more_vertThe Lancet Series on pathology and laboratory medicine in low-income and middle-income countries is a promising addition to global health efforts towards building capacity for universal health coverage. Michael Wilson and colleagues (May 12, p 1927)1 reported the magnitude of unmet pathology and laboratory medicine services in low-income and middle-income countries, which function with a debilitatingly low share of resources despite hosting 87% of the global population.
Preference: Pathology
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[Correspondence] Artificial intelligence can augment global pathology initiatives – Authors’ reply
We read with interest the correspondence from Junaid Nabi, which suggests that use of artificial intelligence (AI) along with telepathology can provide temporary, scalable solutions to improve access to pathology services, until requisite financing schemes are implemented by developing countries. Although AI will play some role in diagnosis in the future, we believe that solutions of this type could actually detract attention from proven, basic investments that are necessary to provide access to pathology and laboratory medicine services in low-income and middle-income countries (LMICs).
My Health Record opt-out extended
The My Health Record opt-out period has been extended until January 31, 2019.
The Government had to back down and delay the cut-off date for people wanting to delete their digital health records in the new system.
The Senate forced the Government into its embarrassing position by voting in mid-November – just before the opt-out was supposed to end – to extend the period.
Despite this, Health Minister Greg Hunt described the vote as win for the Government because Labor had tried to extend the opt-out period by 12 months.
“Labor’s plan to delay and derail the rollout of the My Health Record was blocked today,” Mr Hunt said after the Senate vote.
“We thank the crossbench for not delaying this important policy change as Labor tried so desperately to do.”
But Shadow Health Minister Catherine King said the Government was “dragged kicking and screaming” into accepting the extension.
“For months, Labor has been calling for an extension in order to get this important reform right. For months, the Liberals have been insisting there was no need for an extension,” Ms King said.
“But in the Senate on Wednesday the Government quietly capitulated and accepted a two-and-a-half month extension.
“It’s extraordinary that Labor had to force the Government’s hand by introducing legislation to make this happen.
“Minister Hunt could have implemented an extension with the stroke of a pen weeks ago.”
More than one million Australians have already chosen to opt out of My Health Record system. The extension gives another 17 million Australians the opportunity to do the same.
AMA President Dr Tony Bartone said the time had come now to get on with the process of implementing the online system, which he described as an important and valuable tool in the delivery and communication of health records.
“At the end of the day, it’s called My Health Record because patients will be able to control and ensure who can or can’t see,” Dr Bartone said.
“Now, if a patient doesn’t feel comfortable with the security or privacy provisions that have been enhanced significantly… they can opt-out.
“Now there’ll be a degree of people that will fall into that category, but what we’ve been missing now… we don’t have the critical mass of records created with the critical information and data.
“We still don’t have most hospital data on that My Health Record for the ones that have been created. We’re only now getting the ability to have the pathology and diagnostic imaging results communicated. And the list goes on.”
CHRIS JOHNSON
My Health Record opt-out extended
The My Health Record opt-out period has been extended until January 31, 2019.
The Government had to backdown and delay the cut-off date for people wanting to delete their digital health records in the new system.
The Senate forced the Government into its embarrassing position by voting in mid-November – just before the opt-out was supposed to end – to extend the period.
Despite this, Health Minister Greg Hunt described the vote as win for the Government because Labor had tried to extend the opt-out period by 12 months.
“Labor’s plan to delay and derail the rollout of the My Health Record was blocked today,” Mr Hunt said after the Senate vote.
“We thank the crossbench for not delaying this important policy change as Labor tried so desperately to do.”
But Shadow Health Minister Catherine King said the Government was “dragged kicking and screaming” into accepting the extension.
“For months, Labor has been calling for an extension in order to get this important reform right. For months, the Liberals have been insisting there was no need for an extension,” Ms King said.
“But in the Senate on Wednesday the Government quietly capitulated and accepted a two-and-a-half month extension.
“It’s extraordinary that Labor had to force the Government’s hand by introducing legislation to make this happen.
“Minister Hunt could have implemented an extension with the stroke of a pen weeks ago.”
More than one million Australians have already chosen to opt out of My Health Record system. The extension gives another 17 million Australians the opportunity to do the same.
AMA President Dr Tony Bartone said the time had come now to get on with the process of implementing the online system, which he described as an important and valuable tool in the delivery and communication of health records.
“At the end of the day, it’s called My Health Record because patients will be able to control and ensure who can or can’t see,” Dr Bartone said.
“Now, if a patient doesn’t feel comfortable with the security or privacy provisions that have been enhanced significantly… they can opt-out.
“Now there’ll be a degree of people that will fall into that category, but what we’ve been missing now… we don’t have the critical mass of records created with the critical information and data.
“We still don’t have most hospital data on that My Health Record for the ones that have been created. We’re only now getting the ability to have the pathology and diagnostic imaging results communicated. And the list goes on.”
[Correspondence] Checkpoint blockade therapy resistance in Hodgkin’s lymphoma
About 50 years ago, the enigma of Hodgkin’s lymphoma was depicted as the Hodgkin maze in two editorials in The Lancet.1,2 The uncertainties of the time were expressed through two questions: “Infection or neoplasm?” and “One entity or two (or more)?”.2 Subsequently, advances in cell biology and molecular pathology provided answers to these questions. Substantial evidence now indicates that classical Hodgkin’s lymphoma is a distinct neoplastic entity, with heterogeneous pathological features, which might be associated with Epstein-Barr virus infection.
Advances in treating breast cancer
A world-first study has revealed that triple negative breast tumours can be treated with a drug that cuts the communication between normal cells and tumour cells.
Triple negative breast tumours are the most aggressive and have the fewest treatment options, but Australian researchers were part of a team that has found what is described as a secret hotline between breast cancers and the normal cells surrounding them.
This two-way communication was uncovered in mouse models of disease and investigated further in people. In a Phase I clinical trial, a drug known as SMOi was used to block the communication, resulting in promising clinical responses in several breast cancer patients.
The findings have been published in international journal Nature Communications and are the result of a collaboration between researchers at the Garvan Institute of Medical Research in Sydney, the Centre for Cancer Biology in Adelaide, and GEICAM, a translational breast cancer research group Spain.
The research focused on triple negative breast cancer, where treatment options lag far behind other breast cancer types. Triple negative breast cancer is hard to treat because its cells lack crucial landmarks that are used as targets for medical treatment in other breast cancers.
The researchers investigated the role of non-cancerous cells, which along with cancer cells are a part of every breast tumour. They then analysed the genetic output of thousands of individual cells within the tumour.
Importantly, they found that cancer cells send signals to neighbouring non-cancerous cells (known as cancer-associated fibroblasts or CAFs). And CAFs talk back: they send back their own signals that help the cancer cells become drug-resistant and to enter a dangerous state the researchers call stem-like.
The researchers disrupted the hotline between CAFs and cancer cells by using the drug, which targets CAFs and stops them from pushing tumour cells towards a stem-like state. In mouse models of triple negative breast cancer, treatment with the drug reduced the spread of cancer, slowed tumour growth, increased sensitivity to chemotherapy and improved survival.
Following the success in mice, The Garvan Institute’s Associate Professor Alex Swarbrick, who led the research, worked with the Spanish translational breast cancer group GEICAM to carry out a Phase I clinical trial in 12 triple negative patients, in which several patients saw measurable responses to the drug.
One patient, who had an aggressive, metastatic triple negative breast cancer that was unresponsive to several other treatments, achieved a ‘complete response’ – her metastatic tumour shrank and became undetectable.
Professor Swarbrick said the research has led to a major step forward in our understanding of how CAFs can drive aggressive cancer.
“It’s the stem-like cells in breast tumours that are particularly bad players, as they can travel to distant parts of the body to create new tumours and are resistant to treatment,” he said.
“We knew that CAFs played a role in turning cancer cells into a stem-like state, but now we know exactly how they communicate with tumours – and how to stop them talking to one another.
“We found that when they received signals from cancer cells, CAFs produced large amounts of collagen, a protein that forms a dense scaffold in the tumour, which increased its stiffness and helped to maintain the stem-like state of the cancer cells.
“When we disrupted the hotline in our models and also in our patients, collagen density was reduced, and the cancer cells weren’t as stem-like anymore.”
Phase I clinical trials in a small number of patients are now complete. The results have been so promising that Professor Swarbrick and his medical collaborators are currently working on designing and funding Phase II trials to test the effectiveness of this treatment in a larger group of patients.
This work was supported by funding from the National Health and Medical Research Council, Love Your Sister, John and Deborah McMurtrie, the National Breast Cancer Foundation, RT Hall Trust and Novartis.
The Centre for Cancer Biology is an alliance between the University of South Australia and SA Pathology.
CHRIS JOHNSON
Getting the right My Health Record
AMA PRESIDENT DR TONY BARTONE
For well over a decade, successive Australian governments have worked to make an electronic health record a reality.
The AMA and the medical profession have been strong supporters of such a record. It promises greater efficiencies in recording, storing, and sharing vital health information. But it must be the right record – one that combines a safe, single record of a patient’s health information with the necessary privacy and security systems in place.
There is a lot of misinformation around now, and people concerned fears of hacking and third-party access to files, but we continue to be assured that the current My Health Record model offers all the relevant protection.
The finite benefits far outweigh the possible concerns. It is a great asset for the health system.
If health care was simple and predictable, and if a patient only ever needed clinical treatment from a single, regular clinician, we would not need a My Health Record at all. The patient’s doctor would have all the patient’s clinical information in their own clinical software on the desktop.
But patients’ lives are more dynamic and unpredictable than this. Emergencies happen. Each patient will be seen by many different doctors for different reasons at different times, and will be treated in multiple settings.
As well as their GP, patients might be treated in hospital, see specialists and allied health professionals, be referred by different doctors to different pathology labs and diagnostic imaging providers. These realities mean that each doctor who treats the patient doesn’t currently have a clear overview of the range of treatments the patient has received.
The My Health Record will help connect care across the health system and start to address the treatment fragmentation.
The multiple doctors and allied health professions who all treat the same patient at various points in time will be able to access a summary of relevant patient clinical data at the time of treatment – irrespective of the clinician’s specialty or physical location in Australia. The result will be safer, faster, and more efficient health care.
We would see a reduction in things like medical harm due to anaphylaxis because clinicians other than the patient’s usual doctor can access the patient’s records quickly and efficiently no matter the location.
The electronic record can save lives. A Brisbane GP recently told a Senate inquiry how the earlier version of the My Health Record saved the life of one of his patients.
He said that the hospital was able to access the information that was in that electronic record and made the decision not give the diabetic patient, who was in a coma, the usual antibiotic that would have been administered for sepsis. This person had a severe anaphylactic allergy to that antibiotic and, if it had been given, would have been killed. That is a powerful example of the value of an electronic health record.
The electronic record will also go a long way to addressing the intractable problem of delayed or non-existent handovers of admitted patients to their GPs on discharge.
It will reduce medical harm due to polypharmacy, which is a big issue. There are an estimated 230,000 hospital admissions costing over $1.2 billion annually due to medicine misadventure in Australia.
My Health Record should also deliver increased efficiencies and reduced waste. Treasury estimates suggest savings of around $123 million by 2020-21 by eliminating avoidable duplicated pathology tests, diagnostic images, and averted medical misadventures.
We have come a long way over the last decade. There has been considerable consultation and trialling to get things right – and safe. We must push ahead with this My Health Record.
This article was first published in Fairfax newspapers on 24 July 2018
Your patients’ health in their hands
Information for AMA Members from the Australian Digital Health Agency about My Health Record.
By Professor Meredith Makeham
Australians are being offered an important choice over the next three months about how they want to interact with their health information.
By the end of 2018, all Australians will have a My Health Record created for them, unless they choose not to have one.
The decision, importantly, is theirs to make after considering the benefits of having immediate online access to their health and care data, and being able to share it with their clinicians.
They will have access to information such as their medicines and allergies, hospital and GP summaries, investigation reports and advance care plans which could not only save their life in an emergency but also help their clinicians find vital information more quickly so that they can make safer health care decisions.
Trusted health care providers – GPs, specialists, pharmacists and others – are likely to find their patients want to talk to them about their decision. The My Health Record system is here to support better, safer care – not to replace current clinical record keeping systems or professional communication. Neither will it replace the patient-doctor relationship and clinical judgement. It is simply a secure online repository of health data and information that wouldn’t be accessible otherwise.
The data flows into the record from securely connected clinical information systems in hospitals, general practices, pharmacies, specialists’ rooms, and pathology and radiology providers. It also provides access to Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) data, the Australian Immunisation register and the Australian Organ Donor registry.
People understandably want reassurance that the Australian Digital Health Agency (the Agency) holds the privacy and security of their health information as its first priority. The system’s security has not been breached in its six years of operation. There is no complacency however – My Health Record system security operates to the highest standards, working with the Australian Cyber Security Centre and others. It is under constant surveillance and threat testing.
The legislated privacy controls are world-leading and easily accessed on the consumer portal. They include features such as a record access control – similar to a PIN – that a person can apply to their entire record so it can’t be viewed unless shared with their clinician. In an emergency, the legislation allows a clinician to ‘break glass’ and see vital medicines and allergy information. However, all instances of this are audited and people can choose to receive a text or email informing them if this happens.
The steps required for a healthcare practitioner to view a My Health Record require a number of security authentications to take place. For a provider to access the My Health Record via their clinical information system, they must be a registered health care provider – for example, registered with the Australian Health Practitioner Regulation Agency. They must also have a valid provider identifier and work in an organisation with a valid organisational identifier.
Software must be conformant, with a secure and encrypted connection to the My Health Record system. In addition, the patient must have a record on the provider’s clinical information system as a patient of the practice.
The Agency has not and will not release documents without a court/coronial or similar order. No documents have been released in the past six years and no other Government agencies have direct access to the My Health Record system.
We know 230,000 hospital admissions occur every year as a result of medication misadventure, costing the Australian taxpayer $1.2 billion annually. Many of these could be avoided if people and their clinicians had better access to vital medicines and allergy information.
The ‘Medicines View’ is a recent addition to My Health Record. It provides a consolidated summary of the most recent medicines information from notes entered by GPs, hospitals, pharmacies and consumers.
Over the past 12 months, the system has enriched its clinical content. Public and private pathology and imaging providers are now connecting and a vast increase in connected pharmacy systems as well as hospitals has occurred. This will accelerate the realisation of benefits as clinicians find they can access a more comprehensive source of information within the My Health Record system.
This month, a national communication plan was launched to ensure Australians are well informed when making their decision. Almost 20,000 My Health Record education kits were distributed to GPs, community pharmacies, aboriginal health services, post offices and public and private hospitals.
Our role as health care providers is to be our patients’ advocate, to support them in making the decisions and choices that will lead to better health outcomes and ensure that they have access to safe and effective care. My Health Record isn’t here to solve all of our problems, but it is an important step forward in our ability to deliver a safer and better-connected healthcare system.
Clinical Professor Meredith Makeham is Chief Medical Adviser of the Australian Digital Health Agency.
GPs to retain access to MBS item 30202
Following representations from the AMA, it has now been confirmed by the Department of Health that GPs will not be precluded from accessing MBS item 30202.
In response to questions from the AMA, the DoH has stated that the MBS Taskforce response to the recommendations of the Dermatology, Allergy and Immunology Clinical Committee had been misreported in the Taskforce’s finding on the website. The reported change to MBS item 30202 would have seen GPs, the predominant users, excluded from claiming the cryotherapy item for removing malignant neoplasms.
The Clinical Committee recommended that the descriptor for MBS item 30202 be amended to replace “specialist” with “Australian Medical Council (AMC) recognised dermatologist”. It was also recommended that the Department of Health should monitor high-volume users to ensure that providers were requesting the appropriate pathology tests to confirm malignancy. At no point was it recommended that GPs be excluded from claiming the item.
However, the material that was released was inconsistent with this and suggested that the MBS Taskforce had recommended to Government that the descriptor be amended to restrict the use of this item to AMC recognised dermatologists and plastic surgeons to support appropriate use of the item and improve patient safety.
The DoH has now acknowledged the concerns raised by the AMA about the potential impact of the change and has confirmed an error was made during the publication of the taskforce’s findings. This will be corrected and amendments to the item descriptors will ensure GPs retain access to this item.
Many GPs, particularly those in rural areas, will be relieved that appropriate patient treatment will not have to be delayed for an unnecessary specialist referral.
MICHELLE GRYBAITIS
AMA President opens his last conference
Dr Michael Gannon opened the AMA National Conference 2018 by figuratively saying goodbye.
In his last opening address as AMA President, which was at times emotional, Dr Gannon detailed a long list of achievements secured by the AMA during his two-year tenure.
And he poured praise on the organisation he said he enjoyed leading since 2016.
“I must say that it has been a huge honour and privilege to serve the AMA and the medical profession as Federal President,” Dr Gannon said.
“It is demanding, challenging, rewarding, and life-changing. The issues, the experiences, the depth and breadth of policy and ideas, and the interface with our political leaders and the Parliament are unique to this job.
“The responsibility is immense. The payback is the knowledge that you can achieve great things for the AMA members, the whole medical profession and, most importantly, the community, and the patients in our care.”
His address focused largely on the ground covered since the AMA met for national conference in 2017.
Describing it as a “very busy and very successful year for the Federal AMA,” Dr Gannon said time had passed very quickly in the job but much had been accomplished.
“Throughout the last 12 months, your elected representatives and the hardworking staff in the Secretariat in Canberra have delivered significant achievements in policy, advocacy, political influence, professional standards, doctors’ health, media profile, and public relations,” he said.
“We all worked tirelessly to ensure that health policy and bureaucratic processes were shaped to provide the best possible professional working environments for Australian doctors and the highest quality care for our patients.
“The unique role of the AMA in health advocacy is that we are looked to for commentary on the breadth and depth of health policy, social policy, and the health system.”
Dr Gannon said strong and robust advocacy led to a number of policy outcomes at the federal political level.
He said many organisations get nothing for their efforts, but the AMA never gives up.
“To be successful in Canberra, you have to learn to take the knocks along with the wins, then go back again and again for a better outcome,” he said.
“It is breathtakingly naïve to think it works otherwise. And that is what we have done, and keep doing.”
In 2017, the AMA launched its regular Safe Hours Audit Report, which gave added focus to the emerging issue of doctors’ health.
To enhance this focus on doctors’ health, AMA coordination of Doctors’ Health Services continues all around the country, with funding support from the Medical Board of Australia.
“We maintained a strong focus on medical workforce and training places, which resulted in the National Medical Training Advisory Network significantly increasing its workforce modelling work,” Dr Gannon told the conference.
“We secured a number of concessions in the proposed redesign of the Practice Incentive Program, as well as a delay in the introduction of changes.
“The AMA lobbied at the highest level for a more durable solution to concerns over Pathology collection centre rents. We focused on effective compliance, and achieving a fair balance between the interests of GP members and Pathologist members.
“We led the reforms to after-hours GP services provided through Medical Deputising Services to ensure that these services are better targeted, and there is stronger communication between them and a patient’s usual GP.
“We successfully lobbied the ACCC to renew the AMA’s existing authorisation that permits GPs to engage in intra-practice price setting. This potentially saves GPs thousands of dollars every year in legal and other compliance costs.
“We ensured a proportionate response from the Government in response to concerns over the security of Medicare card numbers. This avoided more draconian proposals that would have added to the compliance burden on practices, and added a barrier to care for patients.
“We fundamentally altered the direction of the Medical Indemnity Insurance Review.”
The AMA campaigned on the issue of doctors’ health and the need for COAG to change mandatory reporting laws, promoting the WA model.
It led a nationally coordinated campaign with the State AMAs and other peak bodies to uphold the TGA’s decision to up-schedule Codeine.
It campaigned against an inadequate, poorly conceived, and ideological National Maternity Services Framework, which has now been scrapped.
The 2018 AMA Public Hospital Report Card put the political, media, and public focus on the stresses and pressures on public hospitals and all who work in them. The current funding model, based entirely around payments for activity, discourages innovation and is inadequate in addressing the demands placed by an ageing population.
“We prosecuted the case for vastly improved Private Health Insurance products through membership of the Private Health Ministerial Advisory Committee, my annual National Press Club Address, an appearance before a Senate Select Committee, and regular and ongoing media and advocacy,” Dr Gannon said.
“This work was complemented by the launch of the AMA Private Health Insurance Report Card.
“We successfully lobbied for a fundamental change in the direction of the Anaesthesia Clinical Committee of the MBS Review. The Australian Society of Anaesthetists were grateful for our assistance and leadership. Many other Colleges, Associations and Societies have worked out that partnership with, rather than competing with, the AMA is the smartest way to get results.
“We launched a new AMA Fees List with all the associated benefits of mobility and regular updates.
“We saw a number of our Aged Care policy recommendations included in a number of Government reviews.
“We lobbied against what could easily have been an ill-thought-out UK-style Revalidation proposal. Our work resulted in a vastly improved Professional Performance Framework based around enhanced Continuing Professional Development.”
Dr Gannon said the AMA had provided strong leadership right across the busy public health landscape over the past year.
The AMA Indigenous Health Report Card focused on ear health, and specifically chronic otitis media.
The Federal Council endorsed the Uluru Statement from the Heart, acknowledging that Recognition is another key social determinant of health for Aboriginal and Torres Strait Islander Australians.
A product of a policy session at last year’s AMA National Conference was the subsequent updating of the AMA Position Statement on Obesity,
“I think that it is inevitable that we will eventually see a tax on sugar-sweetened beverages similar to those recently introduced in Britain and Ireland,” Dr Gannon said.
“In fact it is so simple, so easy, and so obvious, I worry that it will be seen by a future Government as a ‘silver bullet’ to what is a much more complex health and social policy issue.”
Position Statements on an Australian Centre for Disease Control; Female Genital Mutilation; Infant Feeding and Maternal Health; Harmful Substance Use, Dependence, and Behavioural Addiction; and Firearms were also highlighted.
“We conducted ongoing and prominent advocacy for the health and wellbeing of Asylum Seekers and Refugees,” he said.
“We promoted the benefits of immunisation to individuals and the broader community. Our advocacy has contributed to an increase in vaccination rates.
“We provided strong advocacy on climate change and health, among a broader suite of commentary on environmental issues.
“We consistently advocated for better women’s health services. And released a first ever statement on Men’s Health.”
New Position Statements were also released on Mental Health, Road Safety, Nutrition, Organ Donation and Transplantation, Blood Borne Viruses, and Rural Workforce.
“We promoted our carefully constructed position statement on Euthanasia and Physician Assisted Suicide during consideration of legislation in Tasmania, Victoria, New South Wales and WA,” Dr Gannon said.
“That advocacy was not universally popular. Our Position Statement acknowledges the diversity of opinion within the profession…
“We led the medical community by being the first to release a Position Statement on Marriage Equality, and advocated for the legislative change that eventuated in late 2017.”
In July 2017, AMA advocacy was publicly recognised when the Governance Institute rated the AMA as the most ethical and the most successful lobby group in Australia.
Dr Gannon added that the highlight of the 2017 international calendar for him was the annual General Assembly of the World Medical Association.
“Outcomes from that meeting included high level discussions on end-of-life care, climate change and environmental health, numerous other global social and ethical issues, and seeing the inclusion of doctors’ health as a core issue in both medical ethics and professionalism,” he said.
“I get goosebumps when I read aloud the Declaration of Geneva. It is a source of immense personal pride that I was intimately involved with its latest editorial revision, only the fifth since 1948.
“But our focus remained at home, and your AMA was very active in promoting our Mission: Leading Australia’s Doctors – Promoting Australia’s Health.
“We had great successes. We earned and maintained the respect of our politicians, the bureaucracy, and the health sector.
“We won the support of the public as we have fought for a better health system for all Australians.”
Dr Gannon thanked his family, staff, the AMA Secretariat, Board and Federal Council.
CHRIS JOHNSON