Tuesday, February 18, 2014

Now A Few Have Tried To Use It, We Are Discovering What A Mess The PCEHR Is! Old Saying Confirmed

There is an old saying that the proof of the pudding is in the eating. To support that view we have this that popped up today.

‘Garbled and confused’: trust in e-health dives

18th Feb 2014
THE personally controlled electronic health record (PCEHR) is garbling patient information GPs upload, creating confusing and potentially misleading records, an e-health expert has warned.
The latest criticism of the billion-dollar scheme from former National Electronic Health Transition Authority (NEHTA) chief clinical lead, Dr Mukesh Haikerwal, comes as the health sector awaits the release of the review ordered by Health Minister Peter Dutton late last year.
A de-identified patient record entered into the PCEHR by Dr Haikerwal, and supplied to MO, shows that the reverse chronological order of visits was jumbled up and appeared in the e-health record in random order.
For the PCEHR to be usable, particularly for complex patients with multiple comorbidities, the most recent information must be displayed first with the patient’s history listed chronologically in reverse order, Dr Haikerwal said.
“The way it is rendered into the PCEHR is like a blender. You can see in the PCEHR view it becomes a mishmash both in terms of content — alphabetical or not — and date,” he said.
“Although it is there and may be better than nothing, it is only just better than nothing.”
Information labelled ‘past’ and ‘current’ in the original patient history also became mixed up in the PCEHR.
“Depending which CIS platform you use, it is likely to render differently, but each appears to have its own quirks,” said  Dr Haikerwal.
Lots more here:
Although Dr Haikerwal goes on later to say “Flawed though it is, there is much that can be rescued from the PCEHR. But this is a pretty stark depiction of what the flaw is in the most central document in the whole system,” it is clear he has major concerns and great frustration with the way all this has and is being delivered.
What we are hearing, from a key sponsor of the idea of the PCEHR, is a clear recognition that the PCEHR has been a disastrous mess and the more it is used the more confusing (and clearly dangerous) the whole system has become.
It seems to me we are at real risk of doing some real harm to real patients sometime very soon with this system.
The clear implication is that the PCEHR - as it presently exists - should now be taken down and, if it is to continue, a total rethink is undertaken of how information is managed and displayed before it is allowed to be accessed again. To just muddle on is just absurd on the basis of what Dr Haikerwal is saying. That information of this quality is fed from vendor systems to the PCEHR and then available for display shows how poor the overall conception and implementation of both practice systems and the central hub are.
Of course a total rethink of who manages, plans, governs and leads this program - which surely can’t now be seen as the initial PCEHR - is also critically needed.
Additionally some clarity as to just what the 'new' PCEHR is for, who it is for and what it is intended to do might be a help in the re-design!


Anonymous said...

The article goes on to say that: "A health department spokesperson said NEHTA was working with clinical software vendors, clinicians and IT designers to improve the PCEHR’s usability and design. "One of the improvements this group has been working on is the presentation of patient histories.”

Software vendors were upgrading their products to correct and improve the presentation of information, including its order, the spokesperson said."

In other words, this is an unending journey, with no goal posts that are fixed (just the shifting variety), and no accountability at any point in time. Oh that doesn't work? We are on it, don't worry.

Would love to see the safety reports on PCEHR which never see the light of day. Has this led to actual harm? Hard to imagine it has not.

Not no, nothing to see here, move on, we are on it.

Bernard Robertson-Dunn said...

Who would have thought? Data quality is a problem in the PCEHR.

In this case it seems to be one of sorting.

Do records get sorted:
In order of visit to doctor?
In order of input into PCEHR of data about the visit?

In order of test request?
In order of test?
In order of test results being available?
In order of test being seen by doctor?
In order of test being discussed with patient?

Can the sort orders be changed?

Is there a description of what the PCEHR is capable of in this area in any publicly available document? Any training material for health professional users?

Sorry to keep asking question, but I'd like to understand just how much of a risk this system is. I already have an idea but evidence is always helpful.

K said...

Actually, this looks like (from teh screen shots) it has nothing to do with the pcEHR itself - it's the order in one of the source documents that is uploaded to the system, as constructed by the vendor. the pcEHR itself cannot change the order of the items in the document.

BRB: regarding your question, all this is predictable behaviour of the system as published in the specifications. The sort order in the document is fixed by the authoring system, and not the pcEHR. The rules about the sort order in the document are... well, there are none, so vendors do whatever occurs to them (or not)

Why doesn't the system have rules about sorting of items in the documents? well, apparently the clinical team (lead by who?) couldn't agree what the rules needed to be, so there are none.

Dr David More MB PhD FACHI said...


Exactly..the GP Vendors have implemented things very badly and the PCEHR just publishes their rubbish!

A dangerous fiasco in my view!


Anonymous said...

Those of us who work in developing and implementing healthcare systems know how important it is to define the business rules on how data is presented. Dates are absolutely crucial. If GP vendors are constructing documents in incorrect date order then the PCEHR specifications - specifying how to construct documents and how to view data - are faulty.
This issue and the safety risk (dates and how they are defined and used) was raised to NEHTA and DOHA during the tiger teams reviewing the design and specifications of the PCEHR. Too bad it seems to have been ignored. I think it is a bit of a cop out to suggest that the GP vendors are to blame. Where does the responsibility for the PCEHR start and stop - surely it includes the ability to view the data in the system. If we don't start thinking of it holistically then it will continue to fail.
So costly now to go back and try and fix it. Not only in monetary terms but in credibility and trust.

Dr David More MB PhD FACHI said...

All those involved in this have covered themselves with a pretty inglorious effort and deserve to jointly share some blame for the failure. That runs all the way from the stupid politicians down. Most blame is at the top as these pollies and chief bureaucrats are the most at fault. All the issues flowed from these top few I believe.

There were plenty of experts who counseled care, piloting and full risk consideration but who were told you are clueless idiots.

My sense is the ass covering will now begin!

See if I am not right.


Dr David More MB PhD FACHI said...

BTW - the PCEHR is already an abject failure. Sorry if anyone thought otherwise.


Anonymous said...

Dr H should shoulder the blame with many others. He was a party to the fiasco for a long time and took the money the whole time.
If he had have made a better stand internally from the outset we maybe in a better position today. His remit was snake oil seller, his status lent to the clinical plausibility argument and he took the cash to do it. While his conscious may have caught up with him leading to his departure, the mess is still his to own as well. On a positive at least his feedback now is coming for free and is now transparent for public consultation.

Anonymous said...

I thought there was a process of conformance and compliance testing before a vendor system could attach to the PCEHR? Seems to me, if a vendor system implemented in good faith, has interoperability flaws like the one discussed here, they would have been detected in this process? Unless the process itself is silent on such issues?

Anonymous said...

Dr H like his colleague Dr Pinkear and the other clinical leads had no practical experience in healthIT. They were seduced by a sense of self importance in thinking they could lead the world by deploying the PCEHR which they naively accepted would work as described by the spin merchants. Seduced by money and ego they set about spinning their empty rhetoric to gullible colleagues across the nation. They were foolhardy, foolish and irresponsible in doing so. They threw caution to the wind. They have helped greatly to waste a vast amount of taxpayers funds and progressively destroy credibility around anything to do with eHealth in the Australian marketplace. In doing so they have contributed to undermining the viability of so many excellent eHealth vendors who had much to offer, but who were pushed away from the day NEHTA was established, then year after year despite their pleas to be allowed to contribute their expertise, while those who knew little went ahead pretending they knew much; ending up where we are today delivering nothing of value. At least Dr H has had the insight at last to admit as much.

K said...

There is a conformance testing process, but that can only test conformance to the specifications, so this is not tested.

Anonymous said...

Just because it's stored on a computer doesn't mean it is usable.
If the order is dependant on the source then the "documents" are not in a form that can be read, understood, nor processed by software. The major flaw in the NeHR system is "it contains dumb documents and not useful data".
It's like having a bank where transactions are kept as images and requires a bank teller to use a calculator every time you want to know your account balance or make another transaction. Sure, it's better than keeping transactions on paper and accessible from all branches but it really doesn't automate transactions.
We need usable data for automating clinical and research uses. It currently appears the NeHR has no plan, no money and no timeframe for this to happen.
The estimated benefits assumed the data could be used but reality is far from this and so the real benefits are also far lower than the estimates.
~~~~ Tim C

Eric Browne said...

"Just because it's stored on a computer doesn't mean it is usable. " Hear, Hear!
Unfortunately, so many people out there do not realise the implications of the PCEHR containing "dumb" (or stupid) documents. Many dream of all that data that can be used for decision support or mined for future benefit. Little do they understand the reality.

Grahame Grieve said...

Eric, it's not so much the "document" part that prevents data mining, as the general lack of clinical agreement about the data.

One way to look at this is that using documents has allowed the pcEHR to exist in spite of the lack of agreement over the underlying data, and we shouldn't have tried. That's the glass-half-empty take. The other way is to say that at least we have a repository, and as we start trying to exercise it to do decision support, the need for clinical governance and agreement will finally get some inpetus. That's the glass-half-full take.

The underlying issues are illustrated by a quote from Dr Haikerwal in the original article:

"He also said there was no separate tab to list allergies in the PCEHR and they came under adverse reactions, which could create confusion"

The question of whether to treat true allergies (IgE mediated?) differently to other kinds of adverse reactions is a highly controversial one where there is no consensus among clinicians. pcEHR had to choose one approach.

Until clinicians agree about this kind of stuff, we're stuck we were are now. Of course, it's easy to blame the IT projects, and there's always blame to go around in a project (proportionate to it's size) but that avoids the core problem

Anonymous said...

”Until clinicians agree about this kind of stuff, we're stuck we were are now. Of course, it's easy to blame the IT projects, and there's always blame to go around in a project (proportionate to it's (sic.) size) but that avoids the core problem”

Grahame, just to be clear, what are you stating or implying is the ”core problem”?? Are you stating it’s the inability of clinicians to agree about their data, the semantics of what it represents, and the manner in which it should be safely presented and represented (e.g. ”…kind of stuff…” in your terms)?

If this is an accurate reflection of your previous statement, while on this part I don’t particularly agree or disagree with you either way, what I do take issue with is any implication or acceptance that this issue be addressed or the required lessons learned by Clinicians and Healthcare IT professionals of all stripes, undertaken at over $1B in Taxpayers expense through some person(s) fantasy wet-dream in the PCEHR!

On this aspect alone, the PCEHR is a disastrous failure and those responsible for the over $1B wastage of Taxpayers funds should be ruthlessly held to account. This includes Dr Haikerwal and his NEHTA Clinical Leads cadre deeply responsible in contributing to this PCEHR mess and crime against the Australian taxpayer, especially considering those patients of Australia’s Healthcare system injured, penalised or disadvantaged from the opportunity cost of this over $1B in waste!

• How many hip replacements does over $1B buy?
• How many heart bypass or valve replacements does over $1B buy?
• How many cancer treatments does over $1B buy?
• How much reduction in hospital waiting list time does over $1B buy?
etc, etc, etc…

• How many 5-course dinners at 5-star Hotels hosting NEHTA Soirees – does over $1B buy?
• How many “Consultants” and how many "Light-bulbs" may be changed – does over $1B buy?
• How many NEHTA Semi-trailers and tanks full of diesel fuel – does over $1B buy?

So yes, the issues you posed may well be the priority core problem to be resolved, but on the other hand, does it really require over $1B in Taxpayers funds for the opportunity to “fail” in this lesson!

Remember, there is ”NO FREE LUNCH”, even when or especially when the Taxpayer is forking out for your 5-course 5-star dinners Dr Haikerwal and picking up your tab…

Grahame Grieve said...

re Part A: well, by "core problem" I did mean the "inability of clinicians to agree ...". But there's a scope issue: I'm not claiming that this is "the core problem" for the pcEHR, only that blaming the project for this particular underlying issue is unreasonable. Beyond that... I regret commenting on this now. I should have known better.