Tuesday, April 12, 2011

The PCEHR Concept of Operations - As Released Today - Is Just Not A Goer.

We have these reports from this morning:

Draft plan for e-health disappoints: $500m records system a 'viewing service' for patients

ALMOST $500 million is being spent on an e-health record system that will not provide real-time medical information at the point of care.

Instead, it will serve copies of some clinical documents uploaded from doctors' systems in a voluntary program that puts the control of access in patients' hands.

The long-awaited draft concept of operations for the personally controlled e-health record, to be released today by the Health Department, shows how clinical documents will be pulled together by a "viewing service" and displayed in a format for viewing by patients and health professionals.

Critically, the system will not support clinical decision-making and lacks sophisticated analytics capabilities.

The design gives people a great deal of control over access to records held in the Personally Controlled Electronic Health Record system and consumers will be able to add their own notes to a GP-managed health summary record.

Consumers will access the system via a portal. Doctors also will initially access patient records through a separate provider portal, although in time their systems will be integrated with the PCEHR repository.

A novel approach is the ability for individuals to set access parameters, including requiring providers to use an access code (a PIN or passphrase selected by the patient) to verify consent.

Other controls will be "include" and "exclude" lists for participating healthcare organisations and an ability to limit access to certain documents within in the record.

This ranges from the default "general access" to "no access", which restricts viewing to the original source provider of the information.

More here:

http://www.theaustralian.com.au/australian-it/draft-plan-for-e-health-disappoints-500m-records-system-to-be-voluntary/story-e6frgakx-1226037456206

Reports about and interviews with Ms Roxon are found here:

http://www.theaustralian.com.au/australian-it/roxon-sells-her-vision-of-handing-power-to-the-patients/story-e6frgakx-1226037346609

Roxon sells her vision of handing power to the patients

And here:

http://www.theaustralian.com.au/australian-it/e-health-vision-has-roxon-revved-up/story-e6frgakx-1226037451911

E-health vision has Roxon revved up

The Financial Review has some limited (and not very accurate) coverage here:

http://afr.com/p/business/technology/health_system_hinges_on_support_p0e4GCcUYs6CgwVMq3YtJI

E-health system hinges on support

Emma Connors

KEY POINTS

  • Suppliers of clinical software are expected to upgrade their systems to comply with the new set-up.
  • There is no compulsion to comply before electronic records become generally available next year.

The full documents can be found here:

http://www.yourhealth.gov.au/internet/yourhealth/publishing.nsf/Content/pcehr

What to make of this much ballyhooed document?

My view is that it is not yet a credible or realistic plan and that it is deeply strategically flawed.

First let us consider the strategy underpinnings.

The big ideas in the document are:

1. Personal Control of the Information Held in the PCEHR. Control is exercised, by the patient, by a range of access controls and goes down to a very low level of information granularity.

2. Information Content in the PCEHR comes either from primary systems (GPs, Service Providers, Hospitals or Medicare Databases) or from the patient themselves.

3. No direct linkage between operational systems and the PCEHR. The PCEHR will - at some point - be integrated into operational systems - to be looked up and updated - but not be an actual part of those systems.

4. The PCEHR record will be made up of a Health Summary - curated by an individual’s nominated GP and a series of event summaries and documents (reminds one of the cancelled HealthConnect program of 5-6 years ago!)

5. The PCEHR system will hold some core information while indexing information from other information providers for display to the end-user.

6. The core PCEHR system will be Government operated or outsourced under Government control.

What is wrong with the present set of proposals?

1. Excessive complexity - at least initially - of the proposed shared record.

2. Lack of clarity on system and project governance.

3. Excessive optimism as to what can be achieved in 15 months at a superficial level. Reading closely it is clear NEHTA recognises that what will be delivered in 15 months is going to be extremely limited and that the real project will take many years.

4. Lack or any adoption incentives, especially for providers. There seems to be an implicit assumption that providers will do all this extra work and put up with all this change for no charge.

5. A lack of any real linkage between what is planned and the benefits that are claimed for the initiative.

6. A complexity of proposed access controls which will severely hamper adoption by the public and probably infuriate providers.

What is missing is:

1. Evidence that this approach will work and be adopted by patients and clinicians - especially without financial incentives provided to care providers for the additional work undertaken by them to maintain the system.

2. Evidence that this system will be embraced in sufficient numbers by patients.

3. Any sense there has actually been any serious consultation with many of the stakeholders. Frankly it has been lip service to consultation at best!

4. Government commitment to continued funding beyond June 2012.

If we are to undertake a Shared EHR system developed and operated by Government we need to start with something very simple and credible. Of course all the other parameters from the National E-Health Strategy also need to be observed (standards based etc.)

All this needs to go back to the drawing board, the Government needs to admit trusting techos to develop health IT systems in secret is a bad idea, and do it properly taking full note of international experience.

It is important to remember the despite what the PCEHR is named the patient still does not control the doctor or other providers records. So really the whole idea is pretty silly!

All the patient controls is the copy and we still expect providers to communicate between each other directly. They are hardly going to do it via the PCEHR.

An irrelevant excrescence as you might say - for a lot of money!

To just press on from here, without major change, is lunacy - and will be shown to be so.

Also of major concern is that the AFR reports Minister Roxon as suggesting that additional funds will only flow when what is being done now has proven itself and that she expects the program to be self-sustaining to a considerable degree. This is just total nonsense and there is no way the planned 12 pilots can prove substantial benefits in 14 months leading up to July, 2012 when the 2 year budget allocation runs out.

I wish I could get hold of some of the happy pills these people are taking!

David.

6 comments:

Anonymous said...

I would like some of those happy pills as well - I felt ill after reading this -but frankly, I still don't really understand how this is going to work - 1 of a dozen questions - where are the Conformant Portal Providers and Conformant Repository Providers coming from and what financial incentives will they have? Is this going to be Medibank Private (or NEHTA or Medicare?) - a bit of a catch 22 - if you are not in the eHealth waves, you can't work with NEHTA and so have no chance of developing a product that would be conformant by July 2012 - you need a nose plug to read this as well as the happy pills - it reeks on so many levels.

Anonymous said...

As a major provider I can assure you we will not be supporting this any longer and will now sit and watch the whole thing implode....

Another monumental waste of taxpayers money.

Anonymous said...

Yep, the whole thing has me scratching my head. Putting all the money they are going to spend into sacks and burning it would do more for e-health than this is going to do.

Frankly the events of the next few months are probably going to set us back by a matter of years.

Anonymous said...

From the ConOps, tucked away at the back.

"
A report on the Danish shared record scheme found that increasing the level of complexity does not bring a corresponding increase in benefits [GART2006]. The report recommended focusing on a simple, basic design and concluded getting the level of functionality right is essential.

A report on the UK SCR reiterated that achieving critical mass is essential as clinicians will stop using a system if they fail to find shared records within it [BMJ2010a]. The same report also found that implementing a shared SCR is a major socio-technical challenge, and harvesting benefits will be highly contingent on the abilities of clinical champions and change agents. These champions and change agents need to be able to bridge different stakeholder groups, negotiate complex interdependencies and tensions between groups and mobilise implementation efforts.
"

So....

- we are deploying a more complex system (despite the key lesson we learned from Denmark)

- we recognise we need to get critical mass, so we are putting as many barriers to getting access to information as possible in place (PAC codes indeed - who thinks of this guff?)

Anonymous said...

Yes this collection of notes is a great concern. It appears looking at little snippets like the reference to Denmark but the inclusion of PAC (no comment)that the Architects working on the Concept of Operations and the Analysts and/or Architects working on the requirements are not to keen to agree. The access controls or security concerns seem to be made with no reference to another peice of work in NEHTA around security and access, which I hear is no longer to be funded or properly resourced, not that all but a small dedicated couple of NEHTA people regarded this as important and looking at PCEHR I would assertain NEHTA executives more than likely find having to be constrained by security and privacy an issue that is best buried. I find this difficult to imagine as my source informs me that an executive at NEHTA is himself a security expert.

Anonymous said...

I work at NEHTA. I don't know of any "security experts" on the Executive?