The Shared EHR – Can it Be Done Simply and Make a Difference?

In this short article I want to raise, and attempt to solve at a high level, some of the problems associated with the currently proposed Shared Electronic Health Record (SEHR).

The reason to document this is that in its latest presentations NEHTA is still saying it wants to put a business case for implementation of a National SEHR to the Council of Australian Government by the end of 2008.

What I mean by a SEHR is an arrangement (in its most simple form) where by a variety of feeder systems found in general practice, specialist offices, hospitals and services such as labs, pharmacies and radiology create summary records as they process patients which are then uploaded to a central repository. These summaries are envisaged to accumulate over the life of the patient to form a valuable longitudinal electronic patient record.

The central repository is then accessible to authorised users to assist with the care of the individual patient at some time later.

With minor tweaking around the edges the NEHTA proposal seems to be a re-run of the late 2004 HealthConnect project which was a month or two after that date placed into development limbo. The most evolved public version of the HealthConnect proposal was the Version 1.9 of its proposed Business Architecture (BA).

There do exist some slightly later NEHTA documents providing a “Concept of Operations” for a NEHTA SEHR but these are not publicly available.

It must be reasonably obvious to all that creation of a nation SEHR is not a uncomplicated exercise – indeed, since proposed in late 2001 – very considerable work has been done, pilots of components have been undertaken but any really extensible or expandable success simply has not been demonstrated. Those with a historical bent can follow all this is excruciating detail at the following URL:

http://www.health.gov.au/internet/hconnect/publishing.nsf/Content/home

This site was last updated 17 Feb, 2006.

I will state a prejudice here and state I think the SEHR of the BA Version 1.9 and NEHTA’s present plans are probably too complex, when fully analysed, to be made reality. That said I believe there is the possibility of doing something very clinically useful if those responsible stand back and work out clearly where information should be stored and processed within the health system.

What I suggest is that a practical approach to the SEHR should be a very simple base record – held voluntarily in a central repository - that contains the information that may change the way an individual is treated in the first day or so of an encounter with an emergency facility, hospital or new doctor. If that can be made to work, then, and only then, should consideration be given to doing more in a shared EHR sense.

There are a number of templates available for what to me should be a single form which is stored centrally and updated by the patient and their attending doctor at each appropriate encounter. All that would be stored would be essentially patient demographics, major current illnesses and problems, allergies and current medications, with maybe some free text for special items of warning or alert.

The standard of information I would suggest is appropriate is the amount of information a thorough GP would provide about a patient who as going for an overseas trip where they may need care from a doctor who had never seen them before.

If more detail is required, it is at that point reference is made to the owners of the patient’s detailed information – e.g. laboratory providers, specialists, local GP etc.

Any design that attempts more than this simple approach (of voluntary sharing of a basic information set agreed between the patient and their usual clinical adviser) will get tangled up with a range of issues.

These include:

• Concerns for privacy and lack of control of their personal information on the part of the consumer / patient

• Difficulties and delays in delivery of a workable system due to complexity if a more adventurous approach is attempted.

• Excessive cost in infrastructure requirements.

It seems to me such a basic standardised record would typically be able to be relatively easily read and created by quality GP and other relevant systems – and a secure messaging solution to and from a central repository would not be too difficult to devise within current standards.

Either the Access Card Identifier or the NEHTA Health IHI could be used to safely identify patients if either is available, or an alternative devised if required. Only one would be needed.

Under my approach all the heavy computational lifting – that promotes quality and safety in clinical care – would be done within client systems in the General Practice, Specialist’s Office or Hospital where clinicians engage with the details of care and where decision support is most valuable.

Such a model of a simple shared record and quality computing for the clinical workface (i.e. Local EHR) I find intrinsically appealing and doable today. I hope something practical, quickly implementable and workable emerges from NEHTA’s deliberations in this area.

I am firmly of the ‘walk before you run’ school in Health IT. Round the world we see simplification working and complexity confounding the most energetic. Let’s grasp that lesson and move forward.

David.