Sunday, September 22, 2013

I Am Suffering Considerable Cognitive Dissonance Reading About Australian E-Health These Days. What Do We Really Need To Happen?

A couple of interesting articles appeared last week.
First we had:

Sector calls for transparency and end to mistakes in PCEHR

MEDICAL experts and industry players have urged Tony Abbott to rectify the national e-health record system's "significant mistakes and missed opportunities" and ensure transparency is a key plank in its delivery.
In the lead-up to the election, Mr Abbott vowed to overhaul the cumbersome personally controlled e-health record (PCEHR) program, calling for a review.
Details on who will conduct the review and its parameters are still scant as Mr Abbott only yesterday announced his frontbench, to be sworn in tomorrow.
Peter Dutton has been appointed health minister, as expected, while Nationals NSW senator Fiona Nash is assistant health minister.
Andrew Southcott, previously opposition parliamentary secretary for primary healthcare and the Coalition's e-health spokesman, missed the cut.
About 650,000 people have registered for an e-health record but only 0.6 per cent or 4000-odd shared health summaries exist. These records are created by a patient's GP and contain diagnoses, allergies and medications.
Mr Dutton, a vocal critic of the PCEHR, has described Labor's implementation of the PCEHR as a $1 billion disappointment.
"With nearly $1 billion spent on the program, it has failed to deliver anywhere near what the Labor government promised," he said last month. "The e-health program has been shown to be more about politics than about policy and more about spin than about outcomes for patients."
Pharmacy Guild national president Kos Sclavos said it supported the concept of an audit "because there have been some significant mistakes and missed opportunities".
Mr Sclavos said the Guild would make a detailed submission to the e-health review. It will be centred on three elements: patient issues, pharmacy issues and system issues. "Community pharmacies provide a range of professional services that focus on screening and risk assessment as well as the monitoring of chronic conditions.
"To date, the information collected cannot be uploaded to the PCEHR. This is a gap that must be addressed," he said.
Mr Sclavos said the Coalition's review could result in changes to the PCEHR and the role of community pharmacy. He said his members "need a clear path on the future of the system and at present there are many unknowns".
Australian Medical Association president Steve Hambleton said "We're not happy with the uptake or the process of the PCEHR ... Everyone agrees that e-health has great potential to improve patient healthcare with increased instances of sharing key information about patients but we need to find out why we haven't got there."
More transparency was vital in order to gauge the true situation with the PCEHR.
Dr Hambleton said the system was too cumbersome for doctors and could lead to errors.
Lots more here:
Second we have this.

$1 billion e-health system rejected by doctors as 'shambolic'

September 19, 2013
Sue Dunlevy National Health Correspondent
AUSTRALIA'S billion-dollar e-health system is in danger of becoming an expensive white elephant with doctors refusing to use it.
A key clinical adviser to the government who quit in frustration last month has described the system as "shambolic".
And the medical software industry says the body running the system, the National E-Health Transition Authority, lacks the skills to do the job and warns patient safety could be at risk.
Dr Mukesh Haikerwal who resigned in frustration from work on the e-health record says he's uploaded 150 patient records on to the system but "no-one can read it".
Patients who want a hospital or specialist to see their e-health record have to take their own ipad to the consultation to show the record because hospitals and specialists don't have the software to read it.
Fifteen months after e-health was launched - 888,825 Australians have signed up for an e-health record but by last month doctors had loaded only 5427 health summaries on to the system.
Only hospitals in the ACT and South Australia can currently access the record, although more are scheduled to come on board next month.
Some of the medication records loaded on to the record by the government are wrong and Dr Haikerwal says this could have grave consequences for patients who could be misdiagnosed.
The AMA says doctors or hospitals trying to use the records have less than a 0.5 per cent chance of finding anything clinically relevant.
Last month, four of the clinicians advising the government quit in frustration.
The mounting problems with the system come as it emerged that the cost of Britain's failed e-health system has reached 10 billion pounds.
However, a spokeswoman for the Department of Health said it was wrong to compare Australia's e-health record with Britain's which managed the entire stay for every patient seen or admitted to hospital all the way to their billing system.
Health Minister Peter Dutton who was sworn in on Wednesday has pledged to undertake a "comprehensive assessment" of Australia's e-health record.
Lots more here:
Third we have this.

I’m still an advocate for PCEHR: Haikerwal

19th Sep 2013
DR MUKESH Haikerwal remains an advocate for the government’s personally controlled e-health records (PCEHR) system despite serious concerns about the accuracy of clinical records and the system’s useability.
Dr Haikerwal, who recently quit his post as NEHTA’s chief clinical lead, told MO the system was still “some time off” being a reliable, useful and widely accessible resource for doctors, and there remained much to be gained from the work already completed.
“We all know there are issues with the program and project that need to be fixed up but the positive side is that there is something to be worked from and built on,” he said.
“There is stuff out there now that exists because of the work that has been done over the years. It just has to be in a format that is useful for clinicians.”
His comments followed News Limited reports that quoted him labelling the PCEHR as a “shambolic” system containing potentially incorrect patient medication histories.
He told MO that in at least one case a patient had been given the medication record of another patient sharing the same name.
A GP could conceivably see someone with a PCEHR that said they were taking something like olanzapine (Zyprexa) and say, ‘oh, you have schizophrenia, are you taking these tablets?’ Dr Haikerwal said.
If they did not have schizophrenia then the GP may unnecessarily upset them or give them a medication they don’t need, which is not a good thing, he added.
Dr Haikerwal said there was much work to be done to support and reassure doctors to get them to embrace the PCEHR.
Lots more here:
Last we have this:

National e-health still has a future despite problems: CIOs

Under fire national program lacking the right policy framework for broad adoption
Technology heads in the healthcare sector continue to back the federal government’s controversial and slow moving national e-health record program, saying it has a future despite lacking the critical mass it needs to succeed.
As of July 31, 612,391 Australians had registered for an e-health record, according to a recent National E-Health Transition Authority (NEHTA) report. A further 4500 organisations had registered in the personally controlled e-health record (PCEHR) system and 4585 shared health summaries had been uploaded as of 22 May.
The scheme has come under fire in recent months. In July, Australian Doctor polled 514 general practitioners with two-thirds indicating they will not take part. Earlier this week, a man was accidentally sent another person’s e-health details.
Meanwhile, industry has called for the Abbott government to fix the troubled system. Before he was elected on September 7, Tony Abbott vowed he would seek a review of the struggling e-health program.
Mal Thatcher, CIO at Mater Hospital, said the scheme has not yet reached the critical mass it needs to succeed and is lacking the right policy framework for broad adoption.
“That includes the need for strong ongoing engagement with the entire health ecosystem whether by NEHTA or the current system operator in DoHA. Unfortunately, in my experience at least, engagement has not been nearly effective enough.”
Thatcher also said access to and use of the PCEHR has to be “symbiotic” with clinical practice and electronic medical record systems to convince clinicians that it’s worthwhile. He added that clinicians need to trust the quality and currency of the data and industry needs to articulate a tipping point for adoption.
Bill Vargas, CIO at the Sydney Children’s Hospitals Network, told CIO clincians' time is fairly precious given their heavy workload, so they have to convinced that using these systems will give them benefits as well as for the patient.
Vargas believed that more than half the population and health organisations have to be using the national system for it to reach critical mass.
“This will ensure that information gives a holistic picture of a person’s health record and makes it useful for the ongoing care of the patient.”
Despite some doctors baulking at the system or indicating they will not take part, Vargas believes consumers will drive uptake as they will request that their doctor is connected and contributes to their e-health record.
“In discussion with consumers, in particular parents of young children, they have an expectation that this will occur in the future or else they will seek doctors who are connected to e-health,” said Vargas.
Vargas said the benefits of sharing appropriate and concise clinical information between treating clinicians for the benefit of the patient should “no longer be an argument.”
“The potential reduction in clinician incidents by having information about current medications, allergies, diagnostic results or medical conditions would be a great benefit to the patient and the health system,” said Vargas.
More here:
When taken as a whole it seems to me a few things emerge pretty clearly - other than some of the headlines not quite reflecting what the articles are saying.
First there does not seem to be a single commentator who is of the belief that the status quo is even alright - let alone ideal.
Second there is a pretty strong view that without major changes in the system and a great deal of work to reshape the NEHRS / PCEHR to be both valuable to / and supportive of clinicians getting their work done it will fail.
Third there seems to be a view that adoption will be driven by consumers. I suspect this is not correct as in its present incarnation the system does not do what patients most value (appointment making, repeat scripts, secure messaging to their doctor etc.)
Fourth there is a pretty clear recognition that the way the Program has been led and delivered has been ill-conceived and not clinician friendly.
What is missing is any real clarity as to what should and needs to be done to address the problems as they have been articulated.
I have my own ideas (which I have rabbited on endlessly about) - but would be very interested to hear just what people believe should be the actual outcomes of the promised review of the whole effort.
Over to you. I look forward to some new ideas on the way forward that can snatch victory from the jaws of defeat!


Trevor3130 said...

From 'Australian hospital statistics 2010-11' (AIHW), Hospital Performance Indicators (p31) -
"In 2010–11, 5.1% of separations reported an ICD-10-AM code indicating an adverse event. The proportion of separations with an adverse event was 5.9% in the public sector and 3.9% in the private sector (Table 3.5). The data for public hospitals are not comparable with the data for private hospitals because their casemixes differ and recording practices may be different."
For example, 'Adverse effects of drugs, etc' - 2.1% (public) 0.7% (private).
Since one of the highlighted benefits of PCEHR is reduction of medication errors, it seems some basic groundwork on definitions and documentation needs to be done. Whose responsibility is that?
Also, do those adverse event notations show up in the PCEHR?

Grahame Grieve said...

No, this information is not part of the pcEHR discharge summary specification. The discharge summary does include both "Alerts" and "Adverse Reactions" but neither of these are the same as "Adverse Events". However it does include a "Clinical Synopsis" where the information about the admission that is relevant to the ongoing care of the patient is included

Anonymous said...

Accenture should accept a lot of responsibility for this shambles. PwC and McKinsey should also be held responsible for the failed change management and adoption program.

A clawback of taxpayer dollars is appropriate.

Trevor3130 said...

ABC Health Report today is on 'Cancer treatment in the private sector'. If this does not raise issues that ought to be addressed by "good" Health IT, then Norman Swan is not asking the right questions.

Anonymous said...

NEHTA were claiming that the PCEHR and electronic scripts/dispensing could prevent ADE's and thus reduce hospitalisation. The problems are, a large portion of these ADE's are not caused by the writing/dispensing errors avoided by eScripts & the PCEHR and the potential for errors still exist. Most ADE's experienced by patients, when seeing a GP, were from the long lists of known side effects (however, these were less likely to require hospitalisation). There is always a first time for an ADR before it can be noted and potentially avoided. The NEHTA cost-benefit analysis heavily relied on reducing ADE's and hospitalisations. The claimed $$$ savings are not going to happen and the costs are far greater than the real benefits.
---- Tim

Anonymous said...

"What Do We Really Need To Happen?"

In short: install some honest ACCOUNTABILITY!

After all these upcoming "expensive" reviews sponsored by the LNP of the PCEHR and other associated failed eHealth funding activities (NASH etc.) with NEHTA and its highly priced Consulting Cohort, if not a solitary head rolls for this blatant waste of Taxpayer funds, then the insider trading and rorting of the Taxpayer under the facade of Big Government eHealth programs and the guise of eHealth enabled Health Reform will surely continue unabashed and quite possibly be escalated as they have got away with so much now for so long that their insatiable self-serving greed will be the only instrument of their parasitic demise.

Cure for Cognitive Dissonance is to understand who is profiting and benefitting from the current state of affairs (follow the money!) where self-interest and the funds to fuel that self-serving self-interest are all it takes to make crystal clear what exactly is happening and why within "Australian E-Health" these days.

When viewed this way, it all becomes very clear on why it is so and transforms the perceived dysfunction into a very reasonable and functional behaviour, albeit at the true cost to the Taxpayer and Australia's Healthcare System Patients and benefit of unethical and unscrupulous characters!

An in-depth Auditor-General audit report tracing where the over $1B in funding has traversed and where it has ended up should make it clear who is pulling the strings to their own benefit. Audits of involved Bureaucrats and QANGO executive bank accounts should also uncover any unscrupulous kickbacks and alleged corruption swirling in this questionable eHealth space.

Anonymous said...

That is some fairly serious accusations, please provide evidence outside of post Pcehr appointments to firms that won contracts to spend the money

Anonymous said...

"An in-depth Auditor-General audit report tracing where the over $1B in funding has traversed and where it has ended up should make it clear who is pulling the strings to their own benefit."

We shall await the inevitable Auditor-General "Audit Report" with bated breath!

Trevor3130 said...

We are watching & waiting to see how 'crowd-sourcing' (Climate Commission) and use of social media (Indi) can force political change.
Pardon me for harping on an old saw, but citizens will not mobilise to force changes to the eHealth agenda until they can see, as taxpayers and patients, how their money is spent.
So, a couple of articles at HBR Blog Network are good to read.
The statement "... more transparency in price and quality data can direct patients to more productive settings, intensifying the incentive for providers to improve on the demand side" applies directly to the dilemma faced by Delia as described in Norman Swan's report.