Wednesday, November 11, 2015
Just Why Is It That Everyone Seems To Think They Are An Expert On E-Health?
This appeared last week:
Friday, October 30, 2015
The latest Health Policy Issues Brief from the Australian Healthcare and Hospitals Association (AHHA) and the Deeble Institute for Health Policy Research has pointed the way forward on developing a national e-health initiative.
Despite significant Government investment in the development of an electronic health record, the e-health initiative has proven difficult to get off the ground. Toward better implementation: Australia’s My Health Record by Krister Partel explores the development of the Personally Controlled Electronic Health Record and identifies challenges and opportunities for the rebranded My Health Record.
“The external review of the Personally Controlled Electronic Health Record went a long way towards identifying areas to improve upon,” said Mr Partel.
“However, experts have raised concerns that have not yet been addressed.”
The brief discusses potential issues with implementation and offers recommendations to assist with the process. Chief among these are the lack of registered users, the difficulties in transitioning from an opt-in to an opt-out system, and the importance of maintaining consistent and coherent governance arrangements.
“The Commonwealth Government’s attempt to reboot the failed Personally Controlled Electronic Health Record is admirable,” said AHHA Chief Executive Alison Verhoeven.
“But more needs to be done to ensure that the same mistakes are not repeated in the rebranded system.
“A well-implemented electronic health record has the potential to promote greater consumer engagement and understanding, reduce waste and inefficiency and improve quality and safety. This Deeble Institute Issues Brief outlines the steps necessary to ensure that My Health Record lives up to its potential.”
Toward better implementation: Australia’s My Health Record is available here.
Here is the link:
Here is the link to the report:
The Executive Summary is worth a browse:
A well implemented and fully utilised electronic health record system should strengthen a health system by improving quality and safety, ensuring continuity of care and improved health outcomes as well as reducing waste and inefficiency in the health system.
Australia chose to pursue a personally controlled electronic health record (PCEHR) system following a 2009 recommendation from the National Health and Hospital Reform Commission. A PCEHR is a special class of electronic personal health record where a consumer controls his or her record content and record access, which means only nominated health practitioners are able to access nominated information in the record.
Due to a lack of uptake and utilisation, in 2015 the Australian Government announced a system overhaul, which included rebranding the PCEHR to My Health Record and moving from an opt‐in to an opt‐out system. While the overhaul attempts to address the key problems identified in a 2013 external review of the PCEHR, a number of experts have flagged concerns with the new My Health Record, which should be addressed prior to implementation.
The following are three key and ongoing implementation concerns along with recommended actions to overcome these concerns.
Lack of registered users, system use and clinical utility
The following actions are recommended to accelerate achievement of My Health Record critical mass, system use and clinical utility:
· comprehensive system security and privacy safeguard review with subsequent action plan to address concerns prior to opt‐out pilots, followed by proactive messaging to consumers and providers that technical security has been dealt with in the design of the record
· comprehensive communications and engagement strategy with targeted and sustained consumer‐ and provider‐specific education and registration activities leveraging consumer groups, peak bodies, professional colleges and software distributors
· Comprehensive and best‐practice provider training based on an iterative process to develop training modules and the training platform with stakeholders
· registration incentives for both consumers and practitioners such as an increased Medicare rebate for system use as part of clinical activity
· technological and business support, including financial incentives to service providers nudging uptake and use
· software default settings linked into the interoperable national health record system
· flexible and clear policy and technical frameworks that are adaptable to clinical need
· structural change to the data sharing model where information necessary to the current treatment of a consumer is shared among the care team
Opt‐in versus opt‐out registration
The following actions are recommended to ensure a smooth transition from an opt‐in to an opt‐out consumer controlled electronic health record with evidence‐based privacy and security protocols:
· comprehensive system security and privacy safeguard review of the current architecture evaluated against a repurposed opt‐out functionality, which includes both threat and risk assessments as well as privacy impact assessments
· action plan stemming from the review to implement a mix of technology, policy and process mechanisms aimed at strengthening security and privacy controls—to be completed prior to My Health Record’s opt‐out trials
· public education campaign demonstrating system security and privacy safeguards
· engagement with software developers and distributors to ensure software compliance with necessary system changes and to ensure ongoing system interoperability
· update current provider training due to opt‐out transition and work with the sector to develop and rollout revised modules
The following actions are recommended to ensure best practice and inclusive My Health Record governance arrangements:
· key national and regional stakeholders as well as consumers should be part of My Health Record’s governance arrangements in order to secure buy‐in from the health and community sectors and key consumer groups
· consideration should be given to the following building blocks for effective governance:
o strong leadership, culture and communication
o appropriate governance committee structures
o clear accountability mechanisms
o working effectively across organisational boundaries
o comprehensive risk management and compliance systems
o strategic planning, performance monitoring and evaluation
o flexible and evolving principles‐based systems
· the Council of Australian Governments’ Standing Council on Health should play a leadership role to ensure these effective governance building blocks become more than aspirational
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I note the author is the AHHA Advocacy Director rather than an e-Health domain expert and it certainly shows.
The key thing that is wrong with all this is an underlying assumption that the basic idea behind the PCEHR is sound, which sadly is plain wrong. Worse, there is no evidence I am aware of that that confirms this model of National E-Health record will work - and be clear it has never actually been tried before.
(The basic idea behind the PCEHR is that it is a national E-health Records System created in parallel to the systems already in use by clinicians. In the PCEHR the information held is controlled by the patient and may not be accessible when needed. The unproven assumption is that this sort of system will be useful and will improve system quality, safety and efficiency.)
Equally the benefits studies quoted for the PCEHR are not actually related to the model of the PCEHR as it has actually been implemented.
What we seem to have here is a classic example of a non-expert trusting that the Government has an optimal technical, functional, clinical, workflow and information design for the national e-Health system and that all is needed is some management, incentive and governance changes around it and it will all be wonderful, benefits will be delivered and all will be well. I know for certain there are many experts who would violently disagree - including myself.
As Sir Humphrey might say there is a very ‘courageous’ assumption buried here (that the basics of the PCEHR are not flawed) that may very well not play out and may result in ongoing waste of money.
Coming from an assumption that the Royle Review identified all that was wrong with the PCEHR is a very, very bad and unwise idea. The non-expert Royle Committee really did not grasp all the issues (especially the clinical, data integrity and workflow issues) that many expert submissions have since identified.
It would be really useful if the DoH actually listened to the many independent experts we have in this area!
Posted by Dr David More MB PhD FACHI at Wednesday, November 11, 2015