One of the big claims from Government, which has been associated with the three years of additional funding for the PCEHR, is that they are going to re-develop the PCEHR to make it more usable for clinicians as this issue was raised by the Royle Review as a major problem.
It seems to me that this is a very, very hollow claim. Thinking about it lets see what can’t be fixed.
1. The PCEHR can never have the flexibility of a locally based Clinical System in displaying the various information held. Simply clicking the various tabs can display much more information than will ever be held (or should be) in the PCEHR.
2. The PCEHR will never be a primary system for the GP and will only be consulted for the occasional patient (who is new to the practice or is away from home) whereas the GP System will be used all the time but it will need to be consuming practitioner time (and costing money) while waiting for the PCEHR to be updated.
3. The speed of access to the PCEHR via the internet will never match the speed and convenience of a local system and most of the time will be irrelevant for the care of most patients.
4. The PCEHR interface will inevitably be less familiar and different to the familiar GP system and so may be less speedy to interpret and understand.
5. Access to the PCEHR during the consultation will always require a conscious decision and extra key clicks and time.
6. Consent for information upload of a clinical summary will need to be obtained on every occasion - with the time involved - in the opt-out environment as consent cannot be assumed before each consultation.
7. Without a major re-design the information held in the PCEHR will not be discreet information but rather lumpy .pdfs which will not provide the utility of results obtained direct from laboratories in terms of cumulative reporting and trend observation.
8. The local system will inevitably contain information which has been locally developed and derived and so will be intrinsically more useful to and trusted by the practitioners in that practice.
9. Inevitably access to the PCEHR will impose workflow and speed consequences and even if a record is known to exist there will be quite a high threshold to spend the time to look up the PCEHR in most cases - unless such access is made mandatory - in which case a clinical revolt, in the absence of major financial incentives, - would be inevitable.
In essence there is no amount of application of lip-stick to this pig that will give it the ease of use, speed, comprehensiveness, familiarity and relevant detail provided by local systems.
I am sure this is what most GPs would see as usability and it seems to me the PCEHR is never going to be in the ball park of what might be required for GP satisfaction.
Delivering the speed, richness and familiarity that is required for real acceptance is just not possible IMVHO.
Do you think the DoH can deliver a usable fix or do you have other issues to add? Let us all know.
David.
4 comments:
You can lead/mandate an opt-out national health record system and feed/link it to whatever government held information system you wish, but you cant make private practitioners write to it- what good are the records if they are not reliable for patient care?
There are some things that are very difficult to "fix" in a system that has already been built and implemented. I suspect that many, if not most, of the characteristics you have listed fall into that category.
Compare it with building a house in the wrong place. Once it's built, no amount of renovation, re-building, extensions, etc will change the fact that it's in the wrong place.
That's what architects are for - helping to deciding on the big things first.
Best practice Information System development methodologies recognise this fact and deal with it up front.
I have never seen a methodology that starts with a Concept of Operations, so I have a very strong suspicion that the whole initiative was doomed from the start.
The PCEHR 'revamp' publicity has been extensive post budget. $485 Million has been committed. Paul Madden has been committed too with presentations before Senate Estimates, vendor and service providers briefing sessions across the country, PulseIT and other media commentary including this blog. It is clear to many that he doesn't really get it. And it's too late - there is no way out for Madden now. He has been entrapped with each foot firmly planted in a bucket of fast setting cement. He is locked in and is now responsible for carrying the can. So he now has no option but to continue stumbling forward as others at NEHTA and DOHA have done before. He and the Department's Secretary have to keep he Minister 'in the dark' and Jane Halton can smile in satisfaction from afar at what she has left behind.
I agree with your conclusions, but not with some of your assertions.
3. Many systems are moving into the cloud and bandwidth is improving. The speed difference is reducing. There are a number of convenience advantages for applications hosed in the cloud too, such as automatic updates.
5. Accessing the data in the PCEHR can be as easy as accessing any information in a local EMR. Yes, it may require a click, but it doesn't have to be difficult when the application is well designed.
7. Only some information in the PCEHR will be held in PDFs. That is pathology and imaging results. I agree that this is a problem. Other data is held in CDAs, which do allow access to the discrete information. If coding becomes consistent, then that data can be aggregated. There is no architectural reason that pathology can't be handled in CDA. Prior to the PUTS and PITUS projects determine trends was difficult where different labs were used.
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