accept registration for anyone with a Medicare card.

Credible, easy to use booking system needed

Talking on web for Pandemics 

On Monday morning I attempted to use the MyDHR system to book a vaccination. I was unable to do so. This was surprising as I have been a client of ACT Health, so should be in their system. It was also surprising how difficult the system was to use (I have given talks around the world on the design of web systems for pandemics).  Instead I booked at a GP clinic, using their working online booking system. 

To ensure as many are vaccinated, as quickly as possible, we need easy to use, functioning vaccination booking systems. I suggest the ACT Government make urgent changes to their system to ensure public safety. 

Unable to Register for a e-Health Record

A letter from the last hospital I was in invited me to register for an e-health record. After going to www.ehealth.gov.au I was directed to australia.gov.au where I filled in some more details, until I got: "A previous session has been started and has not completed. Please try again later." The letter indicated that the e-health  record "... will not contain any clinical data", so I could not see what use it would be, even if I could manage to register for one. So at that point I gave up.

Senate Committee Recommends Electronic Health Records

The Senate Standing Committee on Community Affairs has reported on the Personally Controlled Electronic Health Records Bill 2011,19 March 2012. Despite privacy concerns expressed in evidence to the committee, the report largely supports the implementation of eHealth records.

The committee made three recommendations:

1. (2.24) The committee recommends that the review of the operation of the Act that will occur after two years pursuant to Clause 108 specifically consider the issue of the appropriateness of the vesting of the System Operator responsibility in the Secretary of the Department of Health and Ageing as well as possible alternative governance structures.

2. (2.46) The committee recommends that the review of the operation of the Act that will occur after two years pursuant to Clause 108 consider the opt-in design of the system including consideration of the feasibility and appropriateness of a transition to an op-out system.

3. (2.85) The committee recommends that the bills be passed.

From: Chapter 2 - The bills, Personally Controlled Electronic Health Records Bill 2011, Senate Standing Committee on Community Affairs, Parliament of Australia, 19 March 2012.

Contents

• MEMBERSHIP OF THE COMMITTEE (PDF 24KB)

• Chapter 1 - Personally Controlled Electronic Health Records Bill 2011 and the Personally Controlled Electronic Health Records (Consequential Amendments) Bill 2011

  The referral
  Scrutiny of Bills consideration
  Conduct of the inquiry
  Background to the policy development
  Structure of the report
  

  Chapter 2 - The bills
  

  Introduction
  An overview of the PCEHR system
  General support for eHealth
  Governance arrangements
  Functionality of the PCEHR System
  Timeline
  

• Australian Greens Additional Comments

  Australian Greens Comments
  No Access
  Default Access Controls
  Definitions
  Use of data in research
  Australian Greens Recommend

• Dissenting Report by Coalition Senators

  Adoption, Functionality and Interoperability of the PCEHR
  “No Access” Controls
  The Consumer and the Bill
  Privacy
  Legal Liabilities
  Risk and Patient Safety
  Conclusion
  

• Appendix 1
  

  Submissions received
  Tabled documents
  Answers to questions taken on notice
  

• Appendix 2 - Public hearings

An overview of the PCEHR system

2.5 The PCEHR system will enable any Australian to register for an eHealth record and at the time of registering choose who will be able to access their record and the level of access that those parties may have. Consumers who elect to register will also be able to nominate a representative to help them manage their PCEHR.[5] ...

2.11 Submitters to the inquiry have been in favour of the benefits that will result from the implementation of the PCEHR system, many recognising that it is time that such a system were implemented. ...

2.18 Part 2 of the Personally Controlled Electronic Health Records Bill 2011 (PCEHR Bill) sets out the governance arrangements for the PCEHR system.[19] Part 2 identifies the System Operator and specifies advisory bodies to the System Operator.[20] ...

2.21 The Australian Privacy Foundation (APF) went as far as suggesting that implementation of the PCEHR system should be delayed until the governance arrangements set out in the bill are changed. Implementation on the basis that after two years the System Operator role would be transitioned to an independent body was not enough to allay their concerns ...

2.22 The Medical Software Industry Association (MSIA) also 'believes the System Operator (as described) is impossibly conflicted with roles as System Operator, System funder, and NEHTA Board Member.'[26] ...

From: Personally Controlled Electronic Health Records Bill 2011, Senate Standing Committee on Community Affairs, Parliament of Australia, 19 March 2012.

Broadband for the Bush

Dr Ian Oppermann, Director of the CSIRO ICT Centre talked on "Broadband for the Bush", at an Australian Computer Society meeting in Canberra on 10 August 2011.

Ian Oppermann started his presentation by making the case for CSIRO's ICT credentials, referring to CSIRO's development of CSIRAC (the fourth electronic computer in the world) and the invention of WiFi technology. He pointed out Australia is a big country with a small, literate population, but only 17th in the world for broadband take-up. Ian related how the world are looking to the NBN as a model for national broadband. Ian then pointed to the aging population and resulting increase in health costs, which broadband could help reduce.

The next point wast that Australia is increasingly a services economy. At CeBit Senator Conroy pointed out that Australia's productivity has dropped in the past decade, using statistics from "Australia's Productivity Challenge" (Grattan, 2011). Mining is very productive (in $ produced per hour of work), most services industries (including education) are not. Compared to the USA, Australian productivity is dropping and if mining is excluded Australia is the lower segment compared to OECD countries.

Ian mentioned he had been doing some work in smart grids and this was a conservative industry (as is health). Health expenditure is about 9% of GDP. eHealth records can reduce costs, assuming privacy and other issues can be addressed (I see the latest electronic Journal of Health Informatics is on Smart Healthcare Systems).

Another area is smart technologies, with CSIRO having developed a Care Assessment Platform, which interacts with the patient via a smart phone. The application provides the patient with better more personal service and reduces costs.

Another is a Virtual Critical Care Unit (ViCCU). This allows specialists at major hospitals to advise staff at regional ones, via a telecommunications link, reducing the need to transport patients. As Ian pointed out the major barrier with this is not the ICT, but fitting it to the medical need and training the medical staff to use the technology.

Ian then shifted the topic from e-health to e-Government, from with the example of staff at government agencies available on-line to help fill in forms. That may sound trivial, but a considerable amount of staff time and customer frustration can be saved by this. One point I would disagree on is the need for high resolution real time video for this application. Those who have grown up with text messaging may be more comfortable with that mode. This can also be near real time, making it more convenient for the customer and more efficient for the organization.

CSIRO, NBN Co and others have set up the Australian Centre for Broadband Innovation (ACBI) to research broadband applications, including for the NBN. The NBN fiber will cover 93% of the population, fixed wireless 4% and satellite for the remaining 3%. It should be noted that fiber covers only a tiny area of Australia. As Ian pointed out the fiber is symmetrical, whereas the satellite is not: that is more data can be transmitted from the satellite than can be transmitted to it. CSIRO is researching high speed symmetrical terrestrial wireless data ("Ngara") which can extend the coverage area and the speed. This would be very significant for regional Australia and the world. However, in my view, Ngara will take years to develop and so the current NBN plans should continue.

Dr Oppermann will also speak in Sydney 29 August 2011. Dr Darrell Williamson, Director CSIRO eResearch program, will speak on the same topic in Darwin 8 September 2011, Adelaide 28 September 2011 and Perth 16 August 2011. Dr Alex Zelinsky, CSIRO Group Executive of Information Sciences will speak in Brisbane 13 September 2011.

Broadband Nurses to Lower Medicare Cost

From 1 November 2010 patients can claim on Medicare when
examined by suitably qualified nurses. The nurse can examine a patient on their own (without a doctor), write some prescriptions and referrals.

What might be useful is nurse practitioners linked to doctors by broadband. A nurse practitioner could record the patient history and make an examination. Then, where necessary, the nurse could contact a doctor online. The patient details would appear on the doctor's screen along with live video. The doctor could then make a quick assessment. In most cases they would simply confirm the nurse's diagnosis. But they could request further tests, write a prescription, or ask the patient to come in person.

As the nurse practitioners can now set up practice for themselves, this could change the balance of power in the medical profession and lower costs. Most visits to the doctor would be eliminated. The nurse would be the one the patient goes to see and so the nurse would decide if patient needs to see a doctor and which doctor they will see.

iPad in medical training

The EDUCAUSE Instructional Technologies Constituent Group has been discussing use of the Apple iPad in education. What struck me was the number of universities introducing the iPad for training doctors, pharmacists, dentists and nurses.

Apple on their own web site feature the iPad for Post-critical care. That is in educating the patient about what to do to recover. This is an interesting choice of application, as it avoids most of the issues to do with reliability, performance and security, which apply to medical records applications. The iPad would be used essentially as a fancy flip chart to show the patient diagrams. So it does not much matter if it breaks and it would not need to hold sensitive medical records.

If the iPad works okay in training, as I expect it will, this will create a demand for tablet computers to be used throughout medicine. There have been attempts at using tablet computers previously in hospitals, but these have tended to be large, heavy devices with cumbersome software. The iPad might be what makes e-heath popular and practical.

The ACT Health Library, provided by the Australian National University, has a list of iPhone/iPad/Mobile medical reference works available. This includes several reference works which require medical staff to register with their corporate identification to gain access. Others are apps for a moderate charge. There are also dozens of free items for medical students and patient education.

ACT Health Records Legislation

The ACT Minister for Territory and Municipal Services presented the "Territory Records Amendment Bill 2010" bill to the ACT Legislative Assembly on 23 September 2010. As the explanatory statement says the new legislation is the result of a review to the Territory Records Act 2002 in 2009/10 and brings government recordkeeping under the one set of rules. Most significant is the effect on Health Records kept by government. These will still be protected by separate priovacy legislation but but allows ACT Health to have an integrated Records Management Program.

Hopefully this will enable ACT Health to implement an integrated electronic records management system for ACT hospitals. Recently I attended Canberra Hospital to hear of the results of medical tests, only to be told that the hospital had no record of the tests. The tests had been outsourced from Canberra to Calvary Hospital and there is no sharing of records, electronic or pn paper, between the two publicly funded hospitals. So the doctor then has to spend 20 minutes phoning Calvary Hospital and arranging to have the test results faxed over. Also the doctor was unable to find any previous test results from my previous stay in Canberra Hospital, due to a problem with the Canberra Hospital computer system.

This failure of the ACT Health system not only would have resulted in a waste of public money (with five times the cost is staff time) but also places the health of patients at risk. Hopefully the new legislation will enable ACT Health to implement an integrated electronic medical record system for publicly funded hospitals in Canberra.

As I am designing a course in Electronic Data Management for ANU , I might use the design of electronic records system for Canberra hospitals as a case study. The ANU teaches doctors in Canberra's hospitals and so I can teach the doctors who will need to use the system how that system should work and how to use it.

Humanitarian Open Source Software

The Sahana Disaster Management system is not the only humanitarian Open Source Software (OSS) project. There is also the OpenMRS medical record system and the Humanitarian FOSS Project. Many of such projects take part in the Google Summer of Code where volunteers work intensively on the projects. They also involve university software engineering students encouraged by their institutions to gain experience in teamwork through the projects.

Building the Australian National Health Network

Dr George Margelis, from Intel's Digital Health Group, talked last night in Canberra on "The Patient Journey - What role for IT?" he will be repeating this in Brisbane 17 March.

Dr Margelis, showed a number of interesting before and after video segments of problems with the health system and how ICT could help. Normally I dislike company videos in presentations as they are advertisements for companies. While these were clearly produced for Intel, they were relevant to the topic.

The first video was of someone being rushed to hospital in an ambulance (which I could identify with having had it happen to me). This illustrated how currently medical staff in the ambulance and the hospital use computer based systems, but these are not linked, so that information has to be relayed by voice or paper. A future scenario showed the patent details being shared online between the ambulance and the hospital. Dr Margelis emphasised that none of the technology envisaged was exotic and was not already in use in other fields. It was a matter of integrating it into the medial system in a way which helped the medical staff and the patents.

The major issue was to network records so that dispersed medical services could serve the patient. Dr Margelis showed a scenario networking the ambulance to the hospital, to the remote specialist.

In a later scenario Dr Margelis showed patients using a home based system. This not only monitored the patent and prompted them to take medication, but also connected them to their helpers and medical staff, using a wireless mHealth device.

One problem I had with these scenarios is that they were applying computerisation to an existing system without considering how to change the system. As an example, it is difficult for a hospital to obtain patent's GP records in an emergency, because the records are stored on paper in dispersed GP offices. The Intel solution is to network the records. An alternative low technology solution would be to group the GPs in clinics. These clinics would then be large enough to employ professional record keepers and be open 24 hours a day, so they could respond to emergency record requests. My doctor would not like this as they see themselves as a provider of custom personal services, not part of a corporation. However, the alternative ICT solution will result in some loss of their autonomy.

What Dr Margelis presented was a clear logical vision. The question this raises is why has it not been done? This is not a technical issue, but still an issue for ICT professionals. It is not enough to we have a solution, it is the customer's fault for not buying it. The underlying issues as to why such systems are not implemented need to be addressed.

The Prime Minister has proposed to take over all public hospitals in Australia. As Dr Margelis pointed out, the public hospitals are the smallest and least important part of the health care system. There is a risk that the government will concentrate on hospitals, resulting in better hospitals but an overall decline in the quality of health care and an increase in costs. This would be similar to the situation where the government funded insulation in homes is likely to increase energy use, rather than reduce it. Similarly a networked national hospital system may increase costs and reduce the health of the population.

Some far less glamorous, less expensive, more local community health initiatives, might be far more effective. These could still make use of ICT.

The NBN Company provides one possible model for the health care reforms. Under this approach the government announced an impressive sounding multi-billion dollar national broadband network (NBN). They then set up a government owned company to implement it. What NBN Co has done is architect a national system, but are first implementing small scale local projects. These projects are small enough to be implemented efficiently and provide local benefits in the short term, so the government can be seen to be delivering services (in what might happen to be marginal electorates). One day all these system might join up into the envisaged national system, but in the interim they will provide useful local services to the community and political kudos to the government.

Current attempts at national e-Health standards are mired in the need to have a consultative process between government and industry. NBN overcame this problem with broadband standards by consulting with parties, but making clear that as a company they were not required to wait for everyone to agree and were going to make a decision and then implement that decision. A NHN Co (Australian National Health Network Company) could make similar decisions for e-health standards and the implement them.

The government could announce the goal that all public hospitals would be networked and all patent electronic health records would be available by a set date. Governments and companies which did not wish to cooperate would not be funded.

One interesting question asked was when will patents will be able to ask their doctor to put their records on Google health. This might be useful for the patent, but the doctor would need to be compensated for the extra effort in working out how to do this.

Another question was on casemix to provide appropriate incentives for keeping people healthy, instead of dispensing medicine to them. If there were the right incentives this would provide an incentive for better ICT systems to keep the patents out of hospital.

It was pointed out that there are now international standards for medical imaging (Xrays). There is now under way for standards for the medial records delivered to the patent in the home, so that we will not first build proprietary systems and then have to convert to real standards. It may be that Australia has to accept an international standard which is not as good as a local standard, but which is adequate and has the advantage of widespread acceptance.

See also: ICT in Health Delivery in the 21st Century in 11 November 2008.