HEALTHCARE IN CONTINUUM FOR AN AGEING

POPULATION

National Self Monitoring or Remote Offshore Monitoring for Australia?

Heather Grain, Kerin Robinson, Belinda Torney

HIM Program, School of Public Health, Faculty of Health Sciences, La Ttrobe University, Bundoora, Vic 3058, Australia

Bardo Fraunholz, Chandana Unnithan

School of Information Systems, Faculty of Business and Law, Deakin University, Burwood, Vic 3121, Australia

Keywords: Ageing in Australia, Electronic Health Records, Privacy, Offshore Resourcing.

Abstract: Australia is a country, similar to other developed nations, confronting an ageing population with complex

demographics. Ensuring continued healthcare for the ageing, while providing sufficient support for the

already aged population requiring assistance, is at the forefront of the national agenda. Varied initiatives are

with foci to leverage the advantages of ICTs leading to e-Health provisioning and assisted technologies.

While these initiatives increasingly put budgetary constraints on local and federal governments, there is also

a case for offshore resourcing of non-critical health services, to support, streamline and enhance the

continuum of care, as the nation faces acute shortages of medical practitioners and nurses. However, privacy

and confidentiality concerns in this context are a significant issue in Australia. In this paper, we take the

position that if the National and state electronic health records system initiatives, are fully implemented,

offshore resourcing can be a feasible complementary option resulting in a win-win situation of cutting costs

and enabling the continuum of healthcare.

1 INTRODUCTION

Ageing of populations is a world-wide phenomenon

(Ozanne et al., 1997). However, in the past few

decades, the central characteristic of ageing in

societies worldwide has changed from high birth and

death rates, to lower birth rates and increased life

expectancies (Rowland, 1991). In Australia, failing

fertility rates combined with the baby boomer

generation moving into old age groups have

contributed to the irrefutable demographic change

(ALGA, 2005).

The proportion of people aged over 65 years,

which is currently 13 percent (2.5 million), is

expected to grow to one quarter of the population by

2051. While the proportion of people over 85 years

is expected to grow from the current 1.4 percent to 6

percent during the same period, the people within

the workforce age of 15-64 years is expected to fall

from the current 67 percent to 59 percent (ABS-01,

2007). As a reflection of fertility, mortality and

migration, population ageing in states and territories

shows varied trends (ABS-02, 2007). A significant

dimension of the ageing population is the

multiplicity of needs, interests and backgrounds. A

wide range of inter-related factors including gender,

location, socio-economic status, general health,

culture and education have influenced the ageing

process of individuals.

As Ozanne et al. (1997) recounted, migration

resulting in the multi-ethnic character of the

population seems to imply a need for differential

arrangements in the public provisioning of health

services as the ethnic aged may not share the

attitudes of the mainstream groups. Conversely, the

baby boomer generation is expected to age with

different aspirations and expectations and on

average greater financial means than previous

generations (Australian Government, 2005). In

addition, this generation is growing with transitional

evolutions in technology. Their expectations of

266

Grain H., Robinson K., Torney B., Fraunholz B. and Unnithan C. (2008).

HEALTHCARE IN CONTINUUM FOR AN AGEING POPULATION - National Self Monitoring or Remote Offshore Monitoring for Australia?.

In Proceedings of the First International Conference on Health Informatics, pages 266-273

 SciTePress

independent living, for a longer period, are much

higher compared to those of previous generations.

In a recent research study, “The Economic

Implications of an Ageing Australia”, the

Productivity Commission (2005) concluded that the

delivery of human services, which represents 49

percent of local government expenditure, is

forecasting the main demands from healthcare

provisioning for ageing and aged care. Further, it

reiterated that local councils are more likely to face

budgetary pressures from population ageing than

from traditional activities such as infrastructure

provisioning.

The development of the “Australian Government

National Strategy of an Ageing Australia” has

provided a framework for responding to the

opportunities and challenges of population ageing

(Australian Government, 2005). It implied that

population ageing affects more than aged care

services and that an effective response requires a

holistic approach including local governments.

While Australia operates various initiatives for

specific diseases and risks, the Australian

Government (2005) has called for a more

comprehensive approach to supporting and

promoting health throughout life, which will require

effective action across the continuum of care.

Prevention and management of ill health are

therefore seen as complementary strategies.

How can a continuum of care be facilitated to

cater to the privacy conscious, financially sufficient,

technology savvy generation with an ethnic mixture

of migrant population? Are the current practices or

initiatives ongoing, in alignment with their

expectations of self-monitored, independent living

for a longer term? To explore answers to these

questions, in the next section, we consider the

composite of Australian population: both the ageing

and the aged, and ongoing initiatives.

2 AUSTRALIA IN PERSPECTIVE

One of the key expectations of the ageing population

worldwide is a non-intrusive, privacy facilitating

approach to health care. The generation that is

ageing today has grown with digital technologies

and is able to self-monitor their health to a

significant extent. In an ideal situation, healthy

ageing is preferable to after-care, which has been

recognised as a major pressure on national budgets.

We take the example of USA-based research to

demonstrate the point.

Hayes et al. (2003) reported that over 20 percent

of the USA population in the 85-plus age group were

found to suffer from malnutrition and medication

non-compliance as they do not receive appropriate

interventional treatments by medical practitioners.

This segment had limited capacity for independent

living, with the result that they required continuous

monitoring and daily care. This realisation spurred

the piloting of remote monitoring of the activity of

people in their homes for detecting acute events such

as falls, using unobtrusive techniques (Glascok et

al., 2000; Ohta et al., 2003).

The Point-Of-Care Engineering Laboratory at

OHSU is one among the pioneers in developing

approaches and technologies that allow early

detection of reduced physical and cognitive function

that leads to decreased independence (Hayes et al.,

2003). They identified three key factors that

facilitated this activity: the technologies must be

unobtrusive, flexible and adaptable; and provide

complete privacy. They argued that if people are

aware of technologies, behaviours change and self-

monitoring is un-reliable. Installing un-obtrusive and

inexpensive sensors is perhaps the answer. Second,

technologies needed for health monitoring are

probably not those people would want in their

homes all the time. Therefore, wireless devices and

open standards for device communication are

essential to simplify the placement of technologies

on a needs basis and to meet dynamic health care

needs. Finally, the use of encryption and

authentication techniques including

pseudonomisation, as well as judicious selection of

what information is actually transferred between

devices on the network, are recommended.

Advances in wireless networking, ubiquitous

computing and unobtrusive technologies are now

providing opportunities for facilitating healthy

ageing and aged care, both of which are in the

portfolio of health care provisioning for nations.

2.1 Initiatives

In Australia, two distinct issues confront

governments in healthcare provisioning: providing

for healthy ageing, to ensure a nation of self-

independent individuals; and addressing the needs of

the already aged proportion which needs assistance

for living. We examined initiatives and frameworks

that are ongoing for both categories.

There is a significant move towards e-Health

recognising the facts that the society is increasingly

technology savvy and that people would like to have

the option of self-monitoring their health. In late

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Monitoring for Australia?

267

1999, the Australian National Health Information

Management Advisory Council (NHIMAC) released

a “Health Information Action Plan for Australia”,

which constituted the use of online technologies

within the health sector and laid out national projects

(Ride, 2007). A key recommendation was to develop

a national framework for the use of e-Health records

to improve the efficiency, safety and quality of care

within the requisite privacy legislations.

The initiative of HealthConnect included the

establishment of a national framework for a system

of electronic health records – which involves the

electronic collection, storage and exchange of

consumer health information via secure networks

and within privacy safeguards. The network, with

consumer consent, allows electronic exchange of

clinical information between health care providers.

The information regarding consumer health was to

take the form of standardised ‘event summaries’,

extracted from health care provider electronic

records for consultation, including current and

historic information such as results of pathology and

diagnostic tests, hospital discharge summaries,

chronic illness monitoring, current medications,

allergies, immunisation information and principal

diagnosis (Ride, 2007).

Rather than replacing existing legacy systems at

national, state and territory levels, HealthConnect

proposes a composite of different layers: a records

layer which consists of the regional storage

repositories; a user layer which contains the

computer systems software that will interface with

HealthConnect to allow providers either to

view/review records or add new event summaries to

records; and a national coordination layer that links

all regional storage repositories and provides the link

between these repositories and user/source systems,

allowing people to use their record throughout

Australia (HealthConnect, 2007a) .

However, the challenges for the system are still

numerous. For instance, the states and territories are

not alike, and there are major differences in

geographic size, population density, investment

capacity, information management infrastructure and

health care issues and resources (HealthConnect,

2007b). As a result, each region is at a different

stage of implementation development (Ride, 2007).

HealthConnect works briefly as follows:

peoples’ information is collected at point-of-care.

The shared storage facility helps health care

providers to access information, with consumer

consent. Conversely, an individual may wish to

check progress against key self-management

observations such as blood pressure, weight or blood

glucose levels. According to Ride (2007) who

provides the latest status, this network ensures

robust privacy and security standards. The

expectation is that by 2008, Australia will be well

advanced in achieving the goal of electronic

connectivity between all major health institutions

and health care providers (HealthConnect, 2007b).

From a future perspective, national implementation

within 18 months (as of 2007) is expected in some

areas such as e-prescriptions, e-referrals and hospital

discharge summaries.

An Australian consortium is developing a

possible architecture known as OpenEHR

(OpenEHR, 2007). Based on openEHR release 0.9, a

scalable, secure, shared e-Health record to meet

national standards is being implemented using a

combination of XML, Web Services, J2EE,

Relational database, LDAP and PKI. Via HL7, it

also supports interfaces with external systems and

smart cards. The totally web-driven user interface

works with all popular browsers. It currently

supports hospital doctors, general practitioners,

pathologists, endocrinologists, ophthalmologists,

dieticians, diabetes educators and podiatrists.

Emergency medication, pharmacies and community

nursing are being added (OpenEHR, 2007).

In 2002, Standards Australia published the

AS5017-2002- Health Care Client Identification to

provide a basis for improved association of clients

and their data between organisations. There are

currently two dominant sets of messaging standards

in the Australian health sector: UN/EDIFACT for

financial applications; and Health Level 7 (HL7) for

more clinically-related applications. Other standards

such as DICOM (Digital Imaging and

Communications in Medicine) are applicable to

discrete applications such as diagnostic imaging.

Standards Australia International is developing a

Message Usage Handbook that provides

recommended applications of the messaging

standards. Further development of this message

usage model is anticipated in the short to medium

term (Ride, 2007).

In July 2004 the National E-Health Transition

Authority (NEHTA), a not-for-profit company, was

established by the Australian, State and Territory

governments to develop better ways of electronically

collecting and securely exchanging health

information. Its mission is to set the standard,

specification and infrastructure requirements for

secure, interoperable, electronic health information

systems (NEHTA, 2007). The Australian initiatives

for monitoring health in the ageing are being built on

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the existing principles of privacy, legislation and

standards.

Conversely, there is increased pressure on the

national budget to cater to the 85-plus or

significantly non-independent aged population.

Lifestyles have catered to longevity and perhaps

technology-assisted living. Soar et al. (2007)

reported the current status on approaches to reduce

avoidable hospital admissions through information

technology. The aged Australian prefers home care

referrals, a less expensive alternative to institutional

care. A workshop at the 2005 Health Informatics

Conference identified a lack of reliable identification

of candidates for hospital avoidance as a major

barrier.

Subsequently, the Advanced Community Care

Association (ACCA) was formed to provide a single

point of referral to community service organisations.

Further, “Nexus eCare” developed by Nexus Online

Pty Ltd, provided a proof-of-concept web-based,

community care management system which

identified candidates, mapped services to patients,

automated communication between hospitals and

community service providers. Initially, the system

uses a Rapid Assessment tool to identify avoidable

patients. It incorporates an “intelligent filtering

agent” which continuously monitors the digital data

flow. The final assessment of this approach reveals

that pressure on hospitals, emergency departments

and budgets can be significantly relieved (Soar et al.,

2007).

Philipson and Roberts (2007) reported on the

impact of technology on aged and assisted living in

Australia. This research recognised that the usage of

digital technologies by the aged will become

increasingly an important issue in future years. The

authors point to a number of proactive computing

applications that are being developed which will

assist ageing persons to live longer in their home

environments. Assistive technologies are wide-

ranging, from radio/ultrasound/remote control

appliances, alternate keyboards, voice input devices,

phone amplifiers, etc.

Wireless sensors, for example, can be used to

gather behavioural and biological data, to be input

into computer applications (Philipson and Roberts

2007). Conversely, virtual uninterrupted

communication possibilities as the user moves from

their homes to cars or external places are being

envisaged, with Telstra and other carriers in

Australia contemplating a next-generation network

(NGN). The use of BANs (Body Area Networks)

can be useful in assisting home monitoring of

paraplegics or compensating for deficits of

functioning caused by dementia. BAN, a base

technology for permanent monitoring and logging of

vital signs, is a proven method of supervising the

health status of patients suffering from chronic

diseases, such as diabetes and asthma (BAN, 2007).

Hovenga et al. (2007) have described

comprehensive and recent research developments in

the area of ageing/aged care using OpenEHR. They

proposed an archetype management framework to

facilitate the development of future information

systems and optimise electronic health records

within the aged care sector. According to them,

Australia is leading in the field of developing

Electronic Health Records using openEHR

archetypes. These archetypes describe rich

information structures by indicating how the

information is to be expressed; what is optional and

mandatory; what is a sensible value for each data

element; and other rules (Hovenga et al., 2007:4).

These archetypes have the potential to improve aged

care in many ways such as standardising clinical

content and enabling the data to be interchangeable;

empowering residents by enabling them to switch

providers easily without the need for multiple

examinations; improving provider access to relevant

resident information; providing necessary flexibility

to reflect resident care preferences; and enabling

care providers to access best practice information as

part of daily workflow and decision making

processes at the point-of-care (Hovenga et al.,

2007:4)

Both the aged and the ageing would benefit from

a nationwide semantic interoperability, requiring the

national adoption of a key set of standards. Standard

openEHR archetypes include the adoption of a

standard terminology and set of data types, which

best fit with the openEHR information model but

can be used, to a variable extent, to enable

communication between systems with different

information models. Currently, an international team

lead by Australian experts is engaged in identifying

a common standard set of health data types and

encouraging their adoption into international

standards.

The current clinical information systems tend to

be vendor specific, not adopting standard data

models, due to the lack of agreed standards.

Hovenga et al. (2007) recommend the adoption of

standard structured messages that are compliant with

messaging standards such as developed by Health

Level 7 (HL7) and its international affiliates.

Further, Standards Australia has developed a number

of HL7 standard implementation guidelines for this

purpose (Standards, 2007).

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Having explored the initiatives for aging and the

aged for future, we now look at a critical factor in

the healthcare provisioning - privacy.

2.2 Privacy

Moor (1997) suggested that privacy is felt when a

person is protected from intrusion, interference and

information access by others. In most western

societies, including Australia, this definition may

describe privacy, but it is not a universally accepted

concept. In many Asian societies shielding a person

is not considered correct. In the context of Australia,

which has a significant migrant population from

these societies, it is regarded as acceptable only in

rare circumstances to have the individual’s privacy

violated for general welfare.

For example, in Australia, RFID is used for non-

invasive monitoring (Frost and Sullivan, 2005).

However, does it concur with the needs of privacy

that the ageing population expects today? Where

individual privacy has to be respected, there are

arguments for and against the use of RFID for

monitoring or, for that matter, any forms of

technology. ICTs pose a unique threat to personal

privacy because of the type and quantity of personal

information that can be collected, combined with the

speed of transmission and length of time that the

information can be held (Tavani, 2004:118). RFID

monitoring intensifies ICT-related difficulties in

protecting private information by offering the

information collectors the benefits of ubiquity

coupled with secrecy (Wiebell, 2005).

Mulligan et al. (2007:2) reported on research

within the privacy regulations, detailing issues and

solutions for custodians. They point out that there

are two main ways in which data custodians handle

the demands of privacy protection. The first is to

seek informed consent and the second to respond by

developing mechanisms for ensuring privacy i.e. the

data are sufficiently de-identified and protected such

that they cannot be linked back to the individual.

However, Mulligan et al (2007) reiterate that this

solution does not allow people to control the use of

their data, nor to minimise the potential for

individuals to be harmed.

One methodology (Mulligan et al. 2007:2-3)

involves the separation of personal identifiers from

clinical information and their separate encryption by

the reporting clinician, and submission of these data

to a “trusted third party” who allocates an identifier

specific to paired data items and forwards personal

identifiers and clinical data to separate repositories

(Churches, 2003). As a result, the clinical data from

disparate databases can only be linked by trusted

third parties. For example, personal identifiers are

not provided with specific disease registers.

Mulligan et al (2007) reiterate that this method

requires legal protection and financial support from

government. They also point out that in Western

Australia, the custodians of disease registries and

health databases that contain personal identifiers and

clinical information sign a Memorandum of

Understanding authorising the third party (the

Linkage Unit) to identify data concerning the same

individual in different databases. The Linkage Unit

allocates Unique Anonymous Identifiers for each

individual.

In August 2007, a regulation occurred in the

Federal Parliament of Australia, titled “1.1 Medicare

Australia (Functions of CEO) Amendment Direction

2007 (No.2)”. In plain terms, without contest or

assessment of value for money, Medicare (the

national health insurance program) can scope,

develop, build and test the NEHTA Unique

Healthcare Identifier program. The regulation

authorises NEHTA to make a copy of the two key

identity databases supported by Medicare Australia

(the client and the provider databases) and use them

to provide an identity service. Despite the

prohibition in the Commonwealth Privacy Act

(2000) of personal information being used for

purposes other than for which it was collected by

Government Agencies, it has been decided that

information that was collected to enable Medicare

benefits to be paid is to be used to operate the

NEHTA UHI (AHIT, 2007).

The implications this has, for the trust the

population will have in Medicare Australia to keep

their private information private, are profound

(AHIT, 2007). Some pertinent questions that the

regulations bring forth are:

1. Where is the Privacy Impact Assessment

that validates this approach?

2. Who will be responsible if there is a

security breach and personal details are

released and the individual is harmed?

3. How will the information be protected

from unwanted disclosure or access?

4. What is the legal liability?

Medicare patient and provider databases are key

sources of a healthcare identifier regime being

introduced to support a shift to e-Health programs.

Consequently, records belonging to 99 per cent of

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Australians are contained in Medicare's Consumer

Directory Maintenance System, considered to be the

most up-to-date and accurate government repository

of personal information. The law prevents the use of

Medicare data for other purposes; however, the

Human Services Minister has unlocked access via a

legislative amendment tabled in Parliament on

August 16 (AHIT, 2007).

The durability and applicability of current

legislation relating to privacy is very much in focus

for healthcare provisioning in the continuum of care

for ageing Australia. Furthermore, the OpenEHR

initiatives need to be implemented in conjunction

with continued amendments in legislation and

standards, to ensure privacy protection.

Now we look at another dimension of healthcare

provisioning that is under consideration, i.e.

offshoring.

3 OFFSHORE RESOURCING – IS

THERE A CASE FOR

AUSTRALIA?

In 2004, Curtin University of Technology initiated a

project that examined the long-term feasibility of

off-shoring to India. The considerations included

health services such as radiology and diagnostics

(CBS, 2004). The study is ongoing and results are

yet to be published.

The ACCI (2005) recounts that in the transition

to a globalised economy, offshoring is a viable

option for businesses in Australia, to better manage

costs and quality of services. In the health services

arena, including medical, dental, nursing diagnostics

and health services such as data entry, hospital

administration and processes, offshoring is a viable

alternative. For example, Indian medical

practitioners are interpreting radiological scans for

patients in the USA. The Phillippines is providing

medical record transcription services to a number of

developed nations. However, offshore resourcing

may not be an option where physical presence is

required for legal and/or practical reasons, such as

health care regulations.

Conversely, Australia has a shortage of doctors

and nurses, especially in regional areas (AusGov,

2007). The ABC News (2006) reported an acute

shortage of hospital beds, as citizens spend at least

25 minutes in an emergency waiting room. The

report says the top five reasons for medical

admissions in public hospitals were: respiratory

problems; cardiology and interventional cardiology;

childbirth; renal dialysis; and neurology. While it

may not be possible to offshore some of these

services, non-critical procedures such as monitoring

an asthmatic patient at home, could be done from

overseas with relative anonymity.

For example, if effective pseudonomisation

standards are finalised and therefore neither the

person’s identity nor the location is disclosed, we

argue that there is potential safety for the aged to be

monitored from overseas, given that the person is

not within the limits of harm nor is of interest to the

offshore partner other than those via their work

commitments. Certainly, there is a case for feasible

options in health services offshoring to enable

continuity of health care.

4 OUTLOOK

Drawing conclusions from the above sections, it is

evident that: if there is a functioning, fully

implemented OpenEHR system that enables e-

Health, supported by legislation and ongoing

upgrades of standards that ensure privacy protection

in Australia, this would enable healthcare in

continuum for the ageing population.

Shareable EHR’s such as those proposed in

HealthConnect that are built on OpenEHR will, if

fully implemented nation-wide, have the potential to

address the requirements of a technology savvy,

privacy conscious ageing population who expect

their health services to enable independent long-term

living. However, the key factor is that the system

needs to be fully functional, implemented, and

compliant with legislation and standards, nation-

wide.

At the next level, we consider the budgetary

pressure on national/local governments in the

provisioning of health services as well as the

shortage of doctors and in-patient facilities in

hospitals, in Australia. Currently, while the debate

on offshoring is still rampant, we argue that it can be

a viable option based on the following.

Use of architectures such as those proposed by

OpenEHR would enable non-critical processes to be

separated from critical procedures that cannot be

offshored. Subsequently, as described by Mulligan

et al (2007), the separation of personal identifiers

from this information and submission of relevant

data to a trusted offshoring partner, via a dedicated

portal, is easily possible. The offshore partner on the

other end can allocate identifiers specific to paired

data items and forward personal identifiers and

clinical data to separate repositories. No doubt, the

HEALTHCARE IN CONTINUUM FOR AN AGEING POPULATION - National Self Monitoring or Remote Offshore

Monitoring for Australia?

271

issues of trust and reliability become significant in

such cases.

A specialist offshore radiologist, for example,

who is providing expert opinion based on radiology

reports, does not need the patient’s name. In another

example, if an aged person is being monitored in

their home environment by a medical practitioner

overseas, only the details that are relevant to their

health condition need to be revealed and other

personal details can remain anonymous to the

observer. An online portal can be used for a medical

practitioner at both ends to input radiology reports,

diagnostics and analysis sheets. A general

practitioner at the Australian end could be the

interface and connecting point through a shareable

EHR.

Where the portal is interfaced with an EHR that

meets the NEHTA Privacy Framework requirements

it should provide legal certainty. The identities of

people should not be disclosed to third parties –

enabling privacy protection. The separation of

selected non-critical procedures from the EHR to

offshore providers should ensure that control

remains within Australia, and can be updated

seamlessly via an interface on the online portal. At

that level, compliance with legislation and standards

would also be met via a registered medical

practitioner who would act as the interface.

Therefore, our position is to implement a

shareable EHR, compliant with standards and

legislation and then to resource services offshore,

with anonimised records, to improve service

turnaround, relieving the pressure on government

budgets and the skills shortage, while enabling

healthcare in continuum for a healthier ageing

Australia.

REFERENCES

ABC News (2006). Hospital bed shortage worsens, ABC

Online, Retrieved September 10, 2007, from

http://www.abc.net.au/news/stories/2006/07/03/16775

83.htm

ABS-01 (2007). Population Projections Australia 2002-

2101 Cat.No.3222.0, Australia.

ABS-02 (2007). Population Projections – Statistical Local

Areas 1999-2019 Cat No. 3220.0, Australia.

ACCI (2005). Offshoring a viable option for some

companies, Australian Chamber of Commerce and

Industry Website, Last accessed 10 September 2007,

www.acci.asn.au/text_files/issues_papers/Trade/June

%2005%20-%20Offshoring.pdf

AHIT (2007). Medicare, NeHTA and your Privacy,

Australian Health Information Technology, Retrieved

September 10, 2007, from

http://www.australianit.news.com.au/story/0,24897,22

318001-5013040,00.html

ALGA(2005).Planning for an ageing community,

Australian local government population ageing action

plan 2004 – 2008, Retrieved September 5, 2007, from

http://www.alga.asn.au/policy/healthAgeing/ageing/pl

an/

Australian Government (2005).National Strategy for

Aging Australia, 2005, Australian Government,

Department of Health and Aging, Retrieved

September 10, 2007, from

http://www.health.gov.au/internet/wcms/Publishing.ns

f/Content/ageing-ofoa-agepolicy-nsaa-nsaabk4.htm,

AusGov (2007).Doctors and Nurses, Department of

Immigration Website, Last Accessed 10 September

2007, http://www.immi.gov.au/skilled/medical-

practitioners/index.htm

BAN(2007).Body Area Networks, Fraunhofer, Retrieved

September 9, 2007, from

http://www.ban.fraunhofer.de/index_e.html

CBS (2004).CBS Study looks at benefits and pitfalls of

going offshore, CBS Media Release, Retrieved

September 9, 2007, from

http://announce.curtin.edu.au/release2004/C17704.htm

Churches T (2003). A proposed architecture and method

of operation for improving the protection of privacy

and confidentiality in disease registers, BMC Medical

Research Methodology, 3(1), 1-13.

Frost and Sullivan(2005). Australia RFID applications,

Frost and Sullivan Website, Retrieved September 10,

2007, from http://www.frost.com/prod/servlet/market-

insight-top.pag?docid=49019419

Glascock AP, Kutzik DM (2000).Behavioral

Telemedicine: A New Approach to the Continuous

Nonintrusive Monitoring of Activities of Daily Living,

Telemedicine, 6(1), 33-44.

Hayes TL, Pavel M, Schallau PK, Adami AM(2003).

Unobtrusive Monitoring of Heath Status in an Aging

population, 2-5.

HealthConnect (2007a). Introduction, HealthConnect,

Retrieved September 10, 2007, from

http://www.healthconnect.gov.au/internet/hconnect/pu

blishing.nsf/Content/intro

HealthConnect (2007b). What is happening,

HealthConnect, Retrieved September 10, 2007, from

http://www.healthconnect.gov.au/internet/hconnect/pu

blishing.nsf/Content/whats-happening-1lp

Hovenga EJS, Garde S, Carr T, Hullin CM (2007).

Innovative approaches and processes for capturing

expert aged care knowledge for multiple purposes,

Electronic Journal of Health Informatics

, 2(1):e5, 1-

13.

Koch T, Jenkin P, Kralik D (2004). Chronic illness Self

Management: Locating the self, Journal of Advanced

Nursing, 48, pp 484 -492, EBN Online, BMJ

Publication.

Moor, J.H. (1997). Towards a theory of privacy for the

information age, Computers and Society, 27(3), 27-32.

HEALTHINF 2008 - International Conference on Health Informatics

272

Mulligan E, Rogers WA, Braunack-Mayer A

(2007).Research within the privacy regulations:

Problems and solutions for database custodians,

Electronic Journal of Health Informatics, 2(1):e7, 1-5.

NEHTA (2007). National e-health transition authority,

Nehta Website, Retrieved September 10, 2007, from

http://www.nehta.gov.au/

Ohta S, Nakamoto H, Shinagawa Y, Tanikawa T(2002). A

Health Monitoring System for Elderly People Living

Alone, Journal of Telemedicine and Telecare, 8(3),

151-156.

OpenEHR (2007). Research and Development based on

openEHR, Retrieved September 20,2007, from

http://www.openehr.org/projects/t_projects.htm

Ozanne E, Borowski A, Encel S (1997). Ageing and social

policy in Australia, Cambridge University Press.

Philipson G, Roberts J (2007). Caring for the future: the

impact of technology on aged and assisted living,

Electronic Journal of Health Informatics, 2(1): e1, 1-

Productivity Commission (2005). Economic implications

of an ageing Australia. Productivity Commission,

Canberra.

Ride (2007). Ride D.2.1.1 – Current European practices in

providing interoperability in e-health domain:

HEALTHCONNECT and NEHTA (Australia),

Information Society Technologies, Retrieved

September 10, 2007, from

http://www.srdc.metu.edu.tr/webpage/projects/ride/del

iverables/RIDED.2.1.1%20-

%20CurrentPracticesAustralia.doc

Rowland DT (1991). Ageing in Australia, Melbourne,

Longman Cheshire.

Soar J, Yuginovich T, Whittaker F (2007).Reducing

avoidable hospital admissions of the frail elderly using

intelligent referrals, Electronic Journal of Health

Informatics, 2(1):e3, 1-13.

Standards (2007). HL7 standard implementation

guidelines, Retrieved September 9, 2007, from

http://e-health.standards.org.au

Tavani, HT (2004). Ethics and technology: Ethical issues

in an age of information and communication

technology, Wiley: Hoboken, NJ

Wiebell H (2005). RFID Should Be Restricted by the

State, Information Age, 14

December, Retrieved

September 9, 2007, from

http://www.infoage.idg.com.au/index.php/id;1222880

574;fp;4;fpid;675408222

HEALTHCARE IN CONTINUUM FOR AN AGEING POPULATION - National Self Monitoring or Remote Offshore

Monitoring for Australia?

273