CHAIRMAN —I now call witnesses from the Australian College of Health Service Executives and the New South Wales Branch of the Australian College of Health Service Executives to be sworn. Is there anything you want to add about the capacity in which you appear?

Mr Westcott —I am general manager of Nepean Health in Sydney.

Dr Southon —I am a consultant in Information Technology and have been asked to advise the college.

CHAIRMAN —Before we commence questioning, would you like to give us a brief summary of the submission, perhaps highlighting some points that you think are key matters of which we should take note.

Mr Westcott —I would like to table some points that we would like to make in today's presentation, drawing from the submission. We will cover those points today, if we may.

The Australian College of Health Service Executives is a college which represents professional health executives across Australia. It has a wide representation of members drawn from both the public and private sectors of health service, also from academics in health administration and from consultants. It has about 2,500 members across Australia. The federal branch made this submission and Gray and I are speaking on behalf of it, as New South Wales branch members.

CHAIRMAN —The submission warns that there may be significant pressures influencing assessment of clinical validity arising from possible cost savings, patient convenience, demands on professional relationships or changing professional roles. Could you elaborate, for the benefit of the committee, on your concerns and explain if your statement means that the quality of care may suffer through the practice of Telemedicine and how this may incur costs to the community.

Dr Southon —I will put this in the context that the technology has diverse impact on the organisation and the way people interact with each other, both within organisations and outside organisations. It is very important to take these factors into account, and managers, of course, are in a position of having to understand these interactions and make sure that the various parties interact effectively.

Telemedicine involves facilitating quite sophisticated interactions between people that may have no other way of interacting with each other. They might just have an occasional interaction through this technology and in this process have to undertake quite sophisticated clinical relationships. Unless those processes are enabled and undertaken in the most beneficial way, people may not be able to actually work together effectively under this environment. It is the nature of the interactions between the people involved that have an important impact on the type of clinical process that is achieved.

Mr QUICK —Your members gain some tertiary qualifications to enable them to take up senior managerial executive positions within the health departments.

Mr Westcott —That is right.

Mr QUICK —We heard today from the University of Sydney about how they are making a quantum leap in the training of medical practitioners using available Information Technology. How are you modifying or adapting the courses that your future health service executives are undertaking? Is it a Bachelor of Management, an MBA or whatever it might be? How are you managing the changes in technology? As I said, there seems to be a reluctance running through your submission about what the benefits really might be. Can you explain that, if it is possible?

Mr Westcott —The college has entry criteria attached to it. Tertiary qualifications are required for entry to the college. They are generally undergraduate courses in health service administration, business economics and those types of things or postgraduate qualifications.

The qualifications that have been specifically developed in the area of health service administration are provided through a number of universities around Australia. They are tending more to be delivered at postgraduate level than undergraduate level now. Health service administration is a fairly narrow field. By and large, the college does not encourage people to go directly from school into such a narrow field. It is much better for people to get a general qualification in management, business, accounting or a clinical field and then decide that they want to concentrate on health service management and do a postgraduate masters qualification in that particular field.

As far as the courses themselves are concerned--I think this is one of the issues that we are raising here--the courses that are provided for health service managers have to attempt to adapt to the various sorts of environments that we are working in. There needs to be additional research and additional pilot studies done of how managers operate in an environment where you have Information Technology introduced to it.

A lot of the problems that we are alluding to in our submission are not of a technical nature. The hardware is fine; the software you buy. It is the actual implementation of making the thing work when it gets into the workplace. That is where the manager comes in trying to ensure that the greatest benefits are achieved from the implementation of these systems. Without appearing to be Luddite, as was mentioned earlier, and perhaps sounding a word of caution, it has been shown in a number of cases where systems have been introduced into the health setting that they have been less than successful in meeting the original claims.

Mr QUICK —Can you give us some examples of those because I am interested in that? Could you give me examples of what has been introduced, what has failed and why? You mentioned in an earlier paragraph:

. . . the benefits of such technology cannot be taken for granted . . .

And you say later:

There is a wealth of information amongst the members . . . concerning the successes and failures . . .

I would like to know about some of the failures so we can read up on them and perhaps ask questions when we are wandering around. We could say, `Why did system X and system Y fail and system A and system B succeed? Whose idea were they?'

Mr Westcott —I guess you may not be able to read up on them because those that have failed are usually not too well published. I will just mention one. Gray is more involved in this area in detail and he can give you some more detailed explanations. The New South Wales health department attempted to introduce a new patient administration system recently by purchasing some American software called First Data and the whole project has been totally abandoned and basically they are back to square one now.

Mr QUICK —What would the cost of that be?

Mr Westcott —I think they admit to $15 million, but I have heard more like $80 million was the loss in trying to introduce that system. It was basically trying to take an American system and adapt it to Australian circumstances. This is not a big enough market for the American companies to do that in. They will only put so much in and after that they just write it off.

Mr FORREST —I think I have some idea of what you are talking about. There is a changed relationship between institutions. The way my own office operates, it used to be a letter, then a fax and then a phone call the next day asking, `Why haven't you answered my fax?' Now it is the e-mail and it just takes over the way the office relates. I know what you are talking about there. It seems to me that in reading your submission the emphasis is the wrong way. The emphasis in encouraging the use of this technology has to be the delivery of a better health outcome. That has to be the reason for it. It is certainly one of the reasons why I am enthusiastic in terms of giving a better health outcome for people in rural locations.

I would be interested in your comment along those lines, but the stresses and strains are going to continue, I am afraid, as modern life--and especially in this area of communications--puts us all under more pressure to respond more quickly. But in the health care area it is to deliver a better outcome. A quicker response can save a life. Could I tease you out a little bit more on what you were saying earlier about those pressures?

Dr Southon —I apologise for any interpretation of a negative response. Certainly our objective is to use technology just as effectively as possible, but the effectiveness is the key and we have to make sure the technology is effective. We have to recognise that there is not a very good record of systems being effective. The Commonwealth submission referred to a 90 per cent failure rate. I would not support that. I would support more like 30 per cent but still that is too high.

We have to recognise that it is a very difficult area and, if we are going to be putting money in, we have to have reasonable confidence that is going to be effective. We need to make sure that we get information from the trials. There were comments earlier about the lack of information from trials. We need to understand why that information is not coming from trials. I believe there are a number of reasons for that. We have to provide the managers with the tools by which they can make wise decisions about the use of the funds so that they can make sure that their technology works for them, their organisations and their patients.

CHAIRMAN —To what extent should governments be involved in the development of Telemedicine and health Information Technology? Where there is government involvement, should it be state or federal or both?

Dr Southon —I would say certainly both and both are involved very much as a facilitative role. I believe a lot of the things they are doing are good such as promoting standards and getting people to talk to each other. There is the development of communications and making sure that people know what is going on and are talking to each other effectively and are developing their own initiatives in the framework in which that interacts with other people. It is a very important contribution to be able to keep up with the developments and be able to pick the areas, thereby producing a bit of funding, a bit of information or a bit of encouragement. Then the whole process can be coordinated and developed more effectively.

CHAIRMAN —Can you provide the committee with your views about problems with confidentiality which electronic medical records pose and compare those problems with the very obvious problems that currently exist with respect to paper-based records?

Dr Southon —It is a matter of degree. There is certainly no guarantee with a paper-based record, particularly when it is transmitted through the mail. When people talk about the repository in which all the information is cumulated in one place and a whole lot of people have access to that, then the possibilities of people getting very ready access to enormous amounts of information is very high. That is the element of degree and that needs to be very carefully taken into account.

Mr Westcott —Can I follow that up by saying that it is always a balance and a compromise. When it comes to making information more readily available, generally speaking that is a good thing, but with information systems the ability for people to access vast amounts of information is much greater than under manual paper-based systems. We face this almost daily. Now we have an ability through modification to one of our existing programs whereby we can automatically fax to general practitioners extracts of the computerised data that we keep on patients to keep them informed as to major things that happen to patients when they are in hospital. This mechanism is of huge benefit to a general practitioner. The worse thing a general practitioner will tell you about hospitals is their discharge summaries. They always come late, they are illegible and a whole range of other problems associated with them.

Information Technology can help the GP a lot here simply by recording on a computer every time a major thing happens. It might be the patient being discharged, transferred to another doctor or another hospital and we can flag a variety of things. We have IT systems now which can automatically fax that information to the general practitioner as it occurs. These are very simple but very beneficial things for general practitioners to have. But we have to be sure of the confidentiality issues associated with that. Once you start automatically generating information, if you get it wrong once, you get it wrong for ever. It just keeps spewing out. Hopefully, we have to make sure that the doctors' surgeries from where the information is coming is also providing a secure environment for that information to be captured and collected.

Mrs VALE —On page 7 of your submission you state:

Australia is in an excellent position to take a very important leadership position in developing the understanding and skills that enable health services to optimise the benefit for Information Technology.

Would you like to elaborate on that statement and perhaps let us know your sentiments on how Australia could market its potential in Information Technology within the region and internationally?

Dr Southon —It is based very much on the character of the health system in Australia which is quite diverse but has a very strong public health system base. That contrasts very much with the other competitive countries, typically the United States which has a very strong private sector base but one which has a fairly monolithic structure.

So we have the diversity, but we have that public service character which is characteristic of a lot of our neighbours. I think this gives us the organisational framework in which the systems we develop, and the knowledge we develop in terms of how technology can really be of use, can work with the organisations. Here we are talking about a diverse set of organisations from general practice, community health to hospitals, and how all this works together to produce an effective system. Of course, there are vast differences as well, and these should not be underestimated. But I think in comparison with the other leading nations in terms of developing technology we have a very strong basis too.

Mr ROSS CAMERON —Your three principal recommendations talk about comparative assessment of major IT programs in Australia, that programs be established to enhance our understanding of how technology can best contribute to health services and that educational materials and programs be developed to enable executives and clinicians to develop and use technology optimally. It seems to me that all of those could be done without any involvement at all from government. What do you see as the role of government in this exercise?

Mr Westcott —Certainly the role of government exists in terms of the privacy area, in terms of the security of data. I guess in terms of the other areas there is definitely a need for government to support the learning that health service managers need to go through in terms of the educational environment, the courses they undertake in support of professional development in general. Not a lot of research goes on in the health service management area. Not a lot of research goes on into how effectively IT is implemented. Certainly from my point of view, and from the college's point of view, there is a role for government to encourage some of that research.

Mr ROSS CAMERON —Why do think that that does not happen considering that health is such a huge industry nationally and there are so many corporations of pretty substantial size? Why do you think that research does not happen?

Mr Westcott —A lot of it is to do with evaluation of how implementation goes after the event. Evaluation is not something that is always high on priorities in a lot of industries, and health is really no different. It is not much different to building hospitals and as to how effectively a hospital operates after it is built. That is not evaluated particularly well either. So maybe some of it is just historical and the way people are oriented. Gray, you might have another opinion.

Dr Southon —Health service research worldwide is very poorly promoted and Information Technology research industry-wide throughout all industries is very poorly promoted. When I say research, research in terms of success and failures of Information Technology is very poorly done. So you have got a combination of two poorly promoted areas. The tradition of research in health has been on the clinical area, quite justifiably. It is quite a different mind-set between looking at how you deal with a patient to how do you understand an organisation where a whole host of people work together to treat a whole lot of patients. It is quite a different mind-set, and the research framework has not really made that step.

Mr ROSS CAMERON —If I can just wrap that up as the final question from me, it seems to me we are all here to some extent as an expression of a recognition by the Commonwealth government that this is an emerging important area that may have a substantial impact on the way health services are delivered. The profession itself are the ones who are actually doing the work and who have the clinical expertise and who are dealing with the issues day to day. There seems to be a need for leadership in the field, and it seems to me on both sides--both government and the profession--there is a hesitancy there about who is going to seize the nettle and say, `Well, this is what we are going to do.' Do you have a thought about how we should resolve that?

Dr Southon —I do not see the answer lies with anyone. It is coordinated--it has got to be people working together and facilitating each other. It needs to be in conjunction with the growing technology, so it needs to be a cooperative process--bearing in mind the breadth of the different perspectives. Each group tends to see the system in terms of their world, and that whole process needs to be fitted together.

Mr ROSS CAMERON —So should there be a formal macro attempt, a formal process and an attempt to chart out a course for the future for the profession as a whole or do you think that just an ongoing sort of ad hoc specialty by specialty, project by project, state by state approach is the way to go?

Dr Southon —It is enormous, it is very complex, it is a very uncertain future. It is very dynamic and very challenging as well--and exciting. There are very big hazards in major planning. There is only so much you can plan, and you have got to be aware of the limitations of planning. There has to be a considerable degree of adhockery. You mentioned yourself the initiatives coming up from all over the place. You have to be able to exploit those initiatives. But then you have to develop the coherence so there are not too many different railway gauges, and then the diversions together, so it is a continuing process of bringing together and exploiting the new technology. People are talking about the Internet in ways they were never talking about a year ago. We need to be very flexible to pick up these opportunities as they come along and go with it and not get locked into any specific--

Mr QUICK —I would be interested in your comments on this statement. In a country with distances as vast as Australia's and with differing distributions of health services, electronic records combined with Telemedicine technology is the obvious solution. Whilst these approaches are involved and costly at the outset, the benefits returned to our health care system will be manifold with long-term cost effectiveness greatly improved.

Dr Southon —You cannot predict the future. You cannot say that these benefits are going to be there. Certainly we expect them to be there and we certainly hope they will be there but you can only say they are there when you have proof of them.

Mr Westcott —I think, just to follow that up, that the direction we are taking is towards an electronic medical record, but if it was easy to have developed that electronic medical record it would have been developed by now--there is such a market for it worldwide. But there is not yet universal acceptance of that and there is certainly nothing like universal acceptance of it in Australia. There are other downsides to that as well--the Australia card and all that. You could have had every Australian having an electronic record, but there are other agendas as well. So I think what Gray is saying is right, we need to be keeping the future in focus. This technology will be introduced, there is no doubt about it. The medical profession is very good at dealing with innovations and technology in general, but I guess our voice is the voice of reason and is somewhat taking a measured view of the situation in trying to ensure that we have people in the system who can take a step back every now and then and ask why, why should it be so, and where are the benefits.

CHAIRMAN —Thank you very much for appearing before the committee this afternoon. A transcript of your evidence will be sent to you for checking. Feel free to sit in the gallery for the rest of the day, should you wish to do so.

Short adjournment

[3.02 p.m.]