Healthcare in private care Is the medical director - runs all clinical services across defense. Background in emergency medicine + gp - in a prior life was an engineer. 24 doctors - going to 32, with 850 health workers. NZ law for civial population doesnt apply to people in defence work - medicine act, health act etc don't apply. Armed services are not memebers of the public - they have their own legislation system. They run a policy of aplying to civilian legislation - but also army legislation. Defence force supplies all services a DHB would provide - but also need to be mobile, but in other countries. "Imagine picking up auckland dhb, moving it to Dunedin, then three weeks later moving it to fiji". SOFTWARE We have a standard medical record - profile, medtech doesn't work for them. Its good for small practices, and a 'linear' model of care. They are a small practice in terms of numbers, but not in terms of how they work - more like a DHB. The EHR and service delivery is only a small part of what he does. He exists in the DF for two reasons - ensure indivduals are fit to serve. GPs solve medical issues - thats not their job. Their job is to ensure you're fit to fight. If the problem is solved, thats great - but if they're able to fight with that issue, no problem. 2nd half is information collecting. He needs to show leadership at anytime how many are fit to fight - and what the long term societal burden is. EG send person away, they get exposure, that creates liability. They need to track this liability. Thats complicated when indivduals are in / out of the army regularly. They need to look at it as longitudinal information to inform the DF and government. HEALTHCARE MODELS Healthcare models come in a couple of ways - sickcare vs wellness model. They sit in half way. They provide sickcare, but they also provide wellcare - as they need to make people fit for their job. The other way to look at it is a system of systems - they are a healthcare provider in a business who's core business - is not healthcare. They are an enabler for the main function - so his care has to fit within. The idea that they could put people into linear care doens't work, as they need to make it fit with other people. They dont use 'doctor centric' model. They have doctors who provide the ability to manage complex cases, and they guide and govern the 850 medics + rest of the workforce. The rest of the workforce do 2/3rds of the work. EG in civilian - gp, has a nurse - nurse opperates under limited scope of practice. Doesn't do much in terms of see, diagnose, treat. Medics / nurses in the DF can see, diagonoses, treat - without ever seeing a doctor. They're unique in that they do all their own logistics. Anything they do in secondary care is goverment provided (hospitals) - but all primary is self funded. All prescriptions (not part of pharmac). They use NZ supply system, but they can get stuff from outside the country. How does wellness model work Gp model - healthy population sees 2/3 consultations a year. Eg I've got the flu, needs a sick note- unless chronic disease. They make 11 points of contact a year - 110k patient contacts a year out of the 24 doctors. Most of the contacts are not via their doctors. Provides a huge overview of the population. Sick care contacts- but also where are you at, give you a warrent of fitness. All the contacts provide information tracking How do deal with data One of the reasons they went with profile (for pc) - UI is clunky, but the DB is phenomonal. They had a false start - they're currently fixing all broken parts. The DB drives it, the UI is changeable. At the volume they're running and are going to it's worth while. Defence runs it's own secure netowrk - makes it hard to interface with public health netowrk. Firewall 'like the cold war wall in berlin'. Currently implementing the security systems to let them interface with the rest of the world. Money issue not tech. Once firewall is solved, will be one of the early adopters of the national health record. Firm believer is it'll happen. They're interested in how far it will go. Thinks the first version will be low level demographic. The value for them is further down the track - they want to engage now to drive it forward. The information share for them is - yes there are risks, but a mature model can solve that - not share nothing at all. How do security They run their own redudant system + offsite backup. In theory should never go down, in practice they do. If they do move can do two models- offline or online. Section part out, physically bring it, then merge later. Technically robust, practically not that useful. Prefers a live link to NZ. Has to create the security - usually satellite links (but their are issues). All defense information is confidential info. Inc health record. Subject to offical information act - in terms of what you and DF can do with it. Eg civil - gp is owner and custodian of record. Defence is custodian of the record - CIS is technological. But individual owns the info. Lots of players in the pie. They've been talking to privacy commision about health info and what needs to happen. Yes they have the physical record, but as a business they generate info - who owns that. If they apply predicitve stuff, who owns that info. Is that offical? Can you make a offical information request against that? When you get to that level - there is no such thing as anonomity - its just a data matching exercise. Exercise and diet as part of healthcare They have better info on diet than most - there are consequences in that system. They are a volunteer military. People are there cause they want to. To assess if they're fit to deploy (eg life style choices), when they give info - that might have adverse affects for them (Maybe they cant deploy). Tension around what happens. Take all information supplied with a grain of salt. As much as the doctors provide healthcare, they provide risk assesments. They do psych screening. What they're doing now is immature in what they should be able to do. They had a false start with their OG health record. They still had paper, didn't collect the correct data. They had a look around, decided for profile for DB. They made the decision they would do internal code main + significant configuration. Profile is great for its configurability - when they decided to do it internal they didn't consider the government system to ensure it was in tight control. Didn't take into account that they were very busy, high staff turnover. As a result, experience dropped off. 10 years later, system was unstable, had a wealth of data, but poorly govern - not standardized, not coded. Last 2 years have spent fixing it up. Config and coding is done by vendor - they contract them to do it. Ensure they're ahead of the game. Resources freeed up to do better shit. System is an EHR - but more than that. Can be a tool to drive change. Its a data repo - which has as much value as healthcare provider. The data while poorly governed etc, huge wealth of info. They've had to go away from reporting based on coding - to natural language. In a vast db this is complex. They're working on - User Friendlyness, decisions support standardize process, Predictive analytics. They're talking with Orion, Microsoft etc. Its not truly big data- but it's not small. How do they get the level of intel out of it, but how do they hit that statistically significant spot. They're not into the issues US & UK have, of info just being too big. Capacity to change They have 2 full time to maintain. 1 consultant to do security. Upgrade 6 people to do upgrade, make it sustaintainable. Theres a lot of resources they can throw at it - not like a GP could. However, theres no requirement for a GP to - but there is on a national level. UI The vendor handles design / UI. They're a reasonable size company, but not vast. They're unsure where to put resources - they've put it in backend, not frontend. They're starting to focus on frontend. Dated UI makes it a hard sell. Healthcare software is hard to sell because small market - NZ is tricky due to unusual regulations. Either take American system try to adapt - or take configurable system, and configure for NZ. GPs dont have those resources - DF does, MOH does. Medtech has a fantastic UI - its slick it works. However the backend is trash. DB not on enterprise model. What change would you make "There is no magic wand, no silver bullet. There is a lot of competing demands you have to manage and balance off - based off what you want to achieve, and what your workforce needs. Your workforces view is only a small slice of the pie of what you need from the full system. If I was to ask my Doctors, it would be around the UI, and being able to rapidly get through a consultation without any delays. Everything at their fingertips - no more than 1 click away. Be able to assist them though the process of achieving the right level of documentation. And it needs to provide decision support - without them necessarily having to ask for it. Its all about time and flow. Every-time you take your attention away from the patient, that experience degrades. If I was to look at it from the view of my non-registered, my medics. They work under a standing orders framework. As soon as they start into the documentation - its pre-formated for them. When they get to the diagnosis, theres a pathway and a prescription. What they need is a very templated way of doing things - to be legally compliant. If I was to look at it from my managers point of view - they need the ability to see whats going on. This is where tension shows between providers and managers. Providers don't understand information privacy - don't make public what shouldn't be. Two thousand years of tradition there - well the world's moved on. My managers need to have visibility over the healthcare system - both in quality of record, the flows of information, whats the demands are on the system - whats being seen, all sorts of issues. How is the logistic system going, have we transfered from this drug to that drug. If I look at it from my commanders point of view - all they want to know is - can that person go to fight. They need to find that info without wading though pages of the system. There is no one silver bullet - there will always be tradeoffs. What we're aiming for a 90%+ compromise." Privacy Health info in the DF may be classified - was it part of a classified operation, or a person in a sensitive position. Could it make that person cooersian or pressured. They're careful how they label info. So they have a workforce where not all of the workforce can see the info. Sharing Information is shared like a giant group practice. 10 fixed places + 6 mobile units (in nz or worldwide). Big hubs able to be send. 180 deployed personals they link into - all has to be available at all the time, in all the locations. Civilian They record civilians into the same system - that info is then handed on, the record is maintained as is legally required. Say there was a less robust system - they would quickly outstrip the resources. The size they could potentially have to scale to is immense. They could go from all of DF - to all of NZ - to all of cooalition if needed. Did you ever consider self made? There was a number of worldwide milataries who tried self made - haven't yet seen a successful case. There are example where countries put vast money into systems - in one case more than an entire defense budget. They are still not able to crack it. They don't come at it from a specialist health software dev will come at it. One problem is scope creep - just more and more requirements. Much easier to go to contractor - and lock into a contract. Can't change it until the end. The promise of big data and the alure of having an overview is really powerful - but people making decisions often don't have the technical expertise to understand - what is possible, and what is probable. Probable is depending on how much money. Possible at the moment is just phenonomale. Privacy and large statistical trends. Its fascinating as it changes on what group you talk to. His generation (50's) are terrified of big data. They don't understand technology, and they don't know they already live in a world with no privacy. Practisioners are working in a model that is significantly outdated - but they don't know the world has moved on. If you talk to people less than 30 - they have different view. "When I talked to my young soldiers, and say 'We're going to do this', the reaction is "what, you mean you're not doing it already?" Theres a certain amount of naiviety - but too late, its already done. Work around it. Balancing circle of care - all separate records. They're trying to implement a similar model - with customized portals. By opening it up to all data sources, you have a true total health record - as the individual can enter into it as well. Then you have a true overview. Future - technical oversight - but now also veteran. From when you enlist at 17, to when you die, you sit in my system. The idea that visiblity is gone when your out, isn't useful from a societal level. Theres a burden of service they need to track. They need to look after the people, and learn from the outcomes - change whats happening in the new groups. Collaboration issues Oh yeah issues. Doctors, nurses, social records. 4 pillars of health - spiritual health is one of the 4 pillars of maori health. They have that in their record. So thats all part of the record. Non tradtional providers - the commander, the employer - they need that record as well. So many players are required. They're right out in what is theoreticaly possible in what they need. They might be the only implementer in the world. There are huge issues in that - how do I sell that to workers and patients. When you say predictive analytics- gain enormous changes. But they are best guesses. They will have implications in how they manage people. They've looked at analytics products - but it doesn't work. They need relational DB - then bring it to something else for analytics. Capture in low security, analyses in high security. That is tricky, because the highest analytics don't exist in healthcare- they exist in microsoft. Does he want to give whole DB to a 3rd party. Contracting issues - but not insurmountable. Its the reality of small DF - they will have to contract. Instrumenting soilders. They're 24/7 monitoring - where they are, how fast they're moving, heart-rate - all of it. They have a group in testing. They found there was many injuries in basic training. When they looked at the program, it seemed reasonable. But when they instrumented, they found the reason they was breaking was because 40km of running is sustainable. But its actuall 200km in first week. You run from event to event. When its all considered, its 200km. Thats why they're breaking. Other example is real time EEG. At low end - they send somebody with health problem in it, see if wave is consistent with problem. High end is instrument, put into a simulation, and see what they see. The data volume is huge - and if you add real time EGG - thats insane. In 5 years they want entire DF instumented. They become a lab for the country - but it's dangerous, as they're not representive for the entire country. They have not considered genetic testing, due to privacy. But until I can see business control inside and outisde of DF, not going into that area. They do take tissues sample to hold - to match bodies for DNA typing. Future thinking and implementation They're not represented of other militaries- they came out of a bad start. But he has a supported command change. He has to do the bid system - but they see the value. Scope of change in military vs public They have politics inside DF - but its not like larger world politics. Thats what the ministry is up against. Trying to meet all demands is mind bending. Variety in public healthcare This affects him due to rollout - they have 5 different systems to deal with. And match all individuals. When he passes care there is no drop - there is no national system for this. Interopablity is clunky. Last opinion Huge misconceptions about the data, and what can be done - all up into ministry level. About what can be done to get the outcomes you desire. When you take out political issues, its not that complex of a problem. And thats the advantage he has. DF has two advantages - he can tell people when they're being precious Goal directed organization - if a goal is signed off by chief, thats whats going to happen - everybody gets in line. He was until recently working as an ED - at least 80% of what he saw in ED should've been in GP. But they're presenting to ED due to funding (its free), and perception, they believe theres a higher level of technical expertise- and access. 4h wait at ED, or 5 day wait for GP. Funding He funds everything at primary care- vast number of consultations. Doctors provide small subset. He provides drugs, consults, evertyhing. Xrays etc. Its a free primary care model from service. 2nd care is outsourced via public or private. Demand for 2nd care is lower than general public. The fight is in primary care, and what happens before Model of totally free access to 2ndary care, promotes secondary care delivery. The bottle neck is actually in primary. For a GP to stay viable they need to turn over consultations. GP - 200-250k per year. To make that viable they need to do 10min consultations. But gp wont be funded if those are done as multi-displinary provider / self care provider. They have to do within 10 mins. They make money out of it by stretching problems across consulatations. Its not that GPs lack moral/ethical - but the system is set up like that. Their system doesn't provide problem resolution - but problem maintaince. For him, he requires problem resoultion - they need to be fit to do their job. If they need a practisioner to spend an hour /day with a person, its done. Equipment Locally they use private providers for xrays etc. They do when they deploy, but not economical when at home. They use a funding delegation model. Their was a limit of $400. He couldn't send somebody to an MRI, but an orthopedic surgeon. He removed the funding limit - upped to 2k. People thought there would be huge overspending - there was none. Admistration costs disapeared. And then he upped it to 10k. They can do anything - nothing changed. Then he decided to remove it - as he was signing all the forms. Thats not his job, in 2 years he didn't turn down one. So he upped the funding delegations to 20k. Its a trust based organisation. It works because his workforce knows hes looking at him - they know their monitored. By removing controls, they were doing less than they should, as the responsiblity is on the practisioner not the organisation. Funding / Claims Defence is finacially restrained - they need to put in business case just like any other part. He does like there is no emotion in the process - it all gets ranked, and nobody takes it personally. There isn't the same emotive cases as in public care. They do ACC claims, but thats it. At the end of the day - they're using taxpayers money, so they need to be diligiant. But its all coming from the same bucket, so defence, ACC, no worries.