We Have To Be Very Clear The Report Of The PCEHR Team Is Not Government Policy. However, What Does It Suggest and Will It Work?

I had an e-mail from the DoH E-Health Branch today  which makes this very clear. We are at the beginning of a journey.

“Dear colleague

I am writing to let you know that the Government has released the review of the Personally Controlled Electronic Health Record (PCEHR). A copy of the report is available at:

•  http://www.health.gov.au/internet/main/publishing.nsf/Content/eHealth

The Government supports a national eHealth record system, but it needs to be effective, functional and easy for all Australians to use, while being clinically relevant to doctors, nurses and other frontline healthcare providers.  

The review makes 38 recommendations and outlines opportunities to improve the usefulness of the system.

The Government will continue considering the recommendations over the coming months to understand the issues, their implications and in consultation with key stakeholders, determine the best ways to deliver on the intended outcomes,

As part of this commitment, the Department will be undertaking a range of consultation activities to consider options for responding to the Review recommendations .

I look forward to working with you over the coming months to improve the current and future capacity of Australia's health care system.

Linda Powell
First Assistant Secretary
eHealth Division”

I hope we get both consultation and listening this time!
With that made clear what about the report itself?

First - We have a Vision (p2)

“The electronic health record for Australians, will be a reliable, secure and trustworthy source of key clinical information. It will facilitate efficient and effective treatment of patients by health practitioners and enable consumers to access and manage their own health records in cooperation with their health providers to improve care. It will respect individual privacy but be clinically valuable to all areas of the health care industry. Interaction with the electronic health record will be highly automated and form a natural part of clinical workflows. The value of sharing health information electronically between healthcare professionals, will be demonstrated by enhanced efficiency and effectiveness of the delivery of healthcare, reduced hospitalisations and ultimately lives saved.”

What is made most clear here is an obvious shift which  really suggests a change of intent. As I read this what is now being sought is a record for use by clinicians to co-ordinate their care while providing access to allow the patient to be involved and be aware and comment on what is happening to them. However the issue of having a local and a parallel national system is still not clearly addressed.

Reading the report I noted the following:

1. The level of actual use of the system was actually going down despite continuing patient registrations.

2. The 2013 National E-Health Strategy Refresh is yet to be finalised. - but a (secret) summary exists.

3. The Panel felt the e-Health infrastructure (SMD, IHI, NASH, NPC ) were all in good shape. Some may be not so sure.

4. The benefits case is a total joke - conflating local systems and the PCEHR and pretending to understand the level of benefits possible (p9-11).

5. The barriers to implementation of e-Health slide (p11) certainly covers a lot of the issues.

6. The recommendations are summarised on p15-18 and available in a previous from a blog of May 19, 2014.

7. The rename to MyHR seems at odds to seeking more clinician use.

8. The governance recommendations seem good:

“Given the scale and complexity of the national eHealth work program, Australian Governments should continue to play a lead role in directing and coordinating national implementation activities. However, the move from a focus on nationally shared eHealth infrastructure to meaningful use of eHealth solutions by care providers and consumers, argues the case for a more broadly based involvement in the governance process – particularly extending to clinical and patient communities and private sector health operators.

Key to strengthening the current governance arrangements will be the establishment of an eHealth entity (created through the transformation of NEHTA) that is focused on coordinating execution of the national strategy and the nationally funded eHealth work program. To perform this role it will be necessary for the eHealth entity to have a Board made up of key parties beyond Government representatives (including strong care provider and consumer representation) and to oversight the building of close working relationships across the public and private health sectors and with the health IT vendor community.

Deloitte : National e-Health Strategy for Australia November 2013”(p20).

9. The Panel notes that NEHTA and DoHA just ignored most stakeholders most of the time (How true) (p21)

10. There seems to be an Independent Advisory Council for the PCEHR - members not listed and clearly hardly working if the last 2 years are any guide. (p26)

11. The move to opt out is reasonable but won’t happen in 7 months - and rushing it could be a big problem. (p29)

12. When the Panel says “The PCEHR should be considered a source of supplementary information.” They have it right in my view.  (p31).

13. It seems the Panel noticed patients like to be able to message doctors….”In addition, Secure Messaging is a closed network that operates between clinicians and it has not been designed to include providing Secure Messaging to patients and consumers. Action must be taken to expand the scope of Secure Messaging to a next generation service that ensures interaction between the medical profession and consumers for information that must be passed in a reliably secure manner to facilitate improved workflow and secure communication of private information.”(p40).

14. The NEHTA not listening again theme.

“It is acknowledged that a substantial amount of input was provided by various industry user groups during the development phase, and not incorporated into the PCEHR. Greater implementation of the recommendations provided during the development phase may have resulted in better acceptance and increased uptake of the PCEHR by both clinicians and individuals. Clearly, if the system is not designed around the realities of the clinical environment and workflows, then the uptake of the system will be limited.”

And:

“all medical specialties, other than General Practice, have been largely ignored”(p59)

15. More failure to do what was required from DoHA / NEHTA.

“The PCEHR Concept of operations refers frequently to the importance of governance. It quotes seven governance principles from the National eHealth Strategy including transparency, accountability, appropriate stakeholder representation, sustainability and the balance of local innovation and national outcomes. These principles were not followed, and the result is that a good plan failed.” (p78)

16. Accenture off on a bit of a frolic it seems from this.

“To ensure that the systems operator (in this case Accenture) does what it’s told by the system owner, which is to deliver the functionality specified by the system owner, rather than the operator delivering what it thinks/believes is best for the owner.”(p82)

17. The present PCEHR does not serve the key benefit opportunity. Bad design.

“Medicines management is a significant area of value that is not sufficiently supported within current PCEHR design” (p86)

18. Clinical risk is not really addressed properly.

“The current PCEHR has multiple safety risks including:

o Using administrative data (e.g. PBS data and Prescribe /Dispense information) for clinical purposes (ascertaining current medications) – a use never intended;

o Using clinical documents (discharge summaries) instead of fine- grained patient data e.g. allergies. Ensuring data integrity is often not possible within documents (e.g. identifying contradicting, missing or out of date data);

o Together the secreatean electronic form of a hybrid record with no unitary view of the clinical ‘truth’. Hybrid records can lead to clinical error by impeding data search or by triggering incorrect decisions based on a partial view of the record

o Shifting the onus for data integrity to a custodian GP avoids the PCEHR operator taking responsibility for data quality (a barrier to GP engagement and a risk because integrity requires sophisticated, often automated checking).

o No national processor standards to ensure that clinical software and updates (and indeed the PCEHR) are clinically safe.” (p88)

Overall p53 to p89 are the most valuable as collects all sorts of useful input and Panel .

Commentary.

My Overall Perspective On the PCEHR Review.

1. The key architectural flaws of the PCEHR are not understood and solutions for remedy proposed, neither is there any clarity as to what the system is to do and how it is not actually do it and for whom. It is also clear the panel really did not have a handle on what benefits the PCEHR can actually deliver.

2. If implemented as suggested the system will still not be successful as a valuable clinical tool I believe.

3. To do what is recommended and nothing more will be expensive and has the feel of ‘applying lipstick on a pig’.

4. The lack of real e-Health expertise involved in undertaking this review really shows.

5. Unless opt-out is implemented with great care and much effort around data quality and reliability disaster awaits. This means the change must be slow, incremental and frequently reviewed.

6. Clinical Safety issues are skated over.

7. The fate of the important AMT is not properly identified.

8. DoH and NEHTA have been hopeless in the Governance of Australian e-Health.

9. This is a seriously missed opportunity to make a sensible difference.

Sadly I could not go much above 2/10 for a score.

Sad about that. I look forward to seeing what the Government decides to do. There is no way at all this document could be described as a comprehensive plan for e-Health as Mr Dutton claimed in December.

David.