This appeared while I was resting!
France still seeks an electronic health record
The idea of a ‘dossier médical personnalisé’ (DMP, or electronic health record) for every French citizen was first inaugurated in 2004. Now, over 10 years and €500 million later, we can look at the pros and cons encountered during this still incomplete journey and consider if similar projects would be a useful addition to healthcare administration in other European countries, or not.
Report: Jane MacDougall 16/03/2017
The main DMP aim was that all doctors involved in a patient’s treatment would have immediate access to a complete medical record, to avoid repetition of investigations/prescriptions or risk from overlooked illnesses etc., which can occur when relying on an oral medical history.
Also wanted: Faster exchange of secure information between the various healthcare structures involved in a case e.g. an in-patient having exams in different locations. Another long-term aim was to use the information collected for epidemiological and eco-epidemiological syndromic surveillance to help in the early detection of health problems, as has been the case in the USA from 2013-2014.
A brief history
As early as the 1960s, when the potential power of computing first became apparent, the idea was postulated to digitise medical records as a means to help in population healthcare. However, it was not until 2004 that the French health minister, Philippe Douste-Blazy, launched the DMP as a fully-fledged two-year project to ensure the transfer of medical information between healthcare providers, which he declared would result in €3.5 million annually saved from wasted examinations, prescriptions etc.
Nonetheless, the experiment, which had included, private doctors, hospitals, healthcare networks, and allowed them access to computerised medical notes, was legally terminated by the end of 2006. In the audit of this failed attempt it was decided that any such development had to be considered as a long-term commitment and could not be implemented precipitously. The objectives had to be reconsidered.
Thus, in 2009, it was announced that a new DMP format would be launched in 2010. Online in December 2010, from the 5 January 2014 all French citizens with a Social Security number would be able to create their personal medical dossier. By 2012 the programme still had not met its objectives with only 6,000 medical professionals using the system.
In 2014, Marisol Touraine launched the Second Generation DMP that would be administered completely by Social Security. According to the Health Law of 20 January 2015, the DMP now known as the d’ossier médical partagé’ (shared) will be accessible to all chronically ill and their healthcare professionals in order to share the entirety of the patient’s medical history.
How it should work
A DMP can be created at the demand of a patient, doctor or healthcare provider. In the latter two cases the patient must be informed and their consent received before the record is created. To create a DMP, the healthcare provider or doctor needs compatible software, or to connect to the dossier via the internet. Patient access is by internet only. The dossier belongs to the patient and they control the healthcare provider’s access to it.
Any patient with a ‘Carte Vitale’ and a national social security (SS) number can create a dossier. A doctor or healthcare provider has to be registered with a smart card and know the patient’s SS number. Patient secure access depends on their SS number and a password via a protected HTTPS site. All data are stored in France.
----- Gory details of the failure omitted! Read at your leisure.
Whatever the future of EHR in Europe, one important thing to consider is cost. By January 2015, only 500,000 dossiers, (many of which are empty!) were opened in France, for an average cost of €1,200 each. This is 10 times higher than the original estimates.#
Details: www.dmp.gouv.fr
Here is the link:
Remember, this is a record created for a country of about 65 million people which somehow – despite two (or was it three) attempts – achieved only 500,000 users - and which really has to be said to be a comprehensive clinical and technical failure.
The similarities to the myHR as truly amazing so we now know that the real reason for all the forced adoption and opt-out is at least – in part – due to the abject failure of an opt-in system which was quite similar to the myHR.
In summary, the lesson from all this is that a national system such as this and the myHR are not attractive to the public and despite huge expenditure have a very high risk of failure.
Maybe we (and the ADHA) need to look at other strategies and architectures – once we have some clarity about what the ADHA is really wanting to achieve, which beyond the motherhood statements, is not all that easy to discover. A major rethink certainly seems to be what France is doing.
Turns out there are serious lessons to be learnt from overseas – I wonder why these are not better known?
David.
David word has it that you dare not have an opinion at the ADHA, more than a few radical thinkers have been used as an example to others. I hear the CEO behind all his public facing charm is quite the opposite.
ReplyDeleteI guess it is up to the Board of ADHA to decide how they wish history to remember them by.
The French, after 10 years and with a population of 65million have spent 500million Euros. By my calculation that's about $AUD700.
ReplyDeleteWe've spent over $1.5b in 5 years for a population of about 25million.
Draw your own comparisons.
Maybe the answer is just to spend more and more money.
Or, as I have heard said in a number of large companies, The floggings will continue until morale improves.
Mieux tirer la bougie que de se noyer dans le bain
ReplyDeleteI think Sweden had a similar experience around 2005 an in the years that followed...
ReplyDeleteIt's interesting that this has been around for such a long time but wasn't on the radar when PCEHR was conceived. Other eHR systems were used as comparisons at the time but not this - I wonder why?
ReplyDeleteI find two reported aspects of the French experience of interest. The first is the notion of access to a 'complete medical record'. The second is the notion of secure exchange of information between 'medical structures'.
ReplyDeleteI suggest the first point reflects the dominance of the medical record in our thinking and acting. It is a holy grail reflecting the ability to address all stakeholder interests and needs. This is in contrast to focusing on what information is actually needed at the time and point of care delivery. I am not for one moment suggesting we don't need electronic medical records; rather I am suggesting a paradigm shift to a communications paradigm from the dominant medical record paradigm.
The second point reflects an 'organization-centric' as opposed to 'network-centric' thinking and acting. Healthcare teams exist implicitly and are needed where people have chronic conditions.
As a renal patient, I see the same GP, the same Renal Specialist and a small group of other medicos. They are familiar with my situation and broad history.They already receive copies of my pathology results whether generated by them or another member of my healthcare team. When I see them, they really want to know 'what has changed' and if not already obvious, 'what has brought you here today', before we begin the next consultation.
And, when I have to see a new specialist, or a GP when I am travelling, my Personal Healthcare Summary Record provides the vast majority of the information they need as well as the contact numbers for all of my healthcare team members. The information that is contained in the record is based on the principle of the 'difference that makes a difference'.
Further, the Renal Network covering the ACT and adjacent Southern NSW Local Health District provides Renal Patients with what might be called an 'Access to Information' card. The card has the logos of the two health systems on it, a short description of my renal status (e.g. dialysis or transplant patient, etc.) and a telephone number to call. That telephone number operates 24 hours a day and provides access to specialist advice and additional information as required.
My healthcare team is composed of medicos who operate in the public system and the private system and at times across the ACT and NSW jurisdictions. 'Network-centric' thinking and acting needs information flows that are directed to them as opposed to dropped in some shared electronic health record system absent proper consideration of what action in what time frame may be required of them. This is about enabling and supporting what might be called healthcare 'choreography'.
Finally, the epidemiological and other surveillance measures are really communications issues in the first instance. We have a combination of mandatory reporting as well as the potential to establish a variety of other mechanisms; mechanisms more attuned to the changing needs and priorities of the healthcare system.
At the end of the day, our challenge is really to achieve a revolution in the quality of collaboration.
John,
ReplyDeleteThanks for sharing that "use case" it says more about the requirements for health information systems than anything I've ever seen from NEHTA and/or ADHA.
One observation. What you call 'Network-centric' I'd call 'patient-centric'
Bernard, thanks for your positive comments.
ReplyDeleteI actually do not reduce 'network-centric' to 'patient-centric' in a direct substitution sense.
Rather, it is a way of thinking that reflects our participation in human social networks, as opposed to technology or organization networks.
In healthcare there are two domains that we need to pay special attention to.
The first is what might be called the 'internal' domain which relates to the clinicians.
The second is again, what might be called the 'external' domain which comprises citizens/patients/carers and other stakeholders.
The reason for the distinction is that the communications are very different.
And, to your point about 'patient-centric', I see this through a two level prism as well.
The first is what might be called the 'Journey Flow' prism wherein clinical service teams look at how they handle various types of patients and sort out who is responsible for what and what each contributor needs in order to do their part of the 'choreography'. It is also where the connections to the contributions of other clinicians are identified.
When a patient enters the scene, the nominal 'Journey Flow' becomes a 'Patient-specific Journey Flow' and this is where we find the opportunities and challenges for interaction among and between clinicians. The rubber hits the road literally.
To return to your point, it is because the patient is at the centre of our mutuality that we get to raise and hopefully answer how clinicians will work together both inside and across the various clinical services--whether in the public or private sector.
When you focus at the 'human level' you really begin to appreciate why we need both clear separation with the technology sphere and equally why we need to work out how to 'connect' the two spheres together in a meaningful and effective manner.
The human sphere of healthcare has to inform the electronic/digital sphere about how and under what conditions it can embrace digital pathways. Equally, the point of 'connection' is where the electronic sphere can inform and advise the human sphere of healthcare what is or is becoming possible. With this new knowledge healthcare can re-think and re-design to avail itself of this new potential.
Thanks John. Yes there are differences between 'network-centric' and 'patient-centric' although I doubt that anyone at ADHA would understand them.
ReplyDeleteI suspect the differences between them are far, far less than either is from MyHR. If the ADHA strategy got close to either, it would be a massive improvement.