Tuesday, April 19, 2011

There Is A Lot Of Deliberate Confusion Around Just What Benefits Can Flow from A PCEHR Service. It’s Really Pretty Limited.

The NEHTA developed PCEHR Concept of Operations document is rather thin on the ground as regards the beneficial outcomes that may derive from implementation and use of the PCEHR System.

Here is what the NEHTA press release said:

Draft Concept of Operations for the personally controlled electronic health records (PCEHR) has been released.

12 April 2010. As part of the 2010/11 federal budget, the Government announced a $466.7 million investment over two years for a national Personally Controlled Electronic Health Record (PCEHR) system for all Australians who choose to register online, from 2012-13. To progress further consultation with stakeholders on the PCEHR, the Government has released the draft Concept of Operations document.

Minister for Health and Ageing Nicola Roxon said the release of the blueprint was a major step forward for national health reform and the development of personally controlled electronic health records (PCEHR).

"E-health is one of the critical elements of the Gillard Government's efforts to modernise our health system through national health reform," Minister Roxon said.

"E-health records will drive saver (sic), more efficient and better quality healthcare for Australians.

"Patients will no longer have to remember every immunisation, every medical test, every prescription as they move from doctor to doctor.

"This national blueprint, and the consultation and development that will follow, will help to develop e-health records for all Australians who want one from 1 July 2012."

The draft Concept of Operations document was released today and describes how the PCEHR system will work, its benefits, the structure and the important privacy principles. The release is intended to prompt further discussion on its design and input into areas that require further discussion and development.

The full media release is available here:

http://www.health.gov.au/internet/ministers/publishing.nsf/Content/mr-yr11-nr-nr066.htm

The release is here:

http://www.nehta.gov.au/media-centre/nehta-news/854-draft-concept-of-operations-for-the-personally-controlled-electronic-health-records-pcehr-has-been-released

Page 19 lays out some claimed benefits:

Individuals who choose to participate will have the opportunity to experience the following benefits:

- Access their health information: The PCEHR System will provide secure, quick and easy access to an individual’s key pieces of health information by both the individual and their healthcare providers.

- Receive improved healthcare: The PCEHR System provides opportunities for improved prevention, early intervention and treatment of chronic diseases as well as improved diagnosis and treatment in emergencies.

- Be more informed about healthcare choices: The PCEHR System will allow an individual to access their own PCEHR, view their own records and, in time, may link to health literacy information relating specifically to their needs.

On Page 99 (Section 9.2) we have a slightly different take:

The implementation of a PCEHR System will enable more person-centred healthcare and will support a range of benefits and outcomes, including the following:

Outcome Area 1

Continuity of Care — supporting the provision of uninterrupted coordinated care across different healthcare providers over time.

Benefit.

The PCEHR System shall enable easier access to Event Summaries, Discharge Summaries and other related clinical documents by both healthcare providers and the individual, and will contribute to improvements in:

- Continuity of Care.

- Chronic disease management by healthcare providers.

- Self-management of chronic diseases.

Outcome Area 2

Responsiveness — the ability of the health system to meet the population's legitimate expectations regarding their interaction with the health system.

Benefit

Timely access to an individual’s key health information by both the individual and their healthcare providers may contribute to improvements in:

- Participation by individuals in their healthcare delivery.

- Patient satisfaction with their healthcare delivery.

Outcome Area 3

Safety — avoid or minimise situations which can harm or have the potential to harm patients during the course of care delivery.

Benefit

Access to better quality, more timely patient health information will contribute to:

- Improvements in medication safety (e.g. a reduction in medication adverse events and near miss events).

- A reduction in avoidable/unplanned hospital admissions, emergency department attendances and GP visits.

Outcome Area 4

Accessibility — the ability of individuals to obtain healthcare at the right place and right time irrespective of socio-economic status, physical location and/or cultural background.

Benefit

The PCEHR System has the opportunity to contribute to improvements in:

- Out of hours care.

Outcome Area 5

Efficiency and Sustainability — achieving the desired results with the most cost efficient use of resources (i.e. avoiding wasted equipment, supplies, personnel and energy).

Benefit

Access to better quality, more timely health information will have the opportunity to contribute to:

- Allowing clinical staff to spend more time delivering health services instead of locating information.

- A reduction in duplicate testing.

- A reduction in avoidable/unplanned hospital admissions, emergency department attendances and GP visits.

Outcome Area 6

Appropriateness and Effectiveness — the application of evidence-based best practice at the right place and the right time.

Benefit

The PCEHR System will enable healthcare providers timely access to better quality health information across the health system, which in turn will contribute to:

- Improved clinical decision-making.

- Enhanced quality of recommendations provided by decision support systems.

- More opportunities to provide preventative care.

----- End Extract.

We also need to note Section 2.8.1

2.8.1 Clinical decision support

The PCEHR System will not provide clinical decision support services. It is intended that the PCEHR System will provide information to help drive clinical decision support algorithms and the industry and healthcare professions will take the lead on delivering clinical decision support services.

So what do we take from all this:

1. There is absolutely nothing quantitative about what is claimed as benefits for the PCEHR - we have a collection of motherhood statements about efficiency and ease of access of information. No dollar benefits are attached to anything.

2. There is no comparable model of the PCEHR implemented anywhere in the world and so, at best, the benefits that may flow are speculative at best.

3. Many of the benefits outlined in the use case described in the use case on Page 113 are really dependent on a range of infrastructure that will not be available in 2012 - when the financial decisions regarding further investment is required

4. In reviewing overseas literature we find out that simple is best and adoption is a tricky business (Page 112)!

“Additional findings from other reports include:

- 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. “

5. There is no public cost benefit case for the whole NEHTA project and the PCEHR. The Government seems to be running the line “e-health is good” so just be quiet - and I really doubt they are clear what is actually good about it.

6. Most evidence indicates that changing clinician behaviour and providing information to clinicians is where the vast majority of the benefits pay dirt lies.

7. Without quantifying benefits you can’t work out what incentives for adoption make sense and the risk is you will provide none and therefore get pretty slow and patchy adoption and use.

8 I see no recognition of the issue of the misallocation of costs and resulting benefits that means the users pay for benefits derived by others and typically means, again, adoption stalls.

We really deserve better solution thinking and design though for all this money!

Let’s be clear about all this. The much touted benefits for e-Health are real. But they will flow from a carefully integrated series of e-Health solutions that support the service delivery of and facilitates communication between all the actors (providers, consumers, hospitals, researchers and administrators) in the health system. The proposed PCEHR is pretty peripheral to this ‘main game’ and to keep on with this fiction of resulting benefits from the PCEHR is deceptive and misleading fraud on the part of Government and NEHTA. It is only a small part of the bigger picture.

David.

7 comments:

Bruce Farnell said...

At a cursory glance and at a top level the outcomes look fine. However, the lack of hard / quantifiable measures is a serious concern. These have been substituted with a liberal sprinkling of 'weasel words' which look great but don't provide clarity.

Clearly, the objective is to create an evaluation framework without hard measures so that 'spin', half-truths and case-studies can fill the void. That should be sufficient to convince the Minister to continue the funding post 2012 as the benefits will be 'just around the corner'. Meanwhile, real progress on eHealth in Australia will remain stalled.

Scot M Silverstein MD said...

PCEHR? NEHTA? I'm trying to decide which country has more and/or worse IT acronyms, AU or the US. I'm leaning in the southerly direction from my perch up here at 39° 57' 8" N north latitude.

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

Scott I am not sure we winners when you consider ONC, HIE, NHIN and every variety of HR known PHR, EHR, EMR and so on.

You also have IHE and their endless series of profiles (XDS etc)

Come on down and we will happily provide an introductory course!

David.

Anonymous said...

This has become typical of this Government.

Given the appalling waste record that has been exposed in the Pink Batts fiasco, the Building the Education Revolution and countless other botched up programs, one can logically draw only one conclusion.

This PCEHR Program is doomed from the outset.

The HI Service is a flop, it's failure has been disguised and hidden from real scrutiny through lack of transparency.

The benefits and outcomes that have been identified in the various documents and outlined above are so weak and poorly defined it merely reinforces the conclusion that this whole con job has been dreamt up by inexperienced Healthcare IT newbies and we can only a expect a first generation flop.

Anonymous said...

You're right, I'd forgotten how much all the experienced Healthcare IT people had done to create a viable and interoperable eHealth environment in Australia.

Oh, wait...

Andrew McIntyre said...

I think quite a lot has been done by the Health IT community but there has been a total lack of action by government to actually suggest, encourage or mandate any compliance with standards and as a result we do not have the progress that we should have had. This is a failure of governance. Despite that things like pathology work surprisingly well, although in a brittle way.

Anonymous said...

To: "Anonymous - Thursday, April 21, 2011 6:00:00 AM"

If you truly believe the creation of a "viable and interoperable eHealth environment in Australia" is at the sole discretion and determination of "experienced Healthcare IT people", then the magnitude of your ignorance is only eclipsed by the scale of your arrogance!

Judging by the comment, you're obviously a wise "man/woman of the system" that has all the answers, solutions and resources at your disposal, and therefore is capable of creating a "viable and interoperable eHealth environment in Australia"?

If you operate within NEHTA or DOHA, then I would say it's fair to say, the "experienced Healthcare IT people" are guess what:

still waiting... 2005 and counting... with no evidence or track record created as yet, providing no confidence whatsoever that a "viable and interoperable eHealth environment in Australia" is anywhere visible on the horizon...

To the "experienced Healthcare IT people", hats off for getting as far as you have, despite the interference and visible incompetence of the countless and faceless "men/women of the system", getting in the way and delaying the creation of a "viable and interoperable eHealth environment in Australia" , as they completely don't understand their role and contribution towards the realisation of such an economy!

So while the incompetents reign, and the inmates run the asylum, a "viable and interoperable eHealth environment in Australia" will sadly and tragically remain out of reach...

Recommended Reading: "Terminal Decline" -- (Khadra, 2010)