Sunday, July 27, 2014

I Wonder Why It Is People Keep Pretending ‘eHealth’ Is An Unalloyed Good And The PCEHR Is Largely OK?

This appeared last week.

Andrew Knight: e-Health revolution

Andrew Knight
Monday, 21 July, 2014
THE benefits of having an effective electronic health record seem obvious. Rapid sharing of information, reduction of duplication and greater ownership by patients of their health information offer hope of reduced harm and savings in time and money.
The review of the personally controlled electronic health record (PCEHR) commissioned late last year by the federal government certainly thinks so.
The reviewers point to modelling which suggests that e-health changes could lead to savings of $7 billion a year by 2020. The modelling estimates implementing e-health would avoid 5000 deaths, two million outpatient visits, 390 000 hospital admissions and 10 million laboratory and imaging tests by 2020.
  
The overwhelming majority of those making submissions to the review were also supportive. According to the review, more than 1.2 million Australians have demonstrated support by registering for an e-health record, exceeding the 2013 target.
The new federal government has affirmed its commitment to e-health and continued funding to implement the recommendations of the review. One of the reviewers, GP and former AMA president Dr Steve Hambleton, has been appointed the new chair of the National E-Heath Transition Authority (NEHTA).
Those of us at the coalface of general practice know that the reality of implementation to date has had problems. Uptake by health professionals is well below targets and has plateaued.
The review points to “classic issues of change management” such as lack of strategic direction and clear policies, poor understanding of potential benefits, unengaged or unwilling stakeholders, and poor execution of e-health initiatives.
To be useful, My eHealth Record (as the PCEHR has been renamed) needs high-quality information from GP record systems. This means that investment in engaging, training and supporting general practice is crucial if we are to achieve the e-health dream.
How to achieve successful implementation and use was explored by the Improvement Foundation and 54 general practices through a NEHTA-commissioned Quality Improvement Collaborative. Small practice teams attended workshops separated by supported action periods.
More here:
Here is the abstract of the paper referred to:

The eCollaborative: using a quality improvement collaborative to implement the National eHealth Record System in Australian primary care practices

  1. Andrew W. Knight1,2,
  2. Craig Szucs3,
  3. Mia Dhillon2,
  4. Tony Lembke2 and
  5. Chris Mitchell3
  • Accepted April 8, 2014.

 Abstract

Quality problem The new national patient-controlled electronic health record is an important quality improvement, and there was a pressing need to pilot its use in Australian primary care practices. Implementation of electronic health records in other countries has met with mixed success.
Initial assessment New work was required in general practices participating in the national electronic health record. National implementers needed to engage with small private general practices to test the changes before general introduction.
Choice of solution The National E-health Transition Authority contracted the Improvement Foundation Australia to conduct a quality improvement collaborative based on 9 years of experience with the Australian Primary Care Collaborative Program.
Implementation Aims, measures and change ideas were addressed in a collaborative programme of workshops and supported activity periods. Data quality measures and numbers of health summaries uploaded were collected monthly. Challenges such as the delay in implementation of the electronic health summary were met.
Evaluation Fifty-six practices participated. Nine hundred and twenty-nine patients registered to participate, and 650 shared health summaries were uploaded. Five hundred and nineteen patient views occurred. Four hundred and twenty-one plan/do/study/act cycles were submitted by participating practices.
Lessons learned The collaborative methodology was adapted for implementing innovation and proved useful for engaging with multiple small practices, facilitating low-risk testing of processes, sharing ideas among participants, development of clinical champions and development of resources to support wider use. Email discussion between participants and system designers facilitated improvements. Data quality was a key challenge for this innovation, and quality measures chosen require development. Patient participants were partners in improvement.
-----
There are two key comments I want to make on all this.
First the first three or four paragraphs keep suggesting how wonderful ‘ehealth’ is and how it is obviously great but then we read:
 “Those of us at the coalface of general practice know that the reality of implementation to date has had problems. Uptake by health professionals is well below targets and has plateaued.
The review points to “classic issues of change management” such as lack of strategic direction and clear policies, poor understanding of potential benefits, unengaged or unwilling stakeholders, and poor execution of e-health initiatives.”
Hardly a ringing endorsement of how the PCEHR Program has been conducted!
Second, then we go to the details of the paper where there were 56 practices being supported to get the PCEHR working well and widely. Assuming each practice has a few thousand patients on their books we are talking about 650 shared summaries being uploaded from 1000 registered patients out of a pool of patients that certainly exceeded 100,000 over a six month operational period. In the last month amazingly only 20 records look to have been uploaded in the last month of the trial and the rate of usage was flattening on the graph.
Overall this all looks like a total flop!
Would have been good to have a little update on where things were just before the paper was published rather than reporting now on what was happening almost two years ago!
However, with all that said I do agree with the sentiments in the last two paragraphs in the article:
“History has taught us that important enablers include adequate financial support, local training and practice support and systems that have been properly designed and tested in the real world to be fit for purpose.
Failure to invest effectively in general practice will seriously delay e-health. We need an effective implementation plan which will properly resource and support general practice for success if Australians are to receive the benefits of the e-health revolution.”
Pity fixing the system fundamentally was not also mentioned!
David.

No comments: