Wednesday, September 28, 2011

Is This An Workable Approach To Thinking About the PCEHR? Different National Approaches Are All Over the Place!

The following editorial appeared a few days ago - and as the PCEHR was mentioned I thought it was worth a careful read.

Solving the right health IT problem

September 20, 2011 | William Yasnoff, MD, PhD, President, Health Record Banking Alliance
Twenty years have passed since the Institute of Medicine identified electronic health records (EHRs) as "an essential technology for patient care." However, despite much activity, and some progress, comprehensive electronic patient records are still not available to providers of care.
Most of our efforts thus far have been focused on automating our current record retrieval process: When a patient presents for care and has records elsewhere, a manual request is made to the outside provider and the records, if available, are typically faxed to where they are needed. We have mistakenly believed that if we could just automate this process with electronic health information exchange (HIE), all would be well. This provider-centric approach addresses the wrong problem. Each provider’s records, even if electronic, are not complete patient records.
Treating the symptoms of missing records by automating our current manual "fetch the records" process will not fix this. The locations of all the records for a given patient are not generally known or recorded. Every provider must have an EHR system able to respond immediately to a record request from any other provider (a combinatorial explosion of potential connections). Provider sharing of records is totally voluntary. Records from multiple sources must be correctly identified and integrated in real time. Protecting privacy is very difficult since patient information is located in many different systems. The scattered patient records cannot be feasibly searched for public health, public policy or medical research purposes, eliminating our opportunities to use this information to detect patterns and improve care. Finally, there is no clear business model for sustainability.
Last year's report from the President’s Council of Advisors on Science and Technology concluded that current HIE efforts through the states "will not solve the fundamental need for data to be universally accessed, integrated, and understood while also being protected." Findings of a recent survey of HIEs "call into question whether RHIOs [Regional Health Information Organizations] in their current form can be self-sustaining and effective."
The right problem is ensuring the availability of comprehensive electronic patient records. Solving it requires a patient-centric approach. Imagine each patient having their own secure and private electronic "checking account" for their medical records.
William Yasnoff, MD, PhD, FACMI, is a health IT consultant and President of the Health Record Banking Alliance.  His prior work at HHS resulted in the creation of ONC in 2004.  He is the author of the Health Information Infrastructure chapter in the textbook Biomedical Informatics (Shortliffe & Cimino, eds.). This post appeared at
Read the full article here:
The following paragraph provides some links to some examples.
“This approach, known as a health record bank (HRB) or "patient-controlled EHR" (PCEHR) is already in use in Singapore and Denmark, and is being implemented in the Netherlands. Australia just awarded a large contract to build a PCEHR system by mid-2012. Aided by seed funding from Washington State starting in 2009, several small HRBs are now operational there.”
Here is the announcement from Singapore:

Accenture Implements Nationwide Electronic Health Record System in Singapore

June 20, 2011
Accenture Implements Nationwide Electronic Health Record System in Singapore
Phase One Launch Provides Single Patient Record for Healthcare Professionals
SINGAPORE; June, 21 2011 - Accenture (NYSE: ACN) and MOH Holdings Singapore have launched one of the world’s first national electronic health record (NEHR) systems. Aligned to Singapore’s “one patient, one record” vision, the NEHR enables a single patient health record for clinicians to access across the healthcare continuum. 
As patients visit providers – including primary care clinics, acute and community hospitals – healthcare professionals will be able to access a single patient record for medical information. The NEHR captures medical data, including patient demographics, diagnosis, medications, tests, procedures and discharge summaries, for exchange among clinicians. 
“Our goal is for all Singapore health organizations to have real-time clinical information for treating patients,” said Dr. Sarah Muttitt, Chief Information Officer, MOH Holdings. “This milestone represents a significant step towards achieving our vision.”
“The NEHR will enable insight driven health through the timely access to holistic patient information,” said John Vidas, who leads Accenture’s health business in Asia Pacific.  “Singapore’s vision, leadership and innovation will establish standards and best practices for other regions to follow.”
The Singapore NEHR go-live is the first phase of the effort and was deployed in 10 months.
Full release here:
From Denmark we see a really interesting approach.

Widespread Adoption of Information Technology in Primary Care Physician Offices in Denmark: A Case Study

March 11, 2010
Authors: Denis Protti and Ib Johansen


Denmark is one of the world's leading countries in the use of health care technology. Virtually all primary care physicians have electronic medical records with full clinical functionality. Their systems are also connected to a national network, which allows them to electronically send and receive clinical data to and from consultant specialists, hospitals, pharmacies, and other health care providers. Under the auspices of a nonprofit organization called MedCom, over 5 million clinical messages are transferred monthly. One of the most important innovations has been the "one-letter solution," which allows one electronic form to be used for all types of letters to and from primary care physicians; it is used in over 5,000 health institutions with 50 different technology vendor systems.


D. Protti and I. Johansen, Widespread Adoption of Information Technology in Primary Care Physician Offices in Denmark: A Case Study, The Commonwealth Fund, March 2010.
Full text of issue brief is found here:
I can’t vouch for the third link but it seems to rather double Dutch to me!
Go here if you read the language:
My take is that the guts of the Health Bank concept has some merit. The implementations in the US look nice and simple and are obviously reasonably practical:
See here:
and of course here:
What is happening in Denmark looks like a clever way to skin the Health Information Exchange approach and the Singapore model is still emerging.
Had our powers that be decided to go with Danish simplicity and elements of the Singapore and US approaches we might have had a workable system without all the issues to suit those patients who wanted one and still have been able to enhance our present clinical systems.
I still struggle to know how any of these concepts can make complex long term collections of information easily accessible and useable - so there does seem to be a role for curation of a health summary if a sensible balance between patient desire and clinician time and effort can be struck.
I have to say having a look at what is going on elsewhere is really worthwhile. Comments welcome.


B said...

Would it not be better to solve the right health problem, rather than the right health IT problem?

Australia has a particular health care system and can chose between two fundamental strategic directions for new IT systems:

1) Australia could further automate its existing health systems to increase effectiveness and reduce costs.

2) Australia could take the opportunity to assess if a different health system, underpinned by automated systems, would be more effective at a lower cost.

It seems to me that Australia has adopted the first option but is doing it by implementing a solution that matches another country's health system.

Is there just the faintest chance that the solution for the PCEHR won't match Australia's health problem? And that the PCEHR will lock Australia into a bad way of delivering health?

It's difficult to answer because nobody has properly analysed and understood Australia's health problem.

One might hope that the PCEHR solution accidently matches the problem to some extent, but, as the wise man said, hope is not a good strategy.

Anonymous said...

B said...

"One might hope that the PCEHR solution accidently matches the problem to some extent, but, as the wise man said, hope is not a good strategy"

David: Is it reasonable to think that the same people that came up with a solution to the Singapore EHR are creating the solution to the PCEHR, but are considering how we are different from Singapore?

Anonymous said...

B, do you have an outline what "Australia's health problem" is?

B said...

"David: Is it reasonable to think that the same people that came up with a solution to the Singapore EHR are creating the solution to the PCEHR, but are considering how we are different from Singapore?"

a) The PCEHR is a solution, so a solution to a solution make no sense.

b) The only way there is any chance to get anything up and working by 1 July next year is to implement, as closely as possible, the Singapore solution.

c) The vendor will not be asking "does the PCEHR match the Australian Health problem?" It is not their job. Their job is to deliver the solution as defined. NEHTA and DoHA should be responsible for solving the health information problem.

IMHO, they haven't done so to a sufficient level to build an information system to support the Australian health system.

Dr David More MB PhD FACHI said...

Accenture have recognised it is a little different and have said they will tweak it a bit. See the interview with Brad Cable in The Australian a few weeks back.

I agree with the other point - but when you just buy what is available you get what you get!


B said...

Anonymous said...

"B, do you have an outline what "Australia's health problem" is?"


a) it is a social problem

b) it is a wicked problem

c) it is a changing problem as new sicknesses/diseases emerge and new health technologies are invented

d) there are many stakeholders with competing and contradicting interests

e) there is no overarching governance. i.e. it is, primarily, a self organising system. This makes it difficult to automate at the system level.

f) There is a mismatch between those people who understand the details of health issues (health professionals) but who should not make health decisions and those who do not understand health issues (patients) but who are responsible for making their own health decisions. So called, informed decision making.

g) there is a similar mismatch between the information needs and concerns of health professionals and patients. The first group needs a much information as possible, the second is nervous about who can access it.

h) the “health” industry is mainly reactive and aimed at "curing" people or managing their symptoms. There are also conflicts of interest whereby some stakeholders benefit from more people being sick and hence consuming their services.

i) there is an assumption that better health IT will deliver better health outcomes. This is a bad assumption. Any health project, IT or not, should detail the problem it purports to solve and demonstrate how it solves it.

There are many more characteristics, but my day job calls.

EA said...

Some big players will be at where $1265 entrance fee would allow one to have a face-to-face debate with Jane Halton about "taking all the right steps towards delivering the national health reform by injecting funds into ... modernising county's e-health solutions". (Some careless proof-reading by AFR.)
Meanwhile, in Richard Bacon casts a dim light over Lorenzo.

Dr David More MB PhD FACHI said...

Dr. More,
Thanks for your interest in my editorial. Australia’s move toward patient-controlled EHRs is certainly getting attention here in the U.S., where our efforts to provide comprehensive electronic medical records when and where needed are, as I indicated, not progressing well.
I wanted to respond to the comments about addressing the health problem vs. the health IT problem. While everyone in health IT clearly wants to improve health, I don’t think that trying to directly address that goal with health IT is helpful. What health IT can do is ensure that comprehensive electronic records for each person are available for care. The effective use of those records to improve care (and health) is and will be an ongoing issue. Health IT can help with that, too, by developing new and innovative ways to filter and present relevant information, include decision support (for providers and patients), etc., but these techniques are largely premature if the basic information is not available.
In terms of evidence, it is undeniable that the lack of comprehensive patient information in our current systems of care results in serious adverse outcomes and excess costs. In every health care environment where the comprehensiveness and availability of records has been improved (e.g. Kaiser, Group Health, Harvard Pilgrim), the cost of care has decreased while quality has improved. While no one has achieved “complete” records, there is every reason to expect that further improvements in both quality and efficiency will accompany the availability of complete records (especially since the examples noted are, in many cases, very close to “complete” already).
To be very specific, B said “there is an assumption that better health IT will deliver better health outcomes.” Yes, that is an assumption, but it is completely consistent with all the evidence (as described above). More importantly, it is absolutely clear that the current outcomes (which are not very good) will NOT improve without comprehensive patient information (through health IT).
Regardless of how a health system is organized and funded, it is axiomatic that patient care should always be guided by comprehensive information. It is hard to imagine that anyone would seriously advocate the provision of patient care with incomplete records (unless there was no other option).
Finally, asking health IT to focus on activities that improve health precludes prompt and accurate assessments of progress since health effects are typically long term and influenced by a myriad of confounding factors. In contrast, implementing health IT systems that can deliver comprehensive electronic medical records when and where needed for everyone is a clear, measurable, and achievable goal. It would, in and of itself, be huge step forward for health care and is critical to enabling further positive changes.

William A. Yasnoff, MD, PhD
Managing Partner