Thursday, March 10, 2011

I Am Wondering Just What is Driving The Comment Stream on the PCEHR Blogs? Are They Just Hoping Against Hope It Will Work?

It seems that in the last 48 hours there have been a number of comments on my remarks on the PCEHR program that I find rather surprising.

It seems, just on a quick browse, that there are many correspondents who are expressing the view that the PCEHR program is much better than doing nothing. I would like to suggest there are much better ways the invest the funds - as highlighted in the blog here:

A little history is in order. The idea for a PCEHR sprang from a report to the National Health and Hospital Commission (NHHRC) that came out late in 2009.

As far as I can tell the PCEHR popped up earlier in 2009.

NHHRC Backs Person-controlled Electronic Health Records

Media Release - 30 April 2009

The National Health and Hospitals Reform Commission (NHHRC) today released a supplementary paper to its Interim Report, which outlines the Commission’s support for person-controlled electronic health records for every Australian.

NHHRC Chair, Dr Christine Bennett, said today that the supplementary paper spells out the Commission’s position that an electronic health record is arguably the single most important enabler of truly person-centred care.

“The timely and accurate communication of pertinent, up-to-date health details of an individual can enhance the quality, safety and continuity of health care,” Dr Bennett said.

“A person-controlled electronic health record would enable people to take a more active role in managing their health and making informed health care decisions.”

According to recent research commissioned by the National Electronic Health Transition Authority (NEHTA), 82 per cent of consumers in Australia support the establishment of an electronic health record.

The Commission has made seven recommendations to make person-controlled electronic health records a reality. These include:

    • By 2012, every Australian should be able to have a personal electronic health record that will at all times be owned and controlled by that person;
    • The Commonwealth Government must legislate to ensure the privacy of a person’s electronic health data, while enabling secure access to the data by the person’s authorised health providers;
    • The Commonwealth Government must introduce unique personal identifiers for health care by 1 July 2010;
    • The Commonwealth Government must develop and implement an appropriate national social marketing strategy to inform consumers and health professionals about the significant benefits and safeguards of the proposed e-health approach; and
    • The Commonwealth Government must mandate that the payment of public and private benefits for all health and aged care services be dependent upon the provision of data to patients, their authorised carers, and their authorised health providers, in a format that can be integrated into a personal electronic health record.

The NHHRC supplementary paper, Person-controlled Electronic Health Records, is available on the NHHRC website at under Interim Report of the NHHRC. Feedback can be sent to but must be received by Friday 8 May.

The release is here:

The supplementary paper is found here:$File/Person-controlled%20Electronic%20Health%20Records.pdf

As far as I can tell nothing in the paper demonstrates any proven value in the concept of a PCEHR and the reference provided earlier in the blog today confirms that view.

You can read my detailed negative submission on the whole idea dated May, 2009

As I pointed out then, and re-iterate now, this is an concept which is just not supported by any evidence at present that I am aware of.

Please send the refereed papers along that now confirm the PCEHR concept is a proven one.

Just doing something because it seems like a good idea - and to also plan to spend half a billion dollars in the process - is just not good enough and is appalling process and project management.

This project seems a bit like the NBN that was apparently just made up on the back of an envelope initially and has now grown a life of its own - on very flimsy evidence indeed. I believe there are much better ways to improve Australian E-Health than this nonsense idea.

If any correspondents have evidence that confirms the value of the specific PCEHR proposal - other than to the service providers who hope to deliver it - I look forward to the link!



Anonymous said...

David, Have you ever implemented or delivered a working EHR system in production?

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

Have you?

Yes I have in a number of organisations, as well as reviewing a range of implementation as a consultant.

I assume you think you know it all.

As you are not even game to use your name so I will ignore you from now on!


Anonymous said...

"The lady doth protest too much"

David, Judging by the amount of vitriol I think you must be hitting the mark.

It is very sad that so many people, who have obviously never implemented a complex piece of software in a challenging clinical environment, are teeing off so prolifically.

If some of this energy was directed towards ensuring that the decision makers are across the immensity of the challenge before us, and were encouraging innovation and the initiative of individuals and organisations doing good work in this space, we would be way ahead.

But no, we seem to want to pour our scarce resources into big name consultancies, and big bang magic bullet solutions, which to date have not produced anything of note - indeed it would seem the bigger the price the more attractive it is.

Anonymous said...

I have 3 points to make today after following your blog for a few months:
1) As you know from implementations you are involved with - sitting on the sideline and passing judgement is the easiest role one can play. No accountability required. I just wonder what your real motivation is?
2) The only thing unproven in NeHTAs PCEHR is the PC component. There are now enough EHR projects projects in the world to calm your fears in terms of the overall prospects of EHRs. While I agree with the criticism of the PC part - i think it's probably a necessary evil in a reality in which Australians are paranoid about their personal information.
3) I wonder where things would have gone if the first successful shared EHRs like the one in Israel which someone highlighted a few weeks ago would have waited for the solid evidence you keep looking for. By definition, all great innovation has no solid evidence that comes before it. What solid evidence was around before penecilin was tested?

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


1. My motivation is to try and have NEHTA / DoHA show us the actual plan of what they have in mind with the evidence supporting it.

2. EHRs are something providers use. PHRs are something patients use and the evidence for them is very thin on the gound - see recent blog.

3. Given all the issues with Shared EHR's I have covered elsewhere - and the fate of the UK plans - the very least you do is large scale piloting and not just rushing in! You prove my point by talking of testing / piloting.


Anonymous said...

So there it is.
I have been closely involved in a few EHR projects (not EMRs, EHRs!) and I can tell you that PCEHR (as defined by the "secret" Concept of Operations) is an EHR (not a PHR) with some tough requirements around patient control + a patient viewing capability. It's not a PHR.
Don't get me wrong, I am anything but a NeHTA fan and have my share of concerns about the approach. The exaggerated control given to patients will mean uptake will be slow and will require major investments in education - but throwing the baby out with the water will get us all nowhere.

Anonymous said...

It rather looks like HealthConnect is being used as the pilot for pcEHR. That'd be something along the lines of what you're suggesting. Perhaps you should focus on the definition of success instead of whining about them trying to follow the method you recommend they follow

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

Re the last two comments:

Sorry I don't agree and the semantics get silly sometimes.

EMR - Provider clinical Record.

EHR - Patient Life Long Record held by provider for patient.

PHR - A Patient Life Long Record held and controlled by patient.

EHRs and EMRs used by providers make a difference - PHRs presently lack evidence as to value.

Look at the pictures and it is clear the PCEHR is a PHR that the patient may choose to give provider access to.

The PCEHR idea I believe is rubbish. Disagree all you like, start your own blog or go with the paid spruikers of the NEHTA / DoHA view. I care little and nothing anyone has said has persuaded me I have it wrong.


Anonymous said...

Disagree on the semantics.
EMR - no issue
EHR/PHR - the issue is not who HOLDS them.
EHR - by definition will collate data from one or more EMRs and other clinical systems. Hence, unless implemented within a SINGLE provider organization (which is not the case in PCEHR) they are not HELD by THE PROVIDER. They are either held by a trusted third party or are compiled from records HELD by multiple sources (including but not limited to providers). The issue is not who HOLDs the EHR, it's who the primary target for use of it is. As much as I share the criticism of the overdone patient control in PCEHR - it is still mainly geared towards the clinicians (to serve patients better). The Patient involvement is mainly in order to control access.
PHRs are much more about patients entering their own data and getting wellness and web 2.0 information. those components are included in PCEHR - what's more the Concept of Operations specifically calls out the fact that a PHR is out of scope.

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

Sorry, you clearly don't agree with my view. Fine!

Bottom line is that any record where the patient controls arbitrarily who can access and what they can access is not an EHR in the sense the literature talks of them. It is that simple.

There is just no evidence I can see that suggests these PCEHR's are for providers. See the bottom of the diagram - provider records are clearly differentiated from the PCEHR.

Life long in my mind clearly involves multiple information sources so we are not far apart - except I believe EHR's are for clinician use and should not be fettered by patient control of what clinicians need to do their work!

I also think it just won't work, will be time consuming and confusing for all involved.

If you have access to the current ConOps why not share?


Mr. HIT said...

Reading your dialog here reminds me of an item I saw yesterday coming from Cananda. see - there's a video in there of the CTV broadcasted news item too.
Based on my memory form HIMSS which might be a bit shaky, i would guess that the application used there is DbMotion. Sure - there are differences to Australia. But it looks like the bloody thing can be done.

Anonymous said...

I won't share the ConOps because I signed a piece of paper saying I wouldn't and as much as I think that the restriction of its circulation is wrong, I take my commitments seriously.

So lets end this with what we agree on.
1) I think we both (and others engaged here too not all of the anonymous postings are from me) agree that giving clinicians access to integrated information about a patient's medical history collected from a broad variety of sources is a solid and proven idea.
2) I also believe that we all know that there is a sentiment in the Australian public that won't tolerate "the government" holding these integrated records and that will require citizen to have control over where their data is used. As healthcare and healthcare IT professionals we probably agree that that's a shame. but it's reality.

Where we disagree is around whether the PCEHR as defined does a reasonable job at settling the tension between the two points above.

I respect your opinion that they have not (you're basically saying they have killed it with too much "power to the people" and defacto turned it into a PHR). I feel (having read the whole PCEHR paper) that they have done a reasonable job - not perfect, but reasonable.

I hope that in one of your next posts you can propose an approach that would settle this tension more effectively. that would be constructive in my view.

Thanks for the debate!

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

My view is clear - we should be following the Roadmap laid out in the National E-Health Strategy and not the dreamed up PCEHR path. It is that simple!

And if you think clinicians are going to use their own EMRs and then log into a patient's PCEHR to check it, for the same encounter you are sadly just dreaming.

Simple question - what record is the Doctor going to use 90+% of the time?

Answer: Their local record not the PCEHR.

The whole thing just makes no sense to me knowing how docs work and use EHRs.

The debate is settled - if there is one - by following the National Strategy.


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

Sorry, just another comment.

"1) I think we both (and others engaged here too not all of the anonymous postings are from me) agree that giving clinicians access to integrated information about a patient's medical history collected from a broad variety of sources is a solid and proven idea."

That is what is done by present practitioner EHRs. You don't imagine the government is going to give all the docs new systems. If they don't - and the docs don't want a government operated record - then there are still 2 separate records and that is just a nonsense!

One decent one is all that is needed - in the hands of providers. Once that is working optimally and communicating as it should - then share and then look at patient access to that. The primary record is the provider one!


Anonymous said...

The easiest role to play is not slagging off, it is saying nothing.

Bad things happen when good people do nothing.

Plus on the anon side - most of us who are posting anon is due to the fact that we are in the industry and posting our own views named would be detrimental to our livelihoods.


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

"Plus on the anon side - most of us who are posting anon is due to the fact that we are in the industry and posting our own views named would be detrimental to our livelihoods."

I don't blame people but I do think it is sad open debate is utterly stifled.

Might as well live in a police state!


Tom Bowden said...

I was struck by the comment "giving clinicians access to integrated information about a patient's medical history collected from a broad variety of sources is a solid and proven idea"

Sorry..... this is completely wrong. This is a totally false assumption.If you had been reading what David has been saying, the UK NPfIT has been a disaster, there have been examples of similar cock-ups closer to home as well. Junping to the conclusion that banging everything together in a shared record is the aim, is a very '70s' view of the world. Countries/communities that are harnessing e-health in any meaningul way are certainly not doing it that way!

Anonymous said...

"I don't blame people but I do think it is sad open debate is utterly stifled"

Deate and argument is all very well ......... but how do we actually go about changing things for the better!

It is very frustrating at the clinical coalface reading about all the money that has (and is) being spent - and yet also seeing no way forward apart from a PCEHR proposal that is very pie in the sky and NEHTA archetypes that are even less likely to be able to be implemented!

Even simple issues like secure messaging appear to be have been overengineered to an extent that make them unreliable and too cumbersome!

Suggestions for alternative action and pointers to people/sites that are doing useful and effective development would be helpful....

Anonymous said...

"I was struck by the comment "giving clinicians access to integrated information about a patient's medical history collected from a broad variety of sources is a solid and proven idea""

I also agree that this is a doubtful claim - and for a very simple reason - there is no guaruntee that all the relevant information is collected, and from my experience an incomplete record is perhaps more dangerous than no record at all.

I am reminded of the old diagnostic advice for clinicians, when in doubt about the result 'Treat the patient not the result' - probably good advice in all circumstances.