I was reflecting on a rather interesting series of messages in the GPCG_TALK e-mail list on the transfer of medical records between practices which were using different software – and it occurred to me that the importance of this topic was significantly underestimated in more than the obvious way. My concern centres around the lack of focus and standards setting for GP and Specialist Ambulatory Care / Office systems. Why the concern? The answer is that it is these systems which will have the biggest impact and benefit for our health system.
While we have yet to see the actual report NEHTA claims that the benefits from adoption of more E-Health can be found in the following areas (From May 2007 presentation):
Major sources of benefits
1. Benefits from appropriate use resulting in service substitution
2. Better clinical decision support in:
- Prescribed medications
- Clinical ordering (pathology & imaging)
3. Electronic consultation substitution
4.Reduced rate of population chronic disease progression
5. Reduced hospital costs
6. More efficient community pharmacy processes
7. Improved medication adherence
By the estimates contained in the same presentation it looks to be that between 60 and 65% of the benefits are to flow from improved clinical decision support.
It is also clear from the NEHTA benefits study (of which we have only yet seen a few slides) that there is, on their part, an assumption of major planned change in the connectivity of practices and in the expectations for consistency and safety in clinical practice. This can only happen if the systems on the edge of the health system (i.e. used by GPs and specialists) are much more capable than is the case at present.
The Australian Medical Workforce – when last counted in 2004 (Published in 2006 by the AIHW) was made up of the following active clinicians:
Primary care practitioners - 22,011 (40.8%)
Hospital non-specialists - 6,202 (11.5%)
Specialists - 19,043 (35.3%)
Specialists-in-training - 6,710 (12.4%)
The targets for decision support are the 40% who are GPs and probably roughly 2/3 of the specialists who are in other the fully procedural practice and are in what I would term are in office based practice (In the US called ambulatory practice). This amounts to well over 60% of practitioners.
The other obvious target is community pharmacists to provide a back-up review of the drug related aspects of clinical activity.
So just what a NEHTA’s plans to upgrade and improve the computer support of those who can make a major difference – rather than those who are hospital based and are a much smaller part of the problem?
With its penchant for telling everyone else how to standardise, communicate, process health information and data –and now knowing where the ”paydirt“ lies – what about a major switch of focus to improve GP and Pharmacy Computing?
A very good place to start may be to work with DoHA to identify how best to support GP / Specialist / Pharmacy computing and start working on standards for decision support, usability etc for ambulatory practice. A mandatory standard to ensure all practice systems are able to import and export clinical data in a usable form could be a very useful additional work item. It could be enforced easily through payment / non-payment of Practice Incentive Payments based on compliance with the portable record capability standard.
Additionally, if the work on identifiers and SNOMED CT is going to have any useful impact in the foreseeable future it needs to be linked with a decision support and discrete data messaging upgrade for all the 40,000 or so front-line clinicians.
Why is this major and obvious focus not on the agenda at all? We don’t need a Shared EHR any time soon, we need individual practitioners with effective systems first!
I certainly plan to make this point as clearly as I can to the Boston Consulting Group Review of NEHTA.