Wednesday, April 13, 2011

The Bottom Line According to The European Union is that Shared Electronic Health Records Are a Very Dubious Project.

A colleague who is trying not to cause too much trouble developed this short commentary on the below named report. He has given permission for it to be re-used.

The full report (58 pages) can be downloaded from here:

Review of the Final Report on National e-Health Infrastructures for the European Commission

While the report is relentlessly upbeat and positive, for a number of understandable reasons, buried in the document are a number of very important messages, key among them that shared record systems are failing to deliver benefits, especially given the enormous opportunity costs of pursuing them. Following are two extracts from the executive summary.

“So-called electronic health record (EHR) systems are a consistent element in almost all strategies and roadmaps. But usually EHRs are not well and/or consistently defined, often (implicitly) referring only to a patient summary or similar basic electronic patient re-cord. It is also increasingly evident that clinicians? enthusiasm for comprehensive electronic health records, which may connect patient data in diverse record systems at hospitals, community services etc., relates to perceived benefits in their immediate surroundings (their day-to-day work processes) rather than to a geographically widespread sharing of detailed patient data.

This is saying that clinicians are finding little or no value in shared EHRs.

“Reaching agreement about eHealth strategies and, even much more so, implementing them has almost everywhere proven to be much more complex and time-consuming than initially anticipated.

This is saying that putting in shared EHRs is extremely time-consuming and costly, going way over budget (we are talking billions of Euros here).

In addition, the complexity of eHealth as a management challenge has been vastly underestimated. It is here where an exchange of experience gained, also from failures, and lessons learned may prove particularly beneficial to Europe.

This is saying that it hasn’t gone anywhere near according to plan and that no-one really understands what is going on.

Following are two paragraphs from section 4.

Touted for 20 or more years as the “holy grail? of eHealth, electronic health records (EHR), or more precisely EHR systems, are a consistent element of almost all national strategies and roadmaps. However, whereas EHR-like systems have been implemented or are under development in many healthcare provider organisations, covering patient data from within their own organisational boundaries, and also in various regional health-care systems, there exist hardly any at the national level. The urgent clinical need for large-scale national systems is being questioned more and more, as a recent English evaluation noted: “Clinicians? enthusiasm for electronic health records often related to perceived benefits on their immediate surroundings and did not necessarily relate to the NHS Care Records Service’s goal of geographically widespread sharing of patient data.

This is saying that an enormous amount of money and effort has been poured into something that no-one really wants. It is interesting that out of 27 EU countries only two have made an attempt at implementation.

Recognising that there is, as yet, no universally accepted standard definition, for purposes of this study, a patient's electronic health record (EHR) is understood to be a shared, integrated or interlinked (virtual) record of all his/her clinically relevant health and medical data independent of when, where and by whom the data were recorded. In other words, it is an account of his/her diverse encounters with the health system as recorded in a variety of medical records maintained by various providers such as GPs, specialists, hospitals, laboratories, pharmacies etc. In many cases, an EHR is understood to contain a patient summary as one of its core elements or artefacts. Across most countries, policy documents mentioning EHRs usually do not contain specific definitions, i.e. it remains unclear what is really meant. It seems that, for implementation purposes, mainly patient summaries or extended versions thereof are envisaged.

This means that no-one really knows what should be in a shared record anyway.

In my view the net effect of all of this is that the shared record bubble will soon burst (This will impact shared EHRs at all levels including regional ones) I am also aware through separate sources that key opinion leaders across the world are agreed that the end of attempts to create regional shared records is on its way.

----- End Article Extract.

Really this pretty much says it all. And to add to this I heard that, staggeringly, the Secretary of the Department of Health, speaking at the Health-e-Nation Conference a few days ago, admitted in response to a direct question that there was not an evidence base supporting the planned approach and that Australia had chosen to go its own way because it ‘was different’.

I guess that explains why the recently released PCEHR ConOps is an evidence free zone. There isn’t any!



Anonymous said...

This is positively the most disgraceful state of affairs imaginable. A commitment to spend 456 million dollars at this time on 9 ill-conceived e-health projects in exchange for chopping 400 million dollars out of the medical health and research funding bucket beggars belief absolutely.

Hopefully this appalling state of affairs will be brought by someone in the medical research community to the attention of people like Gus Nossal,Susan Cory and Peter Doherty, will should use this information in their representations to the Prime Minister Julia Gillard who clearly is totally unaware of the incompetence of her government's health department in regard to its administration of ehealth in Australia.

Anonymous said...

The 9 "ill-conceived" projects are only receiving around 50 million dollars. This is less than it cost to create the HI Service!

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

And all the hidden costs for DoHA and NEHTA no one actually knows about!

Remember that they are still planning to spend the whole $450M on the project before July 2012!


Mr. HIT said...

See for heaps of research by the European Commission on EHR, much of which actually points to success. I guess that this is the kind of thing that you'll allways be able to find "evidence" to either support of disqualify.

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

2 things:

1. This is a newer report.

2. EHRs are different from Shared EHRs.

Core provider EHRs work without question!


Mr. HIT said...

1. since when is recency a indicator of accuracy?
2. in Europe, EHRs generally refer to Shared EHRs. a organizational/provider centric EHR is called and EMR or EPR in Europe.
Many of the case studies on that site are about shared EHRs (provider or patient centric - or hybrid).

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


1. Given the authors - recency matters.

2. Semantics on what you call stuff is a major issue and the US even spent money to try and sort it out.

My view of the literature is pretty simple. Shared very limited summaries (Wales, Scotland) can work - more complex stuff fails badly and costs a lot and gets scaled back - the UK.

Doing complex parallel shared records (like the PCEHR) is just nonsense.


Anonymous said...

The business case for the national EHR/EMR/PCEHR or whatever, and more importantly the roadmap that describes the "cascade of benefits" that give professionals, investors and other contributors a reason to play in the technology sandpit, simply don't exist - and never have. It has been based on an investment assumption.

However you may wish to interpret this new EU report it is clear that the "big" EHR agenda is not recognised as a value point at this stage of e-health development and sophistication. Governments are beginning to seek out real value for their precious (increasingly so) investments.

After 30 years involvement in health care and electronic health systems et al I am delighted that, finally, clinical relevance (rather than what I see as technology justifications and vendor rhetoric) is coming to the fore in e-health.

Anonymous said...

The government has a perfect opportunity to both save some money and save some face. In the coming budget they need to announce that the PCEHR delivery will be deferred a year because of the floods, cyclone and other budget constraints. Let the existing projects work through to completion, but defer the national infrastructure and other tenders.

It will save money because the national infrastructure will be less likely to fail, and be cheaper, if the ConOps is allowed full and careful consideration.

It will save face because the risk of failure with the current compressed timelines must be high.

Anonymous said...

Even better, write off the $67 million wasted so far and give $400 million back to medical research so that the absurd proposed slash-and-burn to the NHMRC budget can be avoided.

Oh and throw NEHTA into the dustbin along the way. It will be no loss and it's abolition might actually enable some real progress in eHealth for Australia