The eHealth readiness of Australia's medical specialists - Final Report

Internal medicine – physicians and paediatricians

Page last updated: 30 May 2011

General overview

Description of specialtyInternal medicine specialists or physicians work in the branch of medicine that concerns the detailed diagnosis and nonsurgical management of complex medical problems, especially of internal organ systems. The Royal Australian College of Physicians (RACP) admits fellows in the following faculties: Adult Medicine, Palliative Medicine, Rehabilitation Medicine, Public Health Medicine, and Occupational & Environmental Medicine, and Paediatrics which concerns babies, children and adolescents.
NumberThere are just under 6000 registered practicing physicians and paediatricians.17
Gender mix25% female, 75% male.

The faculties of adult medicine and paediatrics are able to train in a range of sub-specialties as described in the table below. Physicians in several of the sub-specialties, particularly cardiology and gastroenterology, may be trained as ‘procedural’ specialists as they elect to predominantly undertake invasive diagnostic and therapeutic procedures as part of their work.

Medical and Paediatric Sub-specialties18

CardiologyDiseases of the heart
Clinical GeneticsDisorders of the genes
Clinical PharmacologyThe effects of drugs and management of drug therapy
Community Child HealthSocial and physical environmental factors affecting the growth and development of young people whether well, ill, impaired or disabled, generally in community-based or government child health services
Paediatric Emergency MedicineDiagnosis and management of acute/emergency paediatric problems
EndocrinologyDisorders of internal glands and hormones, including diabetes and thyroid disorders
Endocrinology & Chemical PathologyDiagnosis, investigation and management of disorders of chemistry, metabolism and the endocrine system, together with the techniques, management and administration of a chemical pathology laboratory
Gastroenterology and HepatologyDiseases of the gut, liver and associated organs
General MedicineDiagnosis and management of conditions that may be complex, difficult to diagnose or involve multiple organs and systems of the body
Geriatric MedicineManagement of illness and maintenance of health in aged people
General PaediatricsDiagnosis and management of infants, children and adolescents with undifferentiated and complex conditions
HaematologyDiseases of the blood
Immunology & AllergyDiseases affecting the immune system
Infectious DiseasesDiseases caused by infections
Infectious Diseases & MicrobiologyThe investigation, pathogenesis, diagnosis, prevention control and treatment of infectious diseases. Laboratory procedures, management and administration of a Microbiology laboratory
Medical OncologyManagement of patients with cancer and tumours
Neonatal/Perinatal MedicineCare of the foetus, the premature and ill new born
NephrologyDiseases of the kidneys
NeurologyDiseases of the nervous system, including the brain
Nuclear MedicineThe use of radioactivity for diagnosis, and occasionally, the treatment of illness
OncologyManagement of patients with cancer and tumours
Paediatrics & Child and Adolescent PsychiatryDiagnosis and management of children and adolescents with psychological difficulties
Palliative MedicineManagement of people with terminal illnesses; emphasising the quality of life
RheumatologyManagement of joint, muscle and soft tissue disorders
Respiratory and Sleep MedicineDiagnosis and management of sleeping, breathing and lung disorders

Physicians/Paediatricians and eHealth

Examples of relevant eHealth applications

Some example uses of eHealth that physicians could benefit from include:
  • The College has given qualified support to the concept of shared electronic health records in terms of the enhanced safety and quality potentially provided to patients
  • The use of better quality information provided in an electronic format to physicians ‘on-call’ to limit unnecessary call-outs has been cited as a major potential benefit
  • Regional and rural physicians are very interested in telehealth as a means of improving the speed of urgent treatments and access to specialists. During interviews, these physicians mentioned that they do not necessarily require videoconferencing to implement telehealth initiatives
  • The emergence of high-cost highly specialised drugs in haematology, oncology and rheumatology has driven the uptake of eHealth solutions in these sub-specialties to better manage the complex treatment algorithms required by the Pharmaceutical Benefits Scheme (PBS), hospitals and other regulators.

Current eHealth ‘position’

The RACP considers that information and communication technologies have a significant role to play in creating opportunities for new models of care delivery, and that information management is fundamental to healthcare delivery and electronic applications can improve the quality, safety and effectiveness of clinical decisions. There is increasing demand for clinical information to be exchanged between individual healthcare practitioners, healthcare provider organisations and health departments.19

There is a spectrum of readiness amongst physicians – almost all have smartphones, which are used in a professional context especially to access information, but about 20–30 percent still do not provide the RACP with an email address as they do not like to receive information or accounts this way. The College believes that 60 percent are in the middle and that it is this group that needs to be addressed by targeted government initiatives. They have a strong view that eHealth is coming whether they like it or not, but say that some physicians may fear punishment by the government for not having kept up with the times in this area, and that this may affect compliance with new programs.

Some of the very busy procedural specialists have had difficulty implementing systems which do not have a user-friendly interface and which are time-consuming to install – getting stuck using both paper and electronic information in the practice, which is not particularly efficient.

Physicians have also reported a number of perceived problems with the government’s approach to eHealth, including that the Medicare Benefits Schedule (MBS) is far too rigid a tool as it stands to be used to fund eHealth. They would prefer a flexible system that can operate using multiple modalities and which is portable, which can also attract government funding.

There is some concern that the current concept for the PCEHR is too GP-centric, diminishing the input from other heath professionals involved in the patient’s care.

Many of the software programs in use are developed for GPs and do not allow the deep focus on one area of medicine that specialist physicians would like, i.e. they contain too much irrelevant information in drop-down menus for example. Connectivity beyond the practice is also cited as a major barrier to eHealth adoption.

Key insights from eHealth readiness survey

  • Internal medicine practitioners’ use of eHealth is relatively consistent with the average use for all medical specialists. They are slightly more likely to use computers to show patients information during consultations (48 percent versus 39 percent of all specialists)
  • Internal medicine practitioners are especially interested in using computers to share health records (68 percent would like to use a computer for sharing information with other practitioners and 52 percent would like to use a computer for sharing information with patients). Internal medicine practitioners are especially interested in accessing a shared patient health summary (64 percent strongly agree versus 51 percent of all medical specialists), often because their patients have complex conditions that require integration and information sharing across multiple care providers
  • Internal medicine practitioners are also interested in using computers for ordering diagnostic imaging (62 percent) and pathology tests (60 percent). Similarly, they are very interested in interactive decision support for ordering prescriptions (60 percent) and for ordering diagnostic tests (56 percent)
  • Computerised records are popular among some internal medicine practitioners for time-saving purposes. 56 percent are interested in completing event summaries/specialist reports on computers (versus 43 percent of all medical specialists) and 63 percent store records at least partially on computers (of these, 72 percent use an electronic health record system)
  • Only 6 percent of internal medicine practitioners currently use telehealth, but 52 percent stated that they probably or definitely will start using telehealth within the next three years. Of these, 59 percent are very interested in using telehealth for training and for consultations with other providers and 58 percent are very interested in telehealth for patient monitoring, which was the highest level of interest in patient monitoring across all specialty segments
  • Perceptions towards eHealth benefits are generally strong for internal medicine specialists. They are especially likely to agree that eHealth will:
    • Improve continuity of care (56 percent)
    • Improve collaboration (55 percent)
    • Improve efficiency (53 percent)
    • Improve quality of care (47 percent)
  • Although just 29 percent strongly agree that eHealth will improve patient satisfaction, this is higher than the average across all specialists (19 percent strongly agree). During interviews, practitioners mentioned that computerised records can help them come across as more knowledgeable about their patients’ individual circumstances because they can access information quickly rather than having to ask the same questions each visit
  • eHealth barriers are similar for internal medicine practitioners as for specialists in general. They are most concerned about system malfunctions or downtime (30 percent strongly agree). They are also somewhat hesitant to use new technology (30 percent strongly agree that they prefer to wait until technology-based systems are proven and established before adopting)
  • Relative to other specialists, internal medicine practitioners are more influenced by financial incentives (37 percent strongly agree). Other influence drivers are relatively consistent for internal medicine.

Characteristics and practice attributes

General workforce trends

Fellowship of the RACP is generally considered a prestigious qualification, and the College has no difficulty attracting the best graduates. There are, however significant issues with workforce mal-distribution. The first is that certain sub-specialties are far more popular than others, particularly the procedures specialties of interventional cardiology and gastroenterology in which private practice can be extremely lucrative. The second is in rural, regional and Aboriginal health, where the majority of services are still provided on a ‘fly-in, fly-out’ basis funded by State and Territory Governments or even individual practices in some cases. The RACP is taking a number of steps to address this through its Rural Taskforce Expert Advisory Group.

Practice settings may include public and private hospitals and day procedure centres, private clinics usually in partnership with other specialists, community settings, outpatients and, Aboriginal Medical Services.

A high-level practice profile of survey respondents suggests:
  • Patient throughput is modest with 70 percent seeing 15 or fewer patients per day
  • The majority (>80 percent) practice in more than one location, reflecting that most maintain practice in both public and private sectors
  • Only a minority of physicians practice purely in the public hospital sector – and those that do tend to be either at the start of their career, or on an academic career pathway. Most physicians maintain a private practice as well as undertaking sessions as a visiting specialist in the public system where they benefit from exposure to a more challenging case mix and academic prestige.
EXHIBIT 33
(D)

Education, registration and accreditation

The Royal Australasian College of Physicians (RACP) is the organisation responsible for training physicians and paediatricians and maintaining practice standards in Australia.

The Royal Australasian College of Physicians
145 Macquarie Street, Sydney NSW 2000
T: (+61) (02) 9256 5444
F: (+61) (02) 9252 3310
www.racp.edu.au

To become a physician or paediatrician it is necessary to successfully complete a six year university undergraduate degree in medicine followed by a year-long internship. It is then possible to apply for a basic training position, during which exams are held and at the end of which selection into advanced training occurs. In total at least an additional eight years of training following graduation is required prior to successfully achieving fellowship of the RACP and subsequently registration as a specialist physician.

The RACP has various training pathways, linked to comprehensive training curricula, complemented by an extensive and wide-ranging program of on-the-job training, working with and learning from experienced clinicians.

Sources of financial reimbursement/role in the healthcare ecosystem

In the private sector Medicare reimburses patients for visits to a specialist 85 percent of the Medicare scheduled fee. In addition, the doctor may choose to charge a further gap above the scheduled fee.

Where people receive their treatment in-hospital as a private patient they are eligible for a Medicare rebate equal to 75 percent of the Medicare Schedule fee. If they hold Private Health Insurance (PHI), they may also receive a rebate from their PHI fund.

Patients receiving medical services in the public hospital system are treated free of charge, however they are not eligible for choice of doctor and may be treated by trainees who are supervised by the specialist on call.

A GP referral is required to access physician care in the private sector.


17AIHW Medical Labour Force Survey 2008, published in 2010.
18Royal Australasian College of Physicians website 2011.
19Royal Australasian College of Physicians website Policy and Advocacy ‘eHealth’ 2011.