Sunday, January 09, 2011

The Clinician Controlled Electronic Clinical Record (CCECR). A Vital First Step.

I have been mulling this nonsense called the Personally Controlled Electronic Health Record (PCEHR) and have formed the view that it is the wrong thing for those who are concerned for Australian E-Health to be working on.

What NEHTA and the three trial implementation sites should be working on is delivering a connected Clinician Controlled Electronic Clinical Record (CCECR) to our working clinicians so they can make a difference to the quality and safety of patient care available to the community.

NEHTA has developed a list of benefits from the PCEHR that reads like this:

“More specific benefits of PCEHRs include:

  • assisting the self-management of stable chronic diseases (for example, high blood pressure, diabetes and asthma)
  • increasing communication between clinicians and individuals by using e-consultations and online services to support self-care management using broadband services and online records to share relevant health information
  • reducing hospital re-admissions by making accessible timely and accurate health information essential to the better coordination of post-hospital care
  • improving use of scarce resources through better quality health information, faster clinical assessments, more accurate diagnoses and referrals, and more effective treatment and prescribing of medication
  • better decision making by healthcare providers and individuals through the availability of more complete, more accurate and more up-to-date health information
  • better policy development as a result of the high quality data potentially available for use in research and planning.”

The list is found here:

http://www.nehta.gov.au/ehealth-implementation/benefits-of-a-pcehr

If you consider this list the elephant in the room is the assumption that clinical practitioners and other service providers are and will be fully automated when the PCEHR arrives and that they will even be interested to get involved given all the other things the Government is asking of them. While we are part way through automation this is a job that is not completed both in either functionality or adoption.

Of course clinicians will also want to understand the disruption all this might cause and how they might be compensated for inconvenience and cost.

Let us be very clear, improvement in clinical outcomes relies on improvements in clinician behaviour as much, if not vastly more, than improving patient behaviour. If your clinician does not suggest to you what you need to do you are pretty unlikely to find out on your own!

It is bizarre that if you look at NEHTA implementation plans there is just total denial that any serious financial support is required to foster change in work practices and in adoption of the HI Service as well as their approach to Secure Messages.

What is happening with things like e-Referral and e-Prescribing is that specifications are being developed but not trial implemented and the expectation seems to be that all the learning and trialling of the NEHTA’s work will be done at the expense of providers.

NEHTA makes this quite explicit!

This is a quote from a presentation by NEHTA Clinical Lead Dr Leonie Katekar that is found here (Page 16):

http://www.nehta.gov.au/component/docman/doc_download/1226-nagatsihid-meeting-17-december-2010-sydney-leonie-katekar

“Computerisation and uptake of nehta products are the responsibility of the health sector (some funding is available through nehta through PCEHR)”

All this is frankly unhinged and just plain wrong! The US and UK have both recognised that the change management and adoption of Health IT is something that need direct financial support. NEHTA and DoHA have this utterly wrong and will get nowhere until they articulate a totally different approach.

That may start with sponsoring and guiding the development of, and then supporting delivery CCEHR capabilities to all who need it. Only once this is achieved in and out of hospital, and information flows between providers are working, does it make sense to think about what the patient access components of an overall e-Health system may look like.

My view is that the PCEHR is little more than a dangerous, politically correct and motivated thought bubble, dreamt up by someone who really did not understand e-Health in the National Health and Hospital Reform Commission, and which will do vastly more harm than good unless we build, activate and stabilise a conceptual distributed CCECR first!

The PCEHR is a political not a practical solution to Australian E-Health! It also probably won't work as the polys expect. What a mess we are in for!

David.

6 comments:

Anonymous said...

At times, I think we're in an infinite loop on the issue of PCEHR vs CCECR, regardless of the nomenclature used. As often happens, when a historical manual system is automated, the rules tend to change.

CCECR perhaps best reflects a better, electronic version of how things are done today (simplistic analogy perhaps). PCEHR reflects a change in practical stance on who owns health information of individuals, and who should control how and where it can be used.

I personally would rather have full collaboration between the loosely coupled set of clinicians caring for me, and so in a PCEHR world I would permit broader access than those overly focused on the privacy aspects of their PCEHR.

I am not saying either view is more correct, but if I measure my government's e-health progress based on net gain, then perhaps an opt-in CCECR is the best way to spend the money.

Paul Fitzgerald said...

David, I agree entirely. I made this point a few weeks ago - the PCEHR needs to be "fed" by something, and to date, there is little in the way of clinical systems implemented in the acute settings, and a set of fairly proprietary systems, used in varying degrees of depth in primary care. There is little in the way of meaningful usage in Aged and Community care so far.
ahhh, the tax payer's (stolen) dollar at work again!

Bruce Farnell said...

I agree David. I'd like to add the point that an understanding of clinician workflow is somewhere at the core of this entire issue. In my opinion there are two options where the PCEHR may gain traction.

The first is that the PCEHR integrates well with existing clinician workflow and existing GP systems. The second is that the benefits are so compelling that the existing clinician workflow is modified to accommodate the PCEHR.

I don't see any evidence of the first option at this stage. For example, none of the GP systems will be able to contribute to the PCEHR record - at least for some time. Also, the PCEHR record is likely to be incomplete (particularly in phase 1) and no-one has a responsibility for managing a health summary. Based on my experience, clinicians faced with incomplete and unmanaged information will look elsewhere. They are too busy to do otherwise. Hence, option two is not looking good either.

Dr David More MB, PhD, FACHI said...

Bruce, I agree that workflow issues are critical. My assessment is that these issues were important in the failure of HealtheLink in NSW.

I had actually meant to mention it as part of this blog, but there was so much that needed to be said -:)

David.

Keith Heale said...

The discussion should not be about PCEHR versus CCEHR: these are distractions, and the PC version (whether PC stands for "Person Controlled" or "Politically Correct") is a complete chimera. Dr Katekar's slides identified NEHTA's role. It is to develop national infrastructure to enable the health sector to move to “semantic interoperability”. If NEHTA and DOHA were interested in improving healthcare through the application of ehealth technology there would be emphasis and urgency on universal secure messaging, and electronic interchange of referrals, reports and discharge summaries, pathology and radiology requests and reports, prescriptions etc. When those things are standardized and IMPLEMENTED and in regular widespread use it may be time to look at some sort of shared EHR. David is absolutely right to point out that there is an urgent need for implementations and field trials of various specifications. These need to be funded, supervised and evaluated. Then the specs and/or the implementations may need to be modified and the cycle repeated. But nobody is taking ownership of this. In relation to the PCEHR Dr Katekar's slides talk of a consultation phase to "assist with the planning, design and development", then she goes straight to "Individuals will be able to register...". What, no implementation phase? Registering will be pretty meaningless with no services running. (Maybe that doesn't matter: the HI has been hailed as a raging success even though nobody can use it.) NEHTA is meant to be about enabling infrastructure, and fundamental services. We need lots of progress in these areas before beginning the discussion about EHRs of any sort.

Dr David More MB, PhD, FACHI said...

Hi Keith:

Here

"What NEHTA and the three trial implementation sites should be working on is delivering a connected Clinician Controlled Electronic Clinical Record (CCECR) to our working clinicians so they can make a difference to the quality and safety of patient care available to the community."

and here:

"That may start with sponsoring and guiding the development of, and then supporting delivery CCEHR capabilities to all who need it. Only once this is achieved in and out of hospital, and information flows between providersare working, does it make sense to think about what the patient access components of an overall e-Health system may look like."

I make the messaging point. I am in violent agreement!

David.