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Doctor in the house

Doctor in the house

At ProCare Health, CEO Ron Hooton has a pharmacist as a CIO and a general practitioner in charge of innovation. So how did this arrangement come about?

Ron Hooton left the New Zealand Defence Force in 2005 after four years as its first chief information officer and moved to a much different sector, and another role — as CEO of ProCare Health. From leading a 200-plus IT department, Hooton now heads an organisation with around 500 general practitioners (GPs) and nearly 400 nurses across 173 practice teams, taking care of more than 660,000 patients.

The CIO, Paul Roseman, was a pharmacist before he moved into ICT. His official title is senior manager, design and development.

Roseman started as a clinical manager at ProCare and when a team was assigned for design and development, he was put in charge. “Around 2007,” says Roseman, “we discovered that a fair amount of development work was related to IT support products for the new clinical programs that we were building.”

Hooton subsequently approached him and said, “Look, most of our new developments involve a certain amount of IT, so how about you look after the CIO role as well as part of the design and development role”.

“I guess you have to say I am a bit of an accidental CIO,” says Roseman.

Chief innovation officer

Two years ago, Dr Karl Cole, a GP, joined ProCare Health as clinical director of information. Hooton says Cole’s role is around innovation, “but innovation from a GP’s perspective”.

“What we want to do,” adds Hooton, “is place a person who has a refined skill set — being very knowledgeable in health information management, and a general practitioner who works in general practice nearly every day and who has a passion for technology.”

As chief innovation officer, Cole fits the above description. He was a doctor with the NZ Defence Force and was in charge of the field hospital in East Timor, when Hooton was Defence CIO. The two however, met when Cole was working for another primary health organisation.

“He [Hooton] wants to make sure we are not disconnected from the GPs at the coalface,” says Cole, who works as a GP two-and-a-half days a week, and puts in the same number of hours as innovation officer at ProCare Health. He says the working hours for the two positions sometimes overlap. “I often have ideas while I am using the systems in general practice.”

He says his dual role allows him to focus on “disruptive innovation”, while at the same time making sure these are useful to the users.

The systems used in the clinical practice at ProCare Health have IT paradigms all the time, explains Cole. “He [Hooton] wants to make sure everything that we are doing is helping the patient and the practice.”

Keep it simple

This working arrangement has led ProCare to utilise online tools to benefit both the patients and the practice. One of these is a system called Predict.

Since the ProCare doctors have multiple practice management systems, Roseman and his team looked at a third party that can interface with all these systems and then develop content in the third system that can then be deployed across the practice management systems.

“What we have been able to do is integrate web forms with the practice management system and when we do that we are capable of reading databases anywhere in the world,” says Roseman.

These are some of the things that doctors cannot rely on the practice management system knowing. Such information has to be checked from separate systems and can have a direct bearing on whether or not a patient can be cared for in a particular way, explains Roseman.

At the same time, if the person is not eligible for a treatment programme, but from his history there is a reason to provide clinical management, the system can update the patient’s records to go into a long-term condition programme.

In the past, says Roseman, the doctor would fill in a form and be told a week later whether there is a place available for their patient on the waiting list.

The system also tackles some workforce issues by reducing the paperwork for doctors and nurses, by automating the claim forms. For patients, it can provide prescription-like vouchers for free access to different health services such as medication packaging, radiology procedures, minor surgical procedures and can provide details on the prescription of the location of pharmacies contracted for medication packaging.

The system is being rolled out progressively across the ProCare practices.

The entire system including Predict is “completely embedded” into the practice management system and the GP will barely realise that the information is being brought to them through another system.

“It is seamless,” says Roseman. “As a GP you have no idea that you are not interacting with your practice management system. We encode the form so they look similar to the practice management system.”

Roseman says he and his team tried to make the system as intuitive as possible.

The GP only has to enter the information once and it is replicated across the system. If the GP adds that a patient has a new long-term condition, it will be shared across the different databases.

“It is not a big departure from the system they are used to,” says Roseman. “That is really important for us because implementing change is one of the biggest barriers to creating change.”

The system has a “traffic light” to inform the GP whether information needs to be updated, or a health status review is needed. If the light is red it means, “You really do need to do something about this now”, says Roseman.

The clinical knowledge that comes up on the screen is specific to the patient. Roseman demonstrates the system for CIO, using the example of a patient with cardiovascular disease.

The screen shows the demographic information about the patient and a series of information tabs with assumed negative defaults, if the person, for instance has not had a heart attack.

The screen will also advise if the information is current, or too old to be reliable with new clinical tests needed.

The information is shared with a database as part of a research on cardiovascular risk with the University of Auckland and software provider Enigma.

A similar study was conducted in Framingham, Massachusetts in the US that involved around 5000 people that were tracked for 10 years. ProCare Health already has some 72,000 people in its database collected over more than seven years.

When compared to other clinical trials, there is virtually no data collection overhead for this research because the data is already being included in the clinical record system, says Roseman. The data is encrypted before it is sent to the university, so the patients’ identities are not divulged. “From there it can calculate all sorts of amazing things,” related to the research, says Roseman.

He explains the system was created by a collaborative of health organisations with software company Enigma and much of the web-form, database and decision support infrastructure is owned and managed by Enigma. “The system is secure because basically we never pass identifiable patient information across it. The patient identifiers are heavily encrypted when it goes over.”

ProCare Health, he says, is proud to be associated with this kind of research, which can estimate how much higher a person’s risk is for cardiovascular disease.

Roseman says one of the benefits of the system is in the risk assessment. On screen the doctor can change certain factors for the patient to see, to demonstrate what their cardiovascular risk would be if they made some lifestyle changes such as stopping smoking. “You could talk about it right then and there.”

The screen also includes hyperlinks to websites that are relevant to the patient’s condition. The doctor can email the information and website links to the patient, who can then review these from home.

ProCare Health was the first to use the Predict system. While other organisations, including two district health boards have adopted the system, ProCare remains a major development partner of Enigma. Roseman says ProCare continues to invest in the overall web-based system, which it intends to commercialise in the near future.

YouTube for doctors

Clinical education, particularly continuing medical education is a big part of ProCare Health’s business.

Cole explains the continuing medical education (CME) sessions are mandatory and some of them involve peer reviews.

ProCare has what it calls ProTube, where doctors can access e-learning modules on demand. “It is in a sense YouTube for doctors,” says Hooton and arose from Cole’s research on harnessing Web 2.0 tools for the practice. Cole, however, credits Hooton for the name. “It is nice, short and catchy. It is YouTube for ProCare doctors.”

Hooton says ProTube allows the doctors “anytime, anywhere to do their clinical education, but there are much broader applications we can see like patient consults.”

This is done through collaboration tools like WebEx and Moodle, so member doctors can also contribute to the medical education section of the website.

Cole says the presenters can prepare a full lecture and a five-minute update. The doctors can watch the modules when it suits them.

Cole says what they are doing is a progression from Web 1.0 technologies, where a conference is recorded and the material loaded into the web. “We are Web 1.9, not quite Web 2.0,” says Cole. “We are moving to 2.0 where GPs and specialist nurses can stack up their own courses, and maintain them.”

He says the system has the capacity to start user-generated content through its forums and comments sections. “That is where we see huge potential.”

“It is quite disruptive to the old model of learning,” says Cole. “It is dispersed knowledge.”

ProCare also conducts web-based meetings on a software-as-a-service model from WebEx. The doctors can run the system on residential broadband and can accumulate credits for CME, while staying up to date with current medical practice from the comfort of their own homes.

For instance, a meeting on a vaccine update can be run through ProTube. In the past there would be small groups consisting of two nurses, who would spend the whole year going around the practices literally doing the same talk at lunch to small groups. Now, the system can be broadcast once and can be viewed by multiple practices, and the medical staff don’t have to leave the office. ProTube has searchable forums and can provide peer support for providers in isolated areas. Doctors can take part in a clinical meeting and share their information about a case.

Cole says this type of collaboration is cited in Thomas Friedman’s book The World is Flat. “All of us are smarter than one of us,” he says, quoting Friedman. “The whole point of this is the ability to contribute to knowledge, to record it, and then produce rapid and relevant content.”

Roseman says the system can also be used for executive meetings. He recently hired a project manager from California, interviewing her using the WebEx meeting centre.

Cole says more and more doctors and nurses are integrating ICT in their medical practice. “They say it is easy to teach a health person ICT than it is to teach an ICT person health.”

In his case, he is interested in ICT’s ability to provide “not just icing on the cake innovations, but really massive changes to the way we practice.”

Cole keeps himself updated in ICT through “self directed study” and researching on the internet. “Researching is what a lot of ICT people end up doing because if you do a degree, within five years a lot of your knowledge is out of date. You just have to look under the hood and ask the really hard questions and keep asking and researching.”

From pharmacy to ICT

Roseman himself has an interesting background story on how he shifted to ICT, following his education and work as a hospital pharmacist in New Zealand and in the UK.

He worked as a pharmacist in UK hospitals during his OE in the early 90s. He came back to New Zealand in 1996, where he continued working in clinical pharmacy. He became general manager of SouthNet, which provided hardware leasing and management systems for GPs. “I was running that right down to doing practices and fixing networks and installing boxes and all sorts of things.”

He says his past roles have helped him immensely at ProCare. “I have got a pretty good sense of what it actually is we need to get out of our developments. I don’t get too hung up on the actual technology that we choose.

“I spend most of the time saying this is what I needed to do with my team of developers and companies we partner with. I need to figure out how we can make it possible.”

On working with Cole, he says, “I don’t think we get star struck by the technology, because we are easily able to see this is going to solve the problem and we understand the health side of it. We understand the problem we are trying to solve.”

Having a CEO who used to be a CIO is valuable, says Roseman. “We don’t have arguments over the technological side.”

Moreover, he relishes the flexibility that Hooton provides him. “He has an opinion, but he doesn’t necessarily force the issue. He gives you the chance to do things your way.”

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