Tuesday, December 01, 2015

I Wonder What The RACGP Is Going To Do About Its Concerns Regarding The PCEHR?

This appeared last week:

The problem with the government's eHealth vision

24 November 2015
THE government is set to introduce changes to the Practice Incentives Program (PIP) eHealth Incentive to encourage ‘active and meaningful use’ of the myHealth Record (formally PCEHR).
To receive the ePIP, it is likely practices will have to meet targets for the uploading of shared health summaries (SHS) to the myHealth Record.
The RACGP argues these proposed changes are misguided.
Not only will they fail to deliver ‘active and meaningful use’ but they represent a missed opportunity to reform the ePIP in ways that would truly support the vision for a shared national electronic health record.
The advent of the Personally Controlled Electronic Health Record (PCEHR) in 2012 was heralded as a national system. It was proposed to ‘enable people to share their health information with their healthcare providers’, it says in its annual report.
A national electronic health record system has the potential to address the fragmentation of health information and deliver significant benefits for both the healthcare provider and healthcare consumer. This is especially in urgent and unscheduled care situations.
Providing access to an individual’s health information via the myHealth Record has the potential to improve the availability and quality of health information.
It should improve the coordination and quality of healthcare delivered to patients.
However, for this vision to be achieved, information in the record must be of sufficient quality to be useful, and the platform used to facilitate the sharing of this information must be safe and efficient.
In its present state, the myHealth Record fails to deliver on both.
The government’s proposed ePIP changes will do little to address these failings.
It is not clear what the value is in uploading a GP’s local health summary to the myHealth Record.
A GP who is the patient’s regular care provider will have the most accurate, complete, timely, safe, consistent, appropriate and relevant information. 
But GPs have traditionally managed their patient records in ways that have worked for them and their practice. 
There has not been a need or requirement for this information to be in a format suitable for transferring and sharing for a range of other purposes. 
It’s just another bureaucratic compliance measure. 
More here:
In summary the RACGP is concerned regarding the quality of information in the PCEHR, the value added for the GP by the PCEHR and the risk that the PCEHR becomes a compliance and not a clinical too. To that we have to add the revelation that the purpose of the PCEHR is not to improve care but to provide a huge database to be mined to get more practitioner control and compliance.
My feeling is that the AMA and the RACGP need to have some pretty intense ‘behind closed doors’ with Government to re-focus where e-Health is going and what it is to do.
Clearly the DoH has a vision for e-Health which is not actually aligned in any way with what clinicians expect.


Bernard Robertson-Dunn said...


IMHO, there are only two things wrong with the Department's eHealth vision:

1. They have no right to be collecting and storing health data on all Australians. They play no direct role in health care and, in their own words, the PCEHR should not be used for clinical purposes.

2. eHealth is much, much more than a dumb database that increases data fragmentation and puts Australians' privacy at risk.

myHealthRecord should not exist. Some of the technology infrastructure might be useful in a totally different architecture, one that didn't have a central database, but that's about it.

The longer myHealthRecord exists, the longer it will be before real progress is made with proper eHealth.

Anonymous said...

Maybe the vision is actually a delusion? The real need is to share quality information with the appropriate people without fragmentation and duplication. You can certainly share the information with the patient as part of that but a repository of raw information of poor quality without filtering the information so that its appropriate for the viewer is appalling for privacy. Centralizing it makes it a honey pot that will wake up sleeping bears.

The fact that the information in the PCEHR is not atomic and unreliable means that decision support is not possible. Large scale data mining does not depend on 100% accuracy but decision support demands accuracy or its simply dangerous. Even the planned lab data is transformed out of atomic format when it ?eventually?? goes into the PCEHR which is just crazy. Why transform the only good quality atomic data into a pdf?

If they had just focused on a high quality medication record it may have been useful, but that depends on a high quality medication terminology, something the AMT (Australian Medicines Terminology) is not. It also requires some standards compliance with existing medication standards, but no, rather than do something useful they go off and invent new pseudo standards dreamed up by a public servant that is low quality and not useful, except maybe for best guess data mining.

This is the Queensland Health payroll on steroids. Unlike that its fails invisibly. Its just a pure waste of billions rather than a waste of billions that causes an uproar because people don't get paid. Now if the make it opt out and force people to use it, that no use, no harm, protection goes away. Are they that silly to expose the uselessness of it all? On balance they probably are... watch this space.

john scott said...

I know from over 20 years work in digital health strategy that the critical mass for effective change is not formed by the few who are gathered around the problem, but when many come to see that the problem needs to be restated in order to be solved.

Clearly the medical community is coming to realize we can't continue this way.

It is time to solve our E-Health strategy problem once and for all.

I suggest it is time for the medical community to call for a halt to the PCEHR on the grounds of Duty of Care. Clinicians and patients are increasingly vulnerable as the juggernaut that is the PCEHR rolls on inevitably to catastrophe. The stakes in prospect have long since disappeared. The stakes at risk are not just money; it is more importantly about peoples' lives and professional reputations.

To move forward we need a new paradigm and narrative. I suggest a starting point could be the paradigm and narrative that informed Australia's efforts in the early 1990s. But we now need more than this. To address the massive challenges facing the health system this century, we need a revolution in the quality of collaboration.

The strategic aims of this collaboration should be to address three national and indeed international issues:
1. To make the health system safer, higher quality and more efficient (healthcare’s triple bottom line);
2. To maximise the benefits from the system working together; and,
3. To contribute to productivity and wealth creation.

We need to put people at the centre of the system. The people who need to be at the centre are the doctors, nurses and other front line healthcare providers with patients and carers as an extension of this centre. This is where the gains are to be made and where they have to be achieved, particularly if we are to address chronic conditions effectively.

We need to appreciate that in the knowledge-based economy it is about cooperation and co-evolution. To borrow a metaphor from music, we need to work 'together in concert'. By this I mean we need to purposefully work out how to work together and in the process of clinical reform to engage effectively with the notion of electronic pathways.

Electronic pathways are first and foremost information flow pathways crossing the boundaries and silos of healthcare to ensure that the right information is at the right place at the right time to enable safe, high quality and efficient clinical activity. Electronic pathways also include navigational assistance and decision support assistance for citizens so that their journeys are smooth and they can make their contributions.

Technology has its place but it is at best a third order priority preceded by; a) agreement on a new E-Health paradigm and narrative; and b) the formation of a trustworthy collaboration mechanism enabling the boundaries and silos that make up our health system to be crossed in support of electronic pathways.

The difficult political decision is the same decision that David Cameron has already made; we need to stop the rot.

Bernard Robertson-Dunn said...

I've said it before, but it bears repeating. The PCEHR is an IT solution to the wrong problem. The primary aim (see the legislation) is to reduce data fragmentation.

Why? Because there is a naive belief that more data will somehow lead to better health care. Or, as experienced system developers, say And Then a Miracle Happens.

The most important thing in health care is to make good decisions. Decisions need good data. Sharing data is a meaningless nonsense.

As a previous comment says "decision support demands accuracy or it's simply dangerous". The data in the PCEHR is of dubious, unknown accuracy and is potentially overwhelming.

A clinician needs the right data at the right time. The PCEHR is a fire hydrant of undifferentiated data which the average clinician will use at their peril. They will rely on their own eHealth record system to make decisions because they trust it more than they trust the PCEHR.

And the more the department tries to embellish the system with proposals like opt-out, third party Apps and secondary use, the more they erode what little trust there is.

And I totally endorse John Scott's statements, particularly:

"it is time for the medical community to call for a halt to the PCEHR on the grounds of Duty of Care."

"The stakes at risk are not just money; it is more importantly about peoples' lives and professional reputations."

"To move forward we need a new paradigm and narrative"

".... we need a revolution in the quality of collaboration"

Anonymous said...

The RACGP/GPs could of course put their money where their mouth is and simply not apply for the ePIP cash.

The current position seems to be "we like your incentive money, we just don't want to do activity it is meant to incentivize".

If they think contributing to the PCEHR is a crock - then fine, it's a perfectly valid position to take to say we don't believe this is clinically useful etc.

But don't ask for the money as well.

Bernard Robertson-Dunn said...

In its efforts to better protect the data in the myhealthrecord system, rather than implement security and privacy features that the system currently lacks, they have tried to take a simplistic approach - civil and criminal penalties.

This may well have the unintended (although not unexpected, by the more experienced observers) effect of discouraging GPs from using the system.

If you don't use the system, you can't be accused of misusing it.

GPs need to be educated about this system much more than the general public.

Bernard Robertson-Dunn said...

If the government were serious about Australians taking responsibility for their own health care they could do a lot worse than promote this approach.


Oh, I forgot. They did do a lot worse.

Anonymous said...

Looks like Dr Pinskier has been got at by some colleagues - this is unprecedented from him, really.

If any doctors had the ability to influence the design and build of the PCEHR, it was Pinskier and Dr Haikerwal

Anonymous said...

If any doctors had the ability to influence the design and build of the PCEHR, it was Pinskier and Dr Haikerwal.

However, as they are basically spruikers with no real experience at the coalface in healthIT it should not be surprising to know that they have unwittingly been providing naive exuberant advice to the designers and builders of the PCEHR because they didn't know any better. ....... for which they were handsomely remunerated.

Anonymous said...

You sure it was not a case of the design authority across PCEHR and the techie executives just ignored any input so your precious little thought bubble met the 1 July soft launch?

Bernard Robertson-Dunn said...

IMHO the problem with the PCEHR is not its design but the idea behind it.

Asking doctors to design a national health record system is like asking a handsome cab driver to design a new horse and cab when it really needed replacing by the motor car.

Doctors and other health professionals should be involved but not driving the solution. As John Scott said - we need a new paradigm. This will not come from doctors, IT people, public servants or politicians.

Dr Ian Colclough said...

Exactly - we need a new way of thinking about and solving problems that matter.

Even the UK, after a massive 10 year expenditure on its national eHealth initiative, has finally come to realise and acknowledge that a new health service delivery paradigm is required. That's the easy bit although painful for those who don't want to accept that a new model is required. The hard bit is the thinking, the brain hurts in the process - engineers, well versed in complex high precision engineering projects know that feeling. Ahh, that our masters could open their minds to a new way of thinking - a whole new horizon of possibilities would emerge.