Historical publications

eHealth Future Directions Briefing Paper

for AHMAC meeting 4 October 2007

PDF printable version of AHIC eHealth Future Directions Briefing Paper (PDF 369 KB)
If you have any difficulty accessing the PDF, please contact PACDWEB@health.gov.au

Foreword

Since commencing in my role as Chair of the Australian Health Information Council (AHIC) in January 2007, it has been my pleasure to work with the dedicated and insightful members of the Council to produce this briefing paper.

We commenced the process at our first meeting in February 2007 by identifying the need to undertake some strategic planning for the Council. Through this process we have reformed the way the Council conducts its business towards strategic workshops where members’ expertise and experience, from the end user perspective, has been effectively exercised in producing our advice.

It was a great privilege to Chair the first joint Summit of both the AHIC and National Health Information Management Principal Committees (NHIMPC) in over three years on 18 and 19 June 2007. The eHealth Future Directions Summit was a highly successful meeting that formed the basis of the advice presented in this briefing paper. I would like to thank members of the NHIMPC for their contribution and input towards this important work.

I would also like to take this opportunity to thank members of the Council and the AHIC Executive for their valuable work and support in formulating this advice and look forward to continuing our professional relationship into the future.



Professor James A Angus
Chair of Australian Health Information Council
Dean of the Faculty of Medicine, Dentistry and Health Sciences
The University of Melbourne

Acknowledgements

In developing the eHealth Future Directions briefing paper, the Australian Health Information Council (AHIC) would like to thank the following people for their input and assistance:

Members of the AHIC Executive, particularly Professor James Angus, Professor Enrico Coiera, Ms Yvonne Allinson and Ms Fran Thorn for their valuable input and guidance.

Members of AHIC and the National Health Information Management Principal Committee (NHIMPC) who attended the AHIC eHealth Future Directions Summit and contributed to the briefing paper.

Dr Norman Swan, Ms Karen Carey and Dr Rosalie Chapple of Norman Swan Medical Communications for developing the major components of the briefing paper, expert facilitation of the AHIC eHealth Future Directions Summit and providing valuable strategic advice, intellectual direction and vision.

Ms Christine Giles & Mr Michael Robertson from The Nous Group for the pre-Summit survey design, conducting the Summit survey and providing this valuable stakeholder information for the Summit and for their input and advice on stakeholder engagement in this paper.

The AHIC Secretariat staff from the Department of Health and Ageing, for their high-level administrative support and coordination.

All other contributors to the AHIC eHealth Future Directions briefing paper to AHMAC.

Notes for readers

In reading this document please be aware of the following points:

1. ‘National’ in the context of this report refers to the cross-jurisdictional (Australian and state and territory governments and other agencies, public and private) and cross-sectoral health information management and information and communications technology (IC&IMT) agenda and priorities that require coordination. It is the agenda for which the National Health Information Management Principal Committee (NHIMPC) and Australian Health Information Council (AHIC) currently have responsibility.
2. Given the short timeframe for compiling this briefing paper, we have drawn heavily on existing knowledge and expertise in many health IM&ICT areas. As far as possible, we have tried to avoid reinventing the wheel. A list of the reports and documents used is included in the bibliography (see appendices).
3. The mapping exercise of the existing project landscape is largely confined to projects that are being undertaken or are sponsored by the Australian Government or state and territory governments. It was not possible to cover private sector activity comprehensively, although we did speak with a number of stakeholders from the private sector.

Contents

1. Key Messages
1.1 Recommendations
2. Background
2.1 Roles and Responsibilities of AHIC
3. Policy Consensus
4. The Problem
4.1 So what's the Problem?
4.2 What will happen if we don't act now?
4.3 The Proposition
5. Benefits from eHealth - a Pragmatic View from the International Experience
5.1 Cost Savings and the Long Term International Experience
6. Some Stories from the Frontline
6.1 Margaret's Story
6.2 What it Could Look Like
6.3 eHealth, and Evidence Based Practice - a Case Study
7. The Solution
7.1 The National eHealth Strategy
7.2 Connecting up and Integrating eHealth
7.3 A New Implementation Function/Body
7.4 The Importance of Stakeholder Engagement and Change Management
7.5 Upfront Methodologies for Measuring Success
8. Conclusions
9. Recommendations
Appendix A: Membership of AHIC
Appendix B: Health Policy Requirements of eHealth System
Appendix C: Benefits from eHealth - The International Experience
Appendix D: Bibliography

1. Key Messages

In preparing this advice, AHIC recommends that a number of key messages be considered in progressing the national health information program in Australia, with the aim of improving patient care and its delivery.

As demand increases and healthcare becomes more complex, ensuring that the right patient receives the right care at the right time is impossible without a fully functioning health system that is underpinned by the tools provided by information and communications technology.

It is recommended that these key messages be included in the national eHealth strategy currently being developed at the request of the Australian Health Ministers Advisory Council (AHMAC) and that AHIC’s advice be used, where appropriate, to inform its development.The key messages include:

1. Australia needs an integrated eHealth system and already has some of the necessary foundations

Australia already has a strong base of eHealth upon which to move forward. Many of the components that are needed for an integrated national eHealth system are either in place, in reference sites or in an advanced stage of development. What is missing is the ‘glue’; the bringing together of many separate programs into a national and integrated system, and a clear, well prioritised strategy for that national system’s implementation.

There is no single eHealth ‘magic bullet’ investment. Building an eHealth system for Australia is instead an incremental process requiring consistent and continuous investment and expenditure, with components being added as they are ready or renewed when technology changes.

AHIC therefore believes that a major component of the national eHealth strategy must be “connecting up” and building upon the existing and developing eHealth elements across Australia. Table 1 below outlines what the international experience suggests are the core components and functions of a national, integrated eHealth system along with a summary of AHIC’s mapping exercise, to determine the extent to which these functions and components are underway in Australian jurisdictions.

Through the research that AHIC has undertaken, it is apparent that Australia may actually be doing quite well in developing each of these components and functions across the Jurisdictions. What is needed however is a coordinated approach to ensure that the investment already made in eHealth is maximised and that where possible, we are not reinventing the wheel in rolling out different components of a national health information program.

2. A shared electronic health record can be delivered by 2012

As part of this “connecting up”, AHIC recommends that the implementation of a shared electronic health record (SEHR) be a national priority. Our conceptualisation of the SEHR will inevitably mature and evolve over the next five years, but we strongly recommend that by 2012, Australia should have a fully functioning SEHR (in each of the jurisdictions) across Australia.

AHIC acknowledges that the SEHR could take a number of forms and may include a networks approach that is being developed in the United States of America.

The SEHR may therefore involve the development of technical systems so that health services in a large region, both public and private, are able to allow others to access data and communicate critical messages such as investigation orders and results. By connecting up patient information systems and requiring the interoperation of local systems, we can begin to create SEHR functionality today.

Implementation of a SEHR provides us with the means to assist the workflow of health professionals and transform healthcare services. EHealth can then be both an enabler of new healthcare models and a driver of health care system reform.

The nation should therefore aim to have the core functions of a SEHR in place by the beginning of 2012. This paper identifies those functions and components and indicates an order in which they could be implemented. As jurisdictions such as the Northern Territory have shown, a SEHR can be implemented now.

3. Implementation and sharing should occur across Jurisdictions

National implementation must build on the advances already made around Australia. Several different models for governing implementation at a national level were explored by AHIC in preparing this advice, with members’ collective agreement that an adequately funded and staffed implementation function/ body should be established with responsibility for developing, implementing and monitoring our national eHealth Strategy.

The implementation function/body would have a number of roles. AHIC considers that these roles would include:

• Developing and updating the national e-health strategy, reflecting new health policy drivers, international implementation experiences, technical developments and new research evidence.
• Managing the connection of jurisdictional health information systems, and development of the SEHR.
• Accelerating the uptake of existing eHealth products and experience by accessing and packaging programs that have been demonstrated to work well and facilitating the transfer of knowledge between jurisdictions.
• Building value by creating a team of dedicated staff with varied expertise in health systems, service and multidisciplinary clinical care delivery, information and communications technology, evidence-based practice, organisational change and business process re-engineering.
• Developing a formal process for ensuring e-health technologies are safe.
• Ensuring our jurisdictional and national e-health programs have access to appropriately skilled e-health professionals, through an ongoing capacity building program.
• Developing plans and designing methodology to solve challenges that are common to multiple jurisdictions so that jurisdictions gain value by avoiding duplication.
• Considering the scale, effectiveness, level of integration and potential for interoperation of the elements identified as operating across Jurisdictions.
• Brokering implementation of different components of a SEHR between jurisdictions so that an exchange of knowledge occurs on the ground.

The US experience also tells us that the implementation body/ function may need to be agile enough to be replaced as eHealth matures over time.

4. Stakeholder Engagement

Stakeholder engagement will be an important role of the implementation function/ body. Such engagement is needed so that a clear and transparent operating environment is ensured. It is also crucial to the continual shaping of our understanding of e-health strategy, governance, and implementation. Failure to engage stakeholders has resulted in other international e-health strategies encountering significant difficulties.

The private health sector, clinicians, health professionals and consumers must be included in and consulted with during inter-jurisdictional implementation of the national eHealth strategy.

Consumer engagement in the national health information program is particularly important so that the significant benefits that technology brings to a patient’s health care can be maximised.

5. Measuring Success

Our success should be measured in part by the extent, efficiency, and effectiveness of the implementation of eHealth enabled services over the next five years, complemented by quantitative measurement of increases in workflow for health professionals, and the safety and quality of health services.

It is proposed that baseline measurements be established for performance indicators for each of these outcomes, and a clear and transparent evaluation methodology be agreed upon for all national e-health implementations to ensure that success can be measured during operation of this implementation function/ body.

1.1 Recommendations

In considering its advice, AHIC recommends the following:

1. That a comprehensive national eHealth strategy be developed in consultation with the Jurisdictions, industry, the community and health services, and that this strategy encompasses the advice of AHIC contained in this document.
2. That AHMAC recognise that eHealth is the cost of doing business in the 21st century healthcare and that this will require continuity of investment, accepting that products and hardware will need to be continuously implemented and upgraded in an ongoing cycle of capacity building.
3. That AHMAC recognise that Jurisdictions have many of the necessary eHealth components already and that what is needed is an effective system of knowledge exchange that can accelerate implementation rather than develop new products when existing ones can be used.
4. That a time limited implementation function/ body that is responsible for “connecting up”, building upon existing work and integrating eHealth nationally should be established and funded by AHMAC.
5. That a core set of functioning components of an Australian SEHR should be operating across Australia by 2012.
6. As part of the implementation function/ body, that an implementation plan and resources schedule should be developed to deliver the AHMAC national eHealth Strategy. The processes should be flexible and adaptable over time to the changing/evolving nature of information management and information communication technology.

Table 1: Key Components of eHealth Systems Internationally and in Australia

Clinical Systems

Patient and Client Management Systems

Resource Management

Shared Electronic Health Record

Registries

Medication systems

Laboratory systems

Diagnostic Imaging

Telehealth

Care plans

Patient booking and administration systems

Hospital admission and discharge

Electronic Referrals

Resource management Systems Supply and Human

Public Health Surveillance (aggregation, analysis and dissemination of data)

Financial Systems

Research

Infoway Canada

*

*

*

*

*

*

*

NHS IT Britain

*

*

*

*

*

*

*

*

*

*

*

MedCom Denmark

*

*

*

*

*limited

*

*

Australian aggregating all state activities

*

*

*

*

*

*

*

*

*

*

*

*

*

*

ACT

*

*

*

*

*

*

*

*

*

Vic

*

*

*

*

*

*

*

*

*

*

*

*

NSW

*

*

*

*

*

*

*

*

*

*

QLD

WA

*

*

*

*

*

*

*

*

*

SA

*

*

*

*

*

*

*

*

*

*

*

TAS

* (ePCR)

*

*

*

*

*

*

*

*

NT

*

*

*

*

*

*

*

*

*

*

*

2. Background

This paper has been prepared by the Australian Health Information Council (AHIC) to provide independent advice to Australian Health Ministers through the Australian Health Ministers’ Advisory Committee (AHMAC). The information, conclusions and recommendations arise from an eHealth Summit held by AHIC in Melbourne on June 18 and 19, 2007. It also builds on the work of the National eHealth Transition Authority (NeHTA). The evidence supporting the claims, advice and recommendations in this paper can be found in the appendices.

This is an important juncture in the development of our national health information infrastructure. The work of NeHTA on the standards and foundations of a national eHealth infrastructure is coming to fruition and jurisdictional eHealth projects have reached a ‘tipping’ point where they can be capitalised upon nationally rather than having to start from a zero base.In preparing this brief AHIC conducted a rigorous process including:

1. An analysis of all significant current and proposed models of care operating in Australia as well as identifying the key elements of these models.
2. Identifying enablers of each element of the models of care considered above.
3. Identifying eHealth components and functions that could support each enabler and which when combined realise a fully functioning eHealth system.
4. Analysing the key components of international eHealth strategies and operational systems to identify gaps and confirm the validity of the Australian findings.

AHIC then undertook a survey of jurisdictional eHealth development of the key components identified above. The results demonstrate that as a nation, we are further down the track of eHealth development than many people appreciate and that there could well be a foreshortened implementation phase if knowledge and product sharing were systematised.

Please note that AHIC compiled research and investigation materials to inform its deliberations of the national eHealth strategy and implementation function/ body and these documents can be made available on request.

2.1 Roles and Responsibility of AHIC

AHIC provides advice to the AHMAC in consultation with the National Health Information Management Principal Committee (NHIMPC), on long-term directions and national strategic reform issues and effective use of IM&ICT in the health sector. Responsibilities and key tasks include:

• Advising on how IM&ICT effort can be harnessed to address current and emerging needs in health care delivery, management and planning.
• Providing a coordinated, balanced perspective on major health IM&ICT issues.
• Building partnerships with the private health, IT sector and other industry sectors to promote the more effective and efficient use of IM&ICT in health.
• Promoting and advocating health IM&ICT, particularly in relation to other national reform initiatives such as the safety and quality agenda.
• Providing advice on appropriate mechanisms for stakeholder engagement.
• Strengthening relationships with IM&ICT stakeholders by developing key messages for clinicians, administrators, industry and consumers.
• Promoting information sharing.
• Monitoring the health environment to identify emerging trends and opportunities in relation to clinical practice, the organisation and delivery of health services, health outcomes and new technologies.
• Providing advice in relation to emerging issues, opportunities and risks for health – particularly from an end-user’s perspective.
• Taking account of the NHIMPC work program, considering progress to date and providing advice on future needs for effort.

3. Policy Consensus

The most potent reason for this being an opportune time for national coordination, is that jurisdictions and the Australian Government have agreed that a national eHealth strategy should be developed that clearly articulates how information management and information communication technology could address the policy goals required to meet the challenges of the health system. Some of these challenges could include the growing epidemic of chronic, complex and multiple diseases affecting the ageing Australian population.

In formulating the national eHealth strategy, AHIC considered the following health policy goals:

1. Care should be patient-centred with continuity of care between providers;
2. Care should be evidence-based and as safe and as high quality as possible, with processes to drive continuous quality improvement;
3. Care should be multidisciplinary and coordinated and consider the special needs of people with complex co-morbidities;
4. Care should be provided in a range of settings from acute to home care with the aim being to maximise care in the community;
5. Continuity of care should be maintained with smooth interfaces between acute care and care in the community;
6. Investment should be better targeted to ensure that services and interventions are targeted to best effect, are efficient and effective and with access which is based on greatest need;
7. Funding should be adequate to meet the needs of the community;
8. Continuously improve primary and secondary prevention in chronic diseases such as, coronary heart disease, stroke, diabetes, chronic obstructive pulmonary disease, arthritis, asthma, mental illness and cancer;
9. Promote and support self management - meaning facilitating consumers contributing to their own care and patient/provider care partnerships.

EHealth is not an end in itself but the servant of health policy. Nevertheless it is hard to see how these aims and the consequent models of care can be realised without the use of information management and information communications technologies (IM&ICT).

4. The Problem

4.1 So what's the problem?

There is a vast amount of activity occurring in the eHealth sector across Australia, from the national NeHTA program, primary care and HealthConnect, to the state jurisdictional implementations of larger-scale hospital systems.

Currently none of this activity is co-ordinated on a national basis and none of it feeds into, or connects with other systems. Whilst this style of development may allow individual services to meet their own eHealth needs it is clear from both national and international analysis that the significant benefits from eHealth can only be realised when systems are integrated and data can be shared and aggregated.The barriers to implementation have been well documented in international, national and jurisdictional experiences. The significant challenges are:

• the diversity and fragmentation of the Australian health care system;
• the lack of shared knowledge;
• a failure to meaningfully consult with all clinical stakeholders and involving them in the early stages of development;
• lack of national capacity in e-health with shortages of skilled e-health professionals;
• a failure to ensure workforce readiness;
• resistance to IT among some clinicians;
• potentially expensive and inefficient purchasing practices;
• the lack of high speed broadband; and
• varying experience in change management and the complexities of on the ground implementation.

Some of these challenges are similar across the nation; some are specific to local circumstances. AHIC recommends that the solution to the lack of national co-ordination is to set out a clear implementation path, synergise and build on existing experience, delegate where appropriate and monitor progress according to set targets.

The use of eHealth systems in healthcare also means that quality failure issues can quickly become safety issues. Safe eHealth systems require appropriate quality processes including fail safe systems for critical care. Currently systems are being developed and implemented across Australia that do not include sufficient quality assurance measures and NeHTA does not have safety on its standards agenda.

To achieve safe systems the health industry and IT suppliers will need to operate in a new paradigm, much like that in aerospace and defence, where all software and systems are required to be built to high quality standards using high quality processes.

These standards must become part of the contractual relationship between the health sector and the IT suppliers. Other nations such as the UK and the USA are actively managing clinical software certification through new governance structures. At the moment this is not happening in Australia and there is significant risk that systems under development will be unsafe.

AHIC recommends that the national eHealth strategy address processes to manage and guide relationships, standards development, assessment, conformance and compliance as well as contractual specifications.

4.2 What will happen if we don't act now

While the debate about how and when to implement national action on eHealth continues, the need for eHealth systems remains urgent and real.

A lack of national action forces jurisdictions and healthcare service providers to act alone, solving similar problems in relative isolation often repeating work that could have been done just once; purchasing third party intellectual property which might have been acquired more cheaply through joint negotiations and creating disparate systems that may slow or prevent integration at a later date and be unsafe.There is a tipping point at which the amount of funds spent creating these disparate systems will be so great, and integration so difficult, that the opportunity to realise the gains from creating an integrated system may be beyond reach and the silos of healthcare that have been such a barrier to the continuity of care, will be perpetuated.

4.3 The Proposition

There is not a single jurisdiction in Australia which is not challenged by the pressures of providing health care.

This is driven by:

• the increased acuity and complexity of consumers’ problems in our hospitals;
• the reductions in bed stay which have shifted acuity and complexity to the community;
• the cost of the investigational and therapeutic technologies which have enabled that throughput;
• the greater need for accountability including safety and quality;
• the growing workforce crisis; and
• the information needs of clinicians to practice safely according to the best evidence and the imperative for planners to understand and measure what is really happening in health care, especially in the community.

In particular, there is a need for enhanced, integrated and safe primary health and community care which supports people with multiple conditions which will never be cured, to be looked after outside hospital and be assisted to help themselves as much as they are willing and able.

Health policy development in Australia targets these issues and seeks to implement appropriate models of care. These usually involve coordinated, multidisciplinary primary (and sometimes secondary) health services in the community, often partnered with non government organisations. They aim to be consumer and carer-centric and encourage and support people to self-manage.

AHIC’s main message to AHMAC is that the ceaseless debate about benefits realisation and economic value of eHealth is a distracting and mostly futile exercise. The fact is that eHealth will not save money for Treasuries.

EHealth is a key enabler among others, of raised productivity and efficiency, a more effective and efficient workforce and higher quality, safer and more accessible care in multiple locations producing better health outcomes.

EHealth is thus simply a tool (and cost) of doing business in 21st century healthcare. While much of the work is already occurring in segments across Australia, national investment in eHealth will “close the loop” between these disparate activities and allow the maximum benefits of information sharing to be achieved. Indeed, the policy goals shared by every state and territory cannot be achieved without the extensive use of nationally interconnected IM&ICT.

There is no “king-hit” investment in eHealth which will solve our health system challenges. This is about continuity of investment; accepting that products and hardware will evolve and mature and be replaced in an upward cycle of capacity building in the context of realistic expectations. It is also about involving the private health sector, especially medical specialists, who until now have not had much involvement or contribution to the policy concerning eHealth.

AHIC’s advice to AHMAC is that the community and politicians have a reasonable right to expect a minimum set of eHealth elements to be in place nationally over the next five years, not as ends in themselves, but as enablers of health policy goals and the models of care which will achieve them.

5. Benefits from eHealth - A Pragmatic View from the International Experience

EHealth provides us with a means to transform an unsustainable healthcare system and be the driver of health system reform with the benefits including:

• increased workflow of the health workforce

o better access to more timely patient information at the point of care,
o reduced duplication of taking patient histories
o reduced duplication of diagnostic testing
o reduction in waiting for access to paper patient records and lost patient records
o reduction in avoidable hospital admissions

• Improved access to appropriate care
• Shift to coordinated care in the community
• Increased safety and quality

o reduced adverse incidents due to communication errors
o increased evidence-based practice
o investing in medical devices and drug therapies based on accurate and relevant Australian data and analysis
o motivate, enable and measure changes in clinical practice.

There is a sense that we should be able to identify a number of targets which can be achieved through the eHealth enabled services, and which relate to measurable benefits for consumers, carers, clinicians, health services and funders.

Yet forecasting the benefits to be realised from eHealth can be very complicated, because eHealth is a system level intervention, and it is often difficult in the extreme to isolate eHealth’s effects from the many other changes and forces that are working on the health system at the same time.

There has been a significant international debate about whether or not the much touted savings and benefits from implementing eHealth systems can be gained or indeed, even measured although relatively straightforward measures such as ‘satisfaction’ would have near term value.

As was stated earlier, the recommendation AHIC makes to AHMAC is that eHealth is simply a cost of doing business in a modern and complex environment and that we retreat from expecting isolated benefits be attributed to eHealth, and that we focus more on the health services we need to support the changing demands on the health system, and on the productivity gains we need to achieve from the workforce in the face of increasing service demands.

This was the threshold issue at the heart of the Canadian eHealth model, Infoway. It does not absolve planners from defining benefits, setting targets related to those benefits and findings ways of measuring them but it does mean that they should not be allowed to paralyse implementation or change management.AHIC argues that the debate into the realisable benefits from implementing eHealth should be limited to the prioritisation of components rather than the eHealth system itself, which should be seen as an enabler of a fast moving, ever more complex system.

A detailed analysis of the expected benefits and possible range of measurable targets is in Appendix C.

AHIC proposes to AHMAC that if this attitude is endorsed then it is likely that one of the most significant barriers to successful implementation - professional resistance - will fall away because whether or not to adopt eHealth ceases to be a choice. It also avoids arguments over unanswerable questions. Health care is probably the last complex industry which does not rely on information management and information communication technology as a basic and pervasive tool. As Don Berwick of the Institute of Healthcare Improvement might say, this is a ‘just do it’.

EHealth offers the opportunity to transform an unsustainable healthcare system and can be both an enabler of health care models and a driver of health care system reform. Accordingly eHealth can be a critical intervention point generating a sense of urgency to bring about the desired changes in the system.

5.1 Cost savings and the long-term international experience

There is a significant cost to maintaining the current paper based systems. Given the debate in the UK over IT implementation in the National Health Service (NHS), AHIC has relied on the British National Audit Office Report in relation to the NHS Connecting for Health program. It states:

“Current paper based systems are a danger to patient safety. It creates cost, delay, inconvenience, incorrect care and treatment and needless loss of life”.

However none of the available financial modelling that AHIC has been able to identify, fully takes into account the cost of keeping the old system compared to the investment in eHealth.

It is implied in much of the financial modelling AHIC has seen that in most cases, efficiencies gained through implementation of eHealth will not lead to an overall reduction in budgets. The critical benefit to be gained is an improvement in workflow, with additional and improved services being provided. The implementation of the German i2 system demonstrated that, in relation to e-Prescribing, a 51% increase in productivity measured as a decrease in unit cost. A detailed summary of the international experience is also in Appendix C.

6. Some Stories from the Frontline

6.1 Margaret's Story (not based on real people)

Margaret is 75 years old, overweight, has arthritis in her knees; her blood pressure, blood sugar and cholesterol are all up but she finds it difficult to control her diet and get exercise. Margaret takes ibuprofen – a non steroidal anti-inflammatory, cholesterol, blood pressure and diabetes tablets - six medications a day which sit in an ice cream container on the kitchen ledge. Her clinical carers all keep their separate records and no-one’s noticed that she’s on ibuprofen, which is contraindicated.

Margaret doesn’t look after herself partly because she’s busy looking after others. Her husband Angelo is 78 and can’t remember things or think straight anymore. He’s reverted to his native dialect, lost most of his teeth and his dentures keep falling out, so eating is a challenge but Margaret’s adamant he’s not going into in a home.Margaret’s daughter Sharon is 43 and has been anxious and depressed since adolescence. She’s divorced and has three children who Margaret looks after. Margaret’s usually a cheery person but lifes getting her down now and the doctor’s put her on antidepressants. Margaret counted how many appointments, services, doctors, community, social workers, and others she deals with. Not only is it a lot; they change all the time. No one knows her whole story – even her GP.

Last Saturday, Margaret had chest pain and went to the local Emergency Department who admitted her. Margaret’s given her history so many times to so many people that in her distress she didn’t know whether she’d told them everything. She forgot to bring in her ice cream container so that the staff didn’t have a clue what medications she was on. They also didn’t realise that her GP was concerned about her last week and sent her off for a stress ECG, chest X ray and routine blood tests, the results of which are on pieces of paper in the GP’s surgery. When Margaret tries to explain her understanding of the test results, things only become more confused.

The hospital repeated some of these tests unnecessarily; Margaret’s blood pressure and blood sugar spiked because staff didn’t know what medication she was on. On the Monday morning, the junior doctor spent an half an hour trying to reach the GP who moves between surgeries and then was on home visits. In the end the GP receptionist looked up Margaret’s notes but still couldn’t tell what she was on as it wasn’t in one place in the notes. The hospital diagnosed angina and discharged her on intensive treatment. Sharon had to get to work so Margaret arrived home to a mess, with no discharge summary and a couple of day’s supply of her new – and different - medications. None of the services who come in contact with Margaret had been notified of her discharge. In fact the hospital never even discovered which services had been caring for her.

Two days later at 5am, Margaret developed severe chest pain, waited till 7 am so she could ring her daughter to come over then called the ambulance. She arrested in the ambulance, was resuscitated but suffered brain damage. The result was permanent institutionalisation for her and Angelo. Sharon’s depression became even more profound and her children were identified as at risk and are currently under consideration for short term foster placement.

6.2 What it could look like...

Jamie’s brought by ambulance into a busy Emergency Department in Adelaide on a Saturday night. He looks as though he’s in his early 20s. The ambulance officers picked him up after he was assaulted outside a bar. Jamie’s incoherent and very scared saying that ‘they’ are after him and seems spooked by noises which no-one else can hear.

The ambos report that people in the pub said he’d been drinking heavily and been seen snorting cocaine and taking ICE over a six hour period. All they’ve been able to get out of him is that he’s from Sydney – a fact confirmed when he eventually let the officers look at his wallet.

Suddenly Jamie loses consciousness. A blood sugar reading registers very low so the nurse practitioners set up an appropriate infusion. They check on their screen for their hypoglycaemia protocol and search their online decision support tool for advice on managing an amphetamine, cocaine and alcohol mix in someone with diabetes.

While they’re waiting for the liaison psychiatrist and ED physician to come over, the nurses submit their PKI authority online and enter Jamie’s name, address and date of birth to see if he has any centralised records. Luckily he has and no other people with those identifiers appear, which is just as well because Jamie’s not coming round the way he should.His shared electronic health record contains his past diagnoses, contacts for his care and a medication list.

Medical professionals can see he does indeed have Type 1 diabetes but has no documented history of mental illness. They also discovered that he was recovering from a DVT that developed in flight from a recent trip to London and that he was still on warfarin, his blood pressure is now falling and his abdomen is swelling rapidly. He’s haemorrhaging from the assault and this is being exacerbated by the warfarin. Appropriate resuscitation is commenced. Jamie’s life was probably saved by the information contained in his SEHR.

Not only that, the staff discover what his insulin regime has been and now know that this is likely to be a first episode of psychosis rather than someone with established schizophrenia.

This changes the approach of the ED Physician in terms of Jamie’s diabetes control and it means the consultation liaison psychiatrist can treat Jamie as early psychosis for aggressive intervention. She messages the community mental health team to come in and arrange Jamie’s immediate follow up so he doesn’t slip through the cracks when discharged. The reply receipt tells her they got the message.

At discharge, the hospital emails Jamie’s summary to his Sydney GP, cardiologist and endocrinologist, noting - with Jamie’s permission - the mental health referral.
Much of this can start to happen now.

6.3 eHealth, and Evidence-Based Practice - a case study

For more than 10 years health systems around the world have spent hundreds of millions of dollars trying unsuccessfully to embed evidence-based practice as the foundation of health care treatments.

In Australia there has been a remarkable success that could be a guide to the potential benefits of eHealth. In Australia more than 50,000 hip and knee joints are surgically replaced each year. The National Joint Replacement Registry (NJRR) commenced national operation in 2002 and collects data from most surgeons implanting prosthetic joints.

The NJRR provided robust evidence that demonstrated which joints performed well relative to specific patient characteristics, information that was immediately put into practice, causing a significant change in orthopaedic practice with doctors actually changing the way they practice.

Since the commencement of the NJRR there has been a significant decrease in revision surgery creating savings of more than $30 million per year just in the cost of the prostheses. The savings to the healthcare system and in terms of pain and suffering and avoidable death are substantial.

The NJRR has demonstrated that the effective collection, analysis and communication of data can have an immediate impact on getting evidence into practice. An eHealth system can extend the NJRR experience to other high-risk interventions bringing to an end the wasted cost and effort of pleading with doctors to use such systems to support their practice.

7. The solution

AHIC recommends that in order for the national health information program to progress, a number of things need to occur.

These include:

1. The development of the national eHealth strategy
2. A “connecting up”, building upon and integration of the eHealth system nationally
3. A new implementation function/ body
4. Industry and consumer engagement
5. Upfront methodologies for measuring success

7.1 The National eHealth Strategy

The first component to resolve the problems facing the national health information program is the development of a comprehensive national eHealth strategy.

AHIC are pleased to note that this work is being undertaken by AHMAC and is currently being scoped by Ms Fran Thorn, Chair of the National Health Information Management Principal Committee and Secretary of the Victorian Department of Human Services.

AHIC recommends that as part of the development of the national eHealth strategy, coordination and implementation of eHealth models operational at reference sites across Australia should be shared and that the advice contained in this paper should be used to contribute to the strategy.

AHIC considers that this will move us as a nation into implementation of those national elements of the e-health infrastructure that are beyond the abilities or remit of the State jurisdictions alone.

In providing this advice, AHIC recommends that the national eHealth strategy should:

• Take into account that eHealth is an enabler, not a driver, of health policy. It should identify, prioritise, and then plan for the implementation of the cross-sectoral eHealth functions that deliver most benefits for consumers, carers, the community, clinicians, health care system managers and industry, policy makers and health service and public health researchers.
• Involve the acceleration of local implementation by the jurisdictions and the uptake of working eHealth systems by facilitating knowledge exchange to maximise the uptake of current successful reference sites and operational systems. It will also involve capacity building of the eHealth workforce and integration of current and future systems, enabling their national operation, across the jurisdictions and the private sector.
• Should aim to build upon existing standards work from NeHTA, and the systems, networks and activities already underway in Australia and internationally.
• Determine the optimum balance between investment in new integrated systems and the integration of systems currently in use using innovative integration mechanisms.

7.2 A "connecting up" and integration of the eHealth system nationally

AHIC recommends that a major component of the national eHealth strategy should be the “connecting up” and building upon the existing and developing eHealth elements across Australia.

This work should include but not be limited to the components of a SEHR. Through the research that AHIC has undertaken, it is apparent that Australia is actually doing quite well with developing each of the components required for a SEHR across the Jurisdictions.

The jurisdiction mapping exercise demonstrated that on a collaborative basis Australia has some operational capacity in all the components and function we examined. However, the roll-out capacity of the projects in each jurisdiction will be variable due to the degree of system maturity and local adaptation required for each program to meet the purpose for which it was commenced.

Australia is well poised to accelerate implementation to a fully operational national eHealth system by leveraging specific practical knowledge and intellectual property of each jurisdiction across other jurisdictions. What we need is a coordinated approach to ensure that the investment already made in eHealth is maximised and that where possible, we are not reinventing the wheel in rolling out different components of a national health information program.

As jurisdictions such as the Northern Territory have shown, a SEHR can be implemented now. The perfect SEHR may never exist. It will be a slowly evolving process whose implementation should not wait until all of the components are ready. The intent of a SEHR is for safer, more effective and productive health care, rather than to replace paper records.

Recent work in the United States demonstrates that rather than investing in and waiting on the creation of new integrated systems, sharing and aggregation of data can be achieved by connecting existing health information systems using innovative integration techniques. This method may even make it possible to avoid the need for a Unique Patient Identifier and the creation of large databases of identified patient health information. Such technical approaches could provide a useful transitional strategy in the development of a fully-fledged national SEHR.

Achieving an effective national SEHR will require a considered balance to be struck between developing new integrated systems and connecting existing systems. There is a national role in determining that balance and providing direction. The provision of support to jurisdictions at a national level will be critical to the success of the SEHR in meeting the needs of all stakeholders.

Many of the eHealth enablers described above depend on the sharing of patient health information. The AHIC eHealth Summit concluded that the SEHR was such a investment in information management and information communication technology in health, that in five years time, the minimum set of functioning components of an Australian SEHR described above should be in place.

This “connecting up” and development can occur with a carefully planned and staged implementation starting as soon as possible.

AHIC acknowledge that any SEHR could take a number of forms. Figures 1 and 2 below list some of the possible functions and minimum elements of a SEHR.

Figure 1: Shared Electronic Health Record Minimum Functions

A fully functional eHealth system could include all of the functions in the diagram below with implementation of each function occurring on a progressive basis with the priority of implementation linked to national and/or jurisdictional needs. However, for the most part, expected benefits in work flow will not be gained until the SEHR creates the linkages between the various functions.

Figure 2: Minimum Requirements of a Shared Electronic Health Record.

7.3 A New Implementation Body/Function

In order to develop and implement the national eHealth Strategy, AHIC recommends that Health Ministers set up a new function/ body whose role is implementation of national eHealth enablers in Australia.

There was unanimous agreement at the AHIC eHealth Future Directions Summit that it was crucial that cohesive, timely and coordinated implementation of the national eHealth strategy required a large number of activities to be conducted as part of an implementation function/ body. This implementation function/ body would be charged with driving and coordinating these activities.

The implementation function/ body could have the following roles:

• Developing and updating the national e-health strategy, reflecting new health policy drivers, international implementation experiences, technical developments and new research evidence.
• Managing the connection of jurisdictional health information systems, and development of the SEHR.
• Extending AHIC’s mapping exercise to a detailed gap analysis,
• Developing a formal process for ensuring e-health technologies are safe.
• Ensuring our jurisdictional and national e-health programs have access to appropriately skilled e-health professionals, through an ongoing capacity building program.
• Inviting jurisdictions and national and international system developers to put forward successful reference projects and systems for wider implementation.
• Assisting in the packaging of intellectual property into a form that is readily exchanged.
• Assisting jurisdictions to implement, adopt and modify proven systems.
• Extending and supporting the work of NeHTA to develop technical capacity.
• Supporting change management across the health sector and establish a comprehensive communication strategy that provides ongoing two way communication.
• Working with appropriate professional training bodies to ensure that eHealth is incorporated into mainstream professional education.
• Managing data storage (through regional hubs controlled by Jurisdictions) and security.

This implementation function/ body should be properly funded to achieve leverage, be able to commission development work on common purpose activities and provide assistance and tools for managing change, training and education. It would include an area that would be responsible for sharing knowledge amongst Jurisdictions.

The implementation function/ body would carry out the implementation development work, co-fund lead projects with jurisdictions and monitor progress according to an AHMAC agreed set of milestones.

The implementation function/ body would be additional to NeHTA, who to date have largely dealt with the technical development of standards for an eHealth system. AHIC believes that the most sensible organisational structure would include NeHTA as part of the implementation function/ body.

7.4 The Importance of Stakeholder Engagement and Change Management

In order to progress the national health information program, substantial change is needed to the way health professional and consumers operate. The UK experience highlights the critical nature of the engagement of the clinical workforce in implementation.

Underestimating the change management task in persuading clinicians to embrace new approaches is a potential barrier to successful implementation. Clinicians can also be a powerful driver and shaper of reform, and have often been ignored by eHealth strategies that emphasise technology at the expense of health service and policy goals.

The AHIC eHealth future Directions survey and Summit outcomes suggested that if we don’t support and engage clinicians and consumers we will not be successful.

This view is supported by research that has identified that the failure of many past health projects can often be attributed to insufficient investment in training and in change management.

An important lesson from the NHS National Programme for IT was that clinical engagement is very important early in the process to ensure that the priorities of the program are in line with those of clinicians and consumers. Experience also shows that without a dedicated effort and dedicated resources this issue often goes unaddressed.

There are many stakeholders involved in the development and implementation of eHealth, all who bring different requirements and priorities.

These stakeholders include the following groups:

• Clinicians and health service providers – for whom there must be an motivation or perceived benefit to take up the new systems or processes
• Consumers – who must be able to use the new systems and processes that are available through eHealth, but also be willing to be involved in supplying personal and health information to these systems and processes
• The health workforce – who must be able to use the new systems and processes correctly and effectively to maximum benefit
• Health service managers – who in setting budgets will balance the cost of any eHealth developments against the potential benefits that they offer
• eHealth professionals – who bridge the worlds of technology and health service delivery, are expert in the unique challenges of using IT in healthcare, and are crucial to effective eHealth strategy development, service design, implementation and outcome evaluation.

Another group of stakeholders that are not part of the health system, but will still play a strong role in the move towards eHealth and therefore must be strongly engaged are IT vendors and developers, who may be involved in the development of eHealth systems or processes. A successful transition to the new systems or processes enabled by eHealth will require strong engagement from these stakeholders.

AHIC recommends that an engagement plan or set of plans, for eHealth would address the steps necessary to ensure that each group of stakeholders is ready, willing and able to support the “connecting up” and implementation of eHealth across Australia.A stakeholder engagement plan should outline the actions required for each stakeholder group around the following components of a project:

• Pre-implementation – setting the required pre-conditions to ensure that the change will be effective
• Implementation – undertaking the implementation successfully
• Post-implementation – maintaining momentum and learning’s from the change.

Table 2 below provides a framework for a stakeholder engagement plan, and outlines the actions that may be undertaken within each of its components to engage with each stakeholder group.

Please note that each of the actions may not necessarily take place at a national level, and may instead be more appropriate at a jurisdictional or local level. For example, encouragement for the uptake of eHealth solutions may be driven through the Medicare rebate at a national level; whereas engagement with IT vendors may occur at a jurisdictional or even local level to ensure locally appropriate implementation of eHealth solutions.

Table 2: Framework for a stakeholder engagement plan

Stakeholder group	Pre-implementation Setting the pre-conditions for change	Implementation Delivering the change	Post-implementation Maintaining momentum and learning from the change
Clinicians and health service providers	Seek input into requirements for eHealth development from clinician perspective	Provide incentives and support/ drive uptake of eHealth solutions	Seek feedback to support continuous relevance of eHealth solutions
Consumers	Seek input into requirements for eHealth development from consumer perspective	Put in place legal, technological and other frameworks that support and protect individual privacy and consent to use	Seek feedback to support continuous improvement of eHealth solutions
Health workforce	Analyse workforce skill gap and develop strategies to address	Build and support workforce capacity to use eHealth solutions	Support continuous learning to increase effectiveness of eHealth solutions
Health service managers	Develop investment model	Provide incentives to support update of eHealth solutions	Use business processes in implementation
IT vendors	Develop the investment model to guide the development of eHealth solutions	Promote development through Public Private Partnerships Provide the framework for the development of eHealth solutions (e.g. through standards and accreditation)	Support further development of eHealth solutions on ongoing basis
eHealth Professionals	Develop evaluation framework,models for eHealth enabledservices, strategies for change management.	Participate in measurement, implementation and change management activities.	Analyse outcome data, seek feedback on implementation process and service designs. Contributeto further eHealth service design processes.

7.5 Upfront methodologies for measuring success

As part of the establishment of a new implementation function/ body, AHIC recommends that strong program management and outcome evaluation methodologies be developed up front to enable success.

The tasks that could be included in these methodologies may consist of:

• A detailed gap analysis of what is actually occurring on the ground in Jurisdictions; and
• Identifying appropriate baseline data and key performance indicators
• Design of an evaluation framework and methodology to track the progress of implementation projects, as well as their impact on process and outcome variables.

AHIC recommends that such evaluation be a component of any implementation program. Without access to data that indicates which parts of the strategy are effective, and which need to be revised, it is unlikely that we will have an effective and sustainable strategy, and we will be unable to effectively engage with industry, clinicians and the broader community.

8. In Conclusion

AHIC believes that implementation of eHealth will take place with or without AHMAC’s involvement. The opportunity for AHMAC is to ensure that the investment in implementation is efficient, integrated, interoperable and above all harnessed to national health policy goals.

The implementation task is not as daunting as it might appear as most, if not all, of the building blocks appear to be in place to a significant extent thanks to the work of jurisdictions and the Australian Government.

The acuity, complexity, speed and accountability of modern health care make integrated eHealth systems a necessity, not a luxury. Now is the time to act and invest wisely.

9. Recommendations

In considering its advice, AHIC recommends the following:

1. That a comprehensive national eHealth strategy be developed in consultation with the Jurisdictions, industry, the community and health services, and that this strategy encompasses the advice of AHIC contained in this document.
2. That AHMAC recognise that eHealth is the cost of doing business in the 21st century healthcare and that this will require continuity of investment, accepting that products and hardware will need to be continuously implemented and upgraded in an ongoing cycle of capacity building.
3. That AHMAC recognise that Jurisdictions have many of the necessary eHealth components already and that what is needed is an effective system of knowledge exchange which can accelerate implementation rather than develop new products when existing ones can be used.
4. That a time limited implementation function/body that is responsible for “connecting up”, building upon existing work and integrating eHealth nationally should be established and funded by AHMAC.
5. That a core set of functioning components of an Australian SEHR should be operating across Australia by 2012.
6. As part of the implementation function/ body, that an implementation plan and resources schedule should be developed to deliver the AHMAC national eHealth Strategy. The processes should be flexible and adaptable over time to the changing/evolving nature of information management and information communication technology.

Appendix A: Members of AHIC

Member	Organisation
Professor James Angus (Chair)	Dean of the Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne
Ms Yvonne Allinson	Chief Executive Officer Society of Hospital Pharmacists of Australia
Professor Enrico Coiera	Director, Centre for Health Informatics, University of New South Wales
Dr Moya Conrick	School of Nursing, Griffith University Royal College of Nursing Australia
Mr Rob Durie	Durie Consulting
Mr Richard Eccles	First Assistant Secretary Australian Department of Health and Ageing
Ms Fran Thorn	Chair of NHIMPC Secretary Victorian Department of Human Services
Dr Peter Garcia-Webb	Australian Medical Association
Professor Nicholas Glasgow	Director, Australian Primary Health Research Institute
Ms Heather Grain	La Trobe School of Public Health
Ms Helen Hopkins	Executive Director, Consumers’ Health Forum
Professor John Horvath	Chief Medical Officer, Australian Department of Health and Ageing
Professor Michael Kidd	Head, Discipline of General Practice The University of Sydney
Dr Ross Maxwell	Rural Doctors Association of Australia
Dr Louis Peachey	Medical Educator Mt Isa Centre for Rural and Remote Health
Dr Andrew Perrignon	Chief Executive Officer, Northern Health
Ms Rosemary Sinclair	Managing Director, Australian Telecommunications Users Group

Appendix B: Health Policy Requirements of eHealth System

An examination of current and proposed models of care in the Australian health care system reveals a wide variety of models that are, for the most part, context specific. In preparing this paper the following models, projects, proposals, guidelines and frameworks have been considered, as well as their evaluations where available:

• The Aboriginal and Torres Strait Islander Coordinated Care Trials
• The Australian Coordinated Care Trials
• US Coordinated Care Trials
• UK Coordinated Care Trails
• Australian Primary Care Collaborative Program
• Better Access to Mental Health Care Initiative
• National Chronic Disease Strategy
• National Service Improvement Framework for Heart, Stroke and Vascular Health
• National Service Improvement Framework for Diabetes
• National Service Improvement Framework for Osteoarthritis, Rheumatoid Arthritis and Osteoporosis
• National Service Improvement Framework for Asthma
• The Blueprint for nation-wide surveillance of chronic diseases and associated determinants
• Pharmaceutical Society of Australia Coordinated Care Position
• WA Data Linkage Project
• Health Smart
• Hospital in the Home
• Nurse Practitioner Project
• Remote Nurse Program
• Home Medicines Review
• Red Tape Taskforce
• Australian Pharmaceutical Advisory Council’s guiding principles to achieve continuity in medication management

Common Characteristics of Models of care

EHealth systems will need to be adaptable to complex needs and multiple models of care over extended periods, so it is necessary to identify common characteristics of models of care can be translated into a set of principles for development and implementation.

Although models of care are diverse and even standardised models of care vary at the local level, it is still possible to identify common characteristics in most models in the following areas:

Characteristics of models of care	Enablers	eHealth components and functions
patient centred care
Services Appropriate for Community and Individual Needs	Support innovative workforce i.e. Aboriginal Health Workers with patient records and management tools i.e. medication management reviews and ePrescribing alerts, standardised care templates etc	Shared Electronic Health Record (SEHR) Electronic Medication Action Plan ePrescribing including alerts Care Plan standardised templates with prompts
Patient Recall and Follow-up Systems	Electronic patient records including alerts and recall functions	SEHR Automated patient notification and recall systems
Streamlined and Efficient Care Planning	Care planning standardisation and templates Electronic referral system Electronic transfer of test results Electronic patient record available between service providers	Care Plan standardised templates with prompts Electronic referral systems Electronic Imaging and Pathology and electronic messaging systems including referral and reporting of diagnostic results SEHR
High Quality Patient Information	Standardised Procedure Specific patient information that is available electronically Standardised Informed Consent and Informed Financial Consent processes	Patient information portal providing standardised procedure specific information sheets and other health information SEHR
Support for Self-management	Being able to access information Having access to information Care plans that include instructions on timely response to changes in symptoms or condition Electronic access to self-management tools i.e. Medication Action Plans, diet plans, exercise charts	Consumer education programme Health consumer information portal providing high quality information SEHR including Patient access to their care plan SEHR to include Medication Action Plans, diet and exercise charts
Care in Diverse Settings including in Community (i.e. Mobile clinics) and in- home care	Mobile, wireless connection to patient IT systems using mobile computer hardware (ie. laptops, PDA etc)	Access to appropriate hardware infrastructure and software
Simplified Booking System	Patient Administration System (PAS)	PAS
Time Delays for Treatment including Waiting Times for Specialist Consultations within Guidelines	Streamlined process for referrals and bookings Ability to measure time delays and compare to guidelines	Electronic booking systems that allow patient or primary service provider access to book direct i.e. Look and Book
Safety and Quality
Evidence-based Care	Support data collection, analysis and dissemination	Information retrieval and Decision support tools
Australian Health Quality Registers (National indicators)	Nationally agreed indicators for collection of data Support data collection, analysis and dissemination	Safety and Quality indicators and benchmarking
Use of Registers: i. Intervention, ii. Immunisation and iii. Therapeutic goods (i.e. devices, drugs) iv. Blood and blood products	Support data collection, analysis and dissemination Linking of results to regulators and funding bodies (TGA, MSAC, PDC, PBAC) so that listing and funding decisions are based on clinical outcomes	Safety and Quality registers with appropriate access
Prescribing and Medication Review,	Electronic prescribing, medication record and medication review	ePrescribing and electronic Medication Action Plans with alerts
Risk Management	Standardised Risk Assessment Frameworks and electronic support systems National collection, analysis and dissemination of adverse incident monitoring and reporting	Safety and Quality indicators and benchmarking Safety and quality registers
Research Capability	Support data collection, analysis and dissemination Ability to encrypt data to ensure personal information remains secure (i.e. WA Data-linkage project)	Data linkage Data encryption
National Professional Registration and Accreditation	National system for data on registration, ongoing training requirements and accreditation	Electronic professional development and accreditation registers
Coordinated Multidisciplinary Care
Efficient Referral System	Electronic referral system	eReferral
Ability to Transfer Patient Notes	Electronic health record that can be accesses by multiple levels of service providers	SEHR
Ability to Transfer Test Results to Minimise duplication and Delay	Electronic recording and transfer of diagnostic tests including pathology, radiology etc	eReferral and Imaging and pathology results reporting
Innovative workforce including practice nurses who can mange plans and nurse practitioners who manage plans and refer, AHWS who can refer	Electronic care plans in electronic patient records Electronic referral systems Electronic booking systems	SEHR eReferral Electronic waitlists
Continuity of Care
Discharge planning including medication review and referral	Electronic discharge plans and summaries Electronic Medication Action Plan including alerts and review of ongoing medications at point of discharge	SEHR including Discharge summary and electronic Medication Action Plan
Integration of data between various service providers	Electronic patient health record	SEHR
Range of settings from acute to community
Facilitate and support care in home	Electronic patient health record Electronic medication review	SEHR including electronic Medication Action Plan
Planning