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Did I Say That?

Pat Gallagher
An IT Consultant Perspective

Issue 76: October 2008
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Did I say that?
Some time ago I wrote an article here about the dire situation that exists in the day to day finance management of our hospitals. You may recall I said quite forcefully that B.bankers should be brought into fix things!
B.hell. A few short months later and, in the USA at least, you wouldn’t trust or get a B.banker to do much of anything.
Watching the debacle on TV it struck me that all the failed and forlorn people, captured on camera walking out of the buildings, all had the same nice cardboard boxes.
Where did the boxes all come from?
I guess some clairvoyant banker must have seen it coming and made a bulk buy of boxes.

Then of course here in NSW we lost a few people too. Including the Health Minister.
Can’t avoid saying that to lose one Minister in a few weeks looks bad, losing four is looking positively banker-like.
But through of all this nonsense, the people, the voters are starting to realise that things are crook in Tallarook and if the State loses an ‘A’ in financial ranking, bottom up change will certainly occur. .
But let’s look at the glass as being half full and hope that the new Health Minister, in NSW, stems some tides, changes some paradigms, focus on some issues, see things to be appropriate, puts all these pledges into the English language and just B.well gets on with it.

Because the truth is that precious little else is being done to put the ‘E’ in electronic, into the health sector.

That said, in writing a IT column the forest and the trees often get more than blurred as we forget what works well, and what isn’t broken.
It isn’t as though the Australian health sector is totally without computing and telecommunication infrastructure.
Far from it. Look at you good folk in community pharmacy.
Been at the bleeding edge of the art for decade or more.
Most GPs, well more then not, have PCs.
Pathology as a group have done sterling work and here and there mostly small Australian software companies have worked away at putting pieces, here and there, in clinical processes and recording systems.

At a governing level the Northern Territory are on the right track with things to do with prescriptions and health records, and again it is largely with Australian developed know-how. Sadly, good as this is, the NT isn’t a large chunk of taxpayer costs or patient numbers; one wonders how well or badly this example of the NT success will cross a border into the plodding machinery of some State bureaucracies.

Did I say prescriptions? Well yes I did. Silly me, next subject
This, in an irrelevant way, reminds of the recent story about a dog trying to send a message. That is, as an analogy of how we can see why the dog ‘failed’ – wrong language system – but not focus one the importance of the message, regardless of the source.

A dog in the USA, and I don’t know if his owner was a banker or not, recently rang 911 with an emergency ‘message’.
True story.
Somehow the dog had been trained, as opposed to knew, how to press 9.1.1, presumably because the banker, huh the owner, was in a state of distress and the dog responded appropriately.
Of course a comedy of sorts ensured as the dog could only whimper in dog-ese and the incoming call operator couldn’t get the information he/she required like the patient’s name, address, problem, who is calling, mother’s maiden name, her date of birth and so forth.
As only it could in the USA, somehow with the telephone line open, or because the mobile phone could be traced, the calvary arrived and the man was saved and the doggie got a bone and we had a happy ending.

Hey, I thought, how many of us health informatics puppies have been whimpering for so long with message that e.enabling the health sector is in a dire situation.
Could it be our fault that no one understands the shrill in the whimper?

Weirdly whimsical and a bit silly as that all might be, it does say one thing; we have most of the IT stuff in place, we just can’t seem to talk in one voice so that a message is conveyed that will deliver a happy ending.

Woof, woof.

Tales of fiction, mystery and delight also surfaced during this past week.
Our Federal Health Minister announced, as Ministers tend to do quite well (‘announcing’ is a well honed skill that they all have), digression aside, announced a policy to re-introduce Case-mix.
Case, not cake.
However a cake might prove to be a more realistic thing to do.
In layperson speak, case-mix is listing all the ingredients, steps, processes and in the right clean and secure environments to carry out a procedure; and, wait for it – price each element to arrive at a single cost per event.

Wacko the derry do go. Whataripper. 

Remember the B.banker story?
Our hospitals can’t track $zillions in bulk dollars over five minutes let alone the cost, per product or item, per procedure, per location, per clinical staff, per B.patient, every hour of every day, of every week.
Don’t it make you cry!

Of course we should have case-mix, or a bill-of-materials record, or a mini bar bill, call it what ya like – knowing the truer cost of each clinical event, per patient, by hospital (oh, oh, just remember, ranking a school’s performance is one thing, ranking a hospitals is even a more terrible injustice to some in our community).
Hotels have case-mix, while hospitals do not have any idea what the cost breakdown is, and for a very good reason.
Many people don’t want anyone in the wider community to know in detail what ‘it’ costs, because measuring results allows for accountability, and for heaven's sakes that will never do.
This is really a bottler of an IT subject. This is what technology does. Given the standards, the right aligned data and harmonised information streams and voila here is case-mix, pardon me, on a plate.
If only!

The Minister, no disrespect, well yes some disrespect to her advisers and for her to believe them, doesn’t see the simple problem.
Or, if they do see it, they haven’t whoofed it clearly yet.
Which in our lay-speak is that case-mix can not be even a wet dream without technology, interoperability, cooperation, communications and without accurate, reliable and accountable financial detail for each and every item in the recipe.

Now I am really flowing.

And why not? Coz, no silly bugger has been ever able to explain that this can only be done from the bottom up.
It is boring. It is tedious, It is unsexy. It is beneath one’s dignity and it is called a chain of chains.
Supply chain, linked to cataloguing chains, linked to administration chains, linked to pricing chains, linked to terminology chains, linked to service chains, linked to clinical chains, linked to admission and discharge chains and all linked harmoniously into a well oiled, information management machine.
Manufacturing operators do it. Producing a packet of pills is all managed by the case-mix/bill of materials knowledge of what something costs to do, item by item, action by action, all under a umbrella of overhead costs.

Arrgghhhh!. How obtuse can any one be? What are they thinking?

But, really I should calm down.
Case-mix isn’t likely to threaten our sense of right and wrong anytime soon.
Why? Because the majority of people in HealthCare hate it. Hate it with a banker’s passion.

Back in the future, I think, back in 1996, was the last time a Pollie trotted out case-mix. 
The fun and games lasted until around 2000 and slowly case-mix faded from the lexicon and the visionary world went back to sleep.
What is extremely poignant is that if ‘we’ had started the case-mix journey in 2000, we just might have got it right by about now.
As many others and I have said, over and over again, without a will there is no way.
This is a people problem.
And unless there is a conscious mass awakening and things just get done naturally, we are in for years of waste.
Until it all turns around when new minds are in charge and decisions are made to do things logically and not emotionally.

As the good folk of NSW will soon consider what to render to the present government, many will think ‘hospitals’ when they stud the clubs.
If any of you, reading this, knows a person in the cardboard box, nice ones mind, business you might give them the tip of a big upcoming sale.

Ah well. Let’s return to the opening subject to give inspiration for a closing message.
Faced with the potential calamity in the US money market the federal stakeholders and regulators have been forced to sit down and think, not of themselves, but, of the people they serve.
That isn’t yet happening here in the health sector. We have a one-dimensional body of advisers sitting around working on plans to tell us all what to do.
Which will never work.
So, perhaps it would be for the best if they could start choosing their nice cardboard boxes, as we speak.

We all have to be aware of, and committed to, one simple plan of action.
We did it nationally with the Decimal Currency and Metric Conversion Boards and we did it superbly, if needlessly, for Y2K.
We need a Health Sector Conversion Board.
With a Council of experts who can represent all voices and vested interests.
With a budget to reach out and carry the nation down one path; which we could for the lack of a better moniker call the – Electronic Health Record Program.
And to complete the program within a sunset of a five-year drop dead date.

The major audience for this combined project is the voter.
The people of Australia.
Those who pay for and use the health sector.
Until they become engaged in this matter, nothing much will ever be accomplished that is wider and deeper than a small hole; dug by a dog to bury a bone.

Certainly not case-mix on Planet Healthcare.

Meanwhile we can all continue to be good doggies and get the bones we deserve.


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