Mr Howard Announces Electronic Medicare Claiming – A Good Thing?

Today the following press release appeared on the Prime Ministers Web Site.

“ELECTRONIC MEDICARE CLAIMING

I am pleased to announce that the Australian Government will be introducing new arrangements to make it easier for people to claim their Medicare rebate.

We will be formally engaging the private sector to manage the introduction of a system for patients to directly claim a Medicare rebate into their bank account with the swipe of a Medicare card at their doctor’s surgery.

This streamlined claiming process demonstrates the Coalition Government’s commitment to Medicare. It will be a huge benefit for families, avoiding the queue at a Medicare office, filling in forms or waiting for cheques.

Through these arrangements, patients will pay for a doctor’s visit and then swipe their Medicare card and EFTPOS card to receive their rebate back directly into their bank account. It is expected the new claiming system, via the EFTPOS network, will be available in the second half of next year.

The new claiming process will not affect bulk billed patients, although it will mean their doctor will receive payment from Medicare more quickly for providing the bulk billed service. This will be a major improvement in the way we pay doctors for bulk billed services.

Each day 80,000 people queue at a Medicare office to claim their rebate. Access Economics estimates that the average cost in time and resources to make that claim is $10.
The private sector has indicated it can provide this technology simply and quickly and the Australian Medical Association has given its support for the proposal.

It will provide real time checking for Medicare and concession status.

Medicare offices, easy-claim booths and other current claiming processes will remain in place while the new system is introduced.

13 August 2006”

On the face of it this all seems to be a great idea. Mr Howard is to be commended in trying to reduce the frustration felt by those queuing at Medicare offices in their lunch time as well as speeding up the payment of claims by practitioners.

The devil, however, is in the detail (again) and there are certainly a number of issues raised by this release.

Before discussing these I guess it is pretty clear the motivation for such a system can be seen in the figures provided by the costs of the Medicare queues. $800,000 per day is a large cost when multiplied by the 260 working days of each year ($208 Million p.a.). Sadly it will be impossible, except in the broadest community sense, to recover that possible benefit as it is largely to be found in the time spent by individuals who could be doing more productive things than queuing with their time. Savings will largely only come as Medicare offices are shrunk and closed - to the disadvantage of all those not fully enrolled in the electronic world. Depending on how much the banks charge for their services there may also be some reduction in the $3.50 spent on processing each transaction.

The larger issues from my perspective include the following:

Firstly this system is obviously designed to be a co-payment collection system for doctors who do not bulk bill. Those who are bulk billed are explicitly not affected according to the release. The impact of the prompt return of the Medicare rebate, and electronic payment of the residual via EFTPOS, will make it easier for doctors to raise their co-payment level and avoid the customer “sticker shock”.

Rather than strengthening Medicare this looks like another piece of sleight of hand to make it easier to reduce the role Medicare plays in paying for GP services.

Secondly, one is forced to wonder just how secure and fraud free a payment system based on the use of the Medicare Card will be. It is well known these cards are widely forged and that the number on issue exceeds by a considerable margin the number of eligible families and individuals – hence the enthusiasm from Mr Abbott (the health minister) to replace them with a smartcard, a much more robust system, as announced a year or so ago (Jul, 2004).

The HealthConnect web site makes the importance of accurate identification clear.

“Health Identifiers

Another significant issue for HealthConnect is the need for a foolproof system of identification to prevent people receiving incorrect treatments. It is vital to have such a system in the transfer of clinical information. Without it, health care providers cannot be certain that the information held in HealthConnect belongs to the individual being treated.

As in every hospital in Australia, HealthConnect local level patient health identifiers are being used in HealthConnect trials to ensure a consumer's medical information is unambiguously linked to that person. Identification arrangements for the whole of state implementation of HealthConnect are still being investigated, but could include a health smartcard.

Longer-term identification arrangements for HealthConnect will need to take into consideration work underway through the National Health Information Group to investigate options for a national health identifier together with appropriate and robust privacy safeguards.” Current as of 23/02/2006 (It should be noted I am pretty sure the NHIG does not know it is doing this! I can’t check as the AHIC Web Site is currently down!)

The policy confusion regarding patient identification issues just continues to deteriorate. We are now planning, it seems, to introduce a payment system based on the Medicare card by the end of 2007. At the same time the Government plans to introduce its Access Card from 2008 on! (This is not mentioned in the PM’s press release – one wonders why - as presumably the Medicare Card is to be replaced by the Access Card!) Of course we also have NEHTA developing its own Individual Health Identifier for patients to also be available in 2008 or so! We can only wonder will this be used as a basis for payments too!

Next there are some real privacy issues that will inevitably emerge unless there is very clear regulation (and possibly legislation) to ensure all the claims information handled by the bank network is kept totally separate from other banking details. For example, would the payment show the doctor providing the service and the date of service? At first glance it will need to have some information of this type. If it does the person’s bank statement may contain information the patient does not wish to appear on their statement (consider the issue of joint accounts, children operating on parent’s accounts and so on).

Further the press release says the AMA and the banks are in favour. Of course they are. For very little additional cost it means, for the AMA easier access to higher co-payments, and for the banks incremental revenue from transaction fees.

Lastly, it seems that as the electronic payments become the norm, the Medicare office is certain to be wound back to realise additional savings. Who will be inconvenienced? Those without an EFTPOS card and those older and typically more infirm who have not mastered the electronic world and still write a cheque or pay cash for things. Again Medicare is hardly being strengthened.

Before concluding it should also be noted there will be a range of practicalities around implementation of this plan that will need very careful planning. How many practices have EFTPOS terminals? What paper trails are required to avoid and detect possible fraud? What will be the impact on current practice workflows? What information will be required to be held by the practice to identify that an EFT refund has been requested and what will be the costs of providing such interfaces into GP computers? A moment of reflection, I am sure, will identify many more issues to be resolved.

I fear what we have here is a proposal which may very well weaken Medicare, increase fraud, violate at least some people’s privacy, disadvantage the old and be very complex to actually implement. It is also curious why this was announced by the PM rather than by the Health and Human Services Ministers given they have been talking about fixing this problem for a good while now.

I will look forward to understanding how the implementation of this proposal will avoid all these apparent risks. It is not clear to this observer that all the un-intended consequences have been properly analysed.

David.

E-Health Excitement in the Apple Isle

Another day, yet another HealthConnect Newsletter – this time from HealthConnect Tasmania. The news provided however is a little less than earth shattering.

From page one we learn that the Project Director is to return from a secondment and that the acting director has left. We also learn, it seems, most of the support staff have day jobs elsewhere and are part time with the project at best.

Next we learn that the Canberra Office of HealthConnect is to manage all engagement with Health System Vendors and that all the senior people had a visit to Katherine in the Northern Territory to share experiences.

Additionally we learn that a project to record ambulance patient transport and clinical information is being recorded on toughened lap-tops rather than paper. This is grandly described as Electronic Patient Care Record Project (ePCR).

From page two we learn that some new projects are to be undertaken. They cover e-mail transfer of triage and discharge medication information and, for the hundredth time, an investigation of the use of a computer to assist in management of warfarin therapy.

We also learn that HealthConnect is alive and well, despite disappearing from the Federal Budget and having totally lost its way as far as Shared Electronic Records are concerned.

I was so overwhelmed by all this I responded to a Tasmanian colleague in the following terms after I was sent the newsletter.

===================================================

Hi You Lucky Tasmanian,

I am just thrilled about the wonderful progress being reported in e-health in Tasmania update from the HealthConnect team. Pity about mislaying their acting project director.

You must be really happy to be in a place where all the action is!

It is good to see e-mail is being used effectively and that for the 20th time someone is using a computer to manage warfarin therapy.

Seems we are probably only a decade (or two) away from the HealthConnect vision of real Shared Electronic Health Records. .but you do have to master the technology first I guess (using a PC, sending e-mail etc) before you can move on.

I look forward to the next instalment with ever growing anticipation and excitement.

Cheers

David.

==================================================

Frankly this newsletter is, just like the other recent HealthConnect newsletters from Canberra and South Australia, a hoax on the Australian people. Truth telling about the terminal fate of the original HealthConnect vision seems to be impossible for the creators of these deliberately deceptive documents. I have no idea why they can’t just tell the plain truth that every observer of the e-Health agenda knows to be true, and move on.

David

E-Prescribing - Part 2

Just when I thought the e-prescribing initiative was settling down for a few weeks, a very useful contribution to knowledge and the state of play comes from the Commonwealth Department of Health and Aging (DoHA).

A statement was circulated today clarifying last week's AHMAC announcement. It said (in full).

“Electronic Prescribing of Medicines

Last week in Brisbane, Health Ministers signalled their intent to remove legislative barriers to electronic prescribing.

Commonwealth Minister for Health and Ageing, Tony Abbott told the Health Ministers meeting on 27 July 2006 that his Government would amend the National Health (Pharmaceutical Benefits) Regulation 1960 to remove a requirement that Pharmaceutical Benefits can only be paid for prescriptions that carry a doctor's signature.

The amendments, which will come into effect on 1 March 2007 will allow for all stages of the prescribing process to be completed electronically and provide an alternative to the present paper prescriptions system. Scripts will be able to be created electronically by prescribers, electronically signed, then transmitted securely and uploaded into the pharmacist's system without the need for re-keying. This will ease the burden created by paper-based prescription processes, allow healthcare professionals to spend more time with patients and reduce the risks of errors and lost prescriptions.

According to the Australian Council for Safety and Quality in Health Care's Second National Report on Patient Safety an estimated 400,000 adverse drug incidents occur in Australia each year. Electronic prescribing will help eliminate those incidents that occur due to poorly handwritten paper prescriptions and transcription errors. It will also support longer term moves to reduce waste in the PBS and improve patient safety stemming from duplicate prescriptions and adverse interactions between different medicines.

While the changes announced last week remove one of the main barriers to electronic prescribing, there are a number of additional steps that will need to be taken before the vision becomes a reality.

States and Territories will first need to examine their own legislation and make any amendments that are necessary to bring it into line with the amended National Health (Pharmaceutical Benefits) Regulation 1960.

Then, governments will need to work with Medicare Australia, the National E-Health Transition Authority, IT suppliers and professional bodies representing doctors and pharmacists to put in place arrangements to ensure the successful operation of electronic prescribing. Key considerations to be addressed will include:-
• the need to ensure security of prescribing information and protect patient confidentiality;
• procedures to validate the identity of prescribers;
• mechanisms to allow patients choice over where and when they have their medicines dispensed;
• integration with doctors' and pharmacists' existing computer systems; and
• arrangements for secure archiving of prescription details.

Given the scale and nature of the practical challenges in any large-scale move to electronic prescribing it may be some time before it is widely adopted. Nevertheless, last week's announcement by the Federal Health Minister is an important move which will yield substantial long-term benefits to patients and health professionals throughout Australia.

Regards

Tam Shepherd
Assistant Secretary
eHealth Branch
Australian Government Department of Health and Ageing”

As far as this goes this is excellent and recognises – as mentioned in my initial comments – that there is considerable work to be done in a range of areas before this can all come to fruition.

However it is also important to note what is not covered in this briefing.

First the strategic and e-health context in which the planning for e-prescribing is to be undertaken remains vague if not totally opaque.

Second there is no target time-line (except a long one) of any sort provided – leading to at least some scepticism about just how serious this actually is.

Third there are a number of Standards related issues that NEHTA is yet to address, as well as the need for consultation with the all relevant stakeholders to see just where this fits in the overall e-health priority list.

Fourth – yet again - the issue of quality of GP and Specialist prescribing decision support and its importance (and indeed the issue of the quality of the GP computer systems in general) is not recognised. To contemplate e-prescribing without fully and carefully addressing this area is folly. I believe that unless we have certified systems with current knowledge bases that provide consistent, evidence based, interactive, point of care advice the business case to e-prescribing is hard to build.

Fifth it is important to note that prescribing information data bases are presently a significant issue with the SA HealthConnect SEHR initiative choosing not to use the database sponsored by NEHTA according to their web-site.

The bottom line is that prescribing error in the absence of quality information is much more of a risk than transcription errors for the patient.

I look forward to further refinement of the e-prescribing plans and indeed a clear outline of the overarching e-health framework into which this initiative fits.

David.

Who Is Kidding Who in NSW?

Sometimes one hears something that stretches credulity, but the plans just announced by the NSW Commerce Department’s Office of the Chief Government Information Office truly “take the biscuit”!

A plan entitled People First – A new direction for ICT in NSW which is said to be the NSW Government ICT Strategic Plan was announced at 9.00am on Thursday 27th July 2006 by the NSW Minister for Commerce, John Della Bosca

It is said that this is “an innovative Government ICT Plan that sets the framework for a coordinated government-wide approach to planning, expenditure and allocation of ICT resources.

It represents a major change in ICT policy direction and will pave the way for a new and more effective way of service delivery for the NSW Government.

The Plan provides a strategic framework to make better use of technology to improve the efficiency and effectiveness of services and systems, both within government and the wider community.

It will allow NSW Government Agencies to work together within a coordinated strategic framework to aggregate ICT initiatives to minimise costs and maximise the use of common applications, infrastructure and processes.

Savings will be redirected to key frontline services such as health, education, policing, disability services and information.”

The claims made in the body of the plan are that it: -

• Will be implemented over 4 years, commencing July 2006.

• Targets initiatives that are inevitable, which no one agency can do singularly, that are common and repeatable between agencies and which provide strategic value.

• Removes the technological barriers that inhibit both the reform of government and e-government initiatives.

• Results in savings of over half a billion dollars over four years.

The claim is made in the detailed document that the plan:

“Directs ICT savings to key front-line services such as health, education, policing, disability services, home and community care, transport and housing.”

Excellent one thinks – a bit more for the areas that need it. But read on. Then we find the following:

“ICT capital expenditure will be reduced by $350 million and recurrent ICT expenditure reduced by $215 million over four years.”

So not only is there no extra money for the front line – worse $565 million over four years is being pulled out the NSW Public Sector IT Budget.

If you believe this will provide improvements in health service delivery, the police and transport systems and so on – you are clearly a believer in the tooth fairy!

On the basis of what is written in this document the whole plan is nothing more than a money saving initiative wrapped up in a collection of pretty A3 charts.

What a pathetic farce!

David.

Oh HealthConnect! – You Have Done it Again!

A few days ago I was told that the South Australian HealthConnect Project has suddenly burst into life after a period of relative inactivity. Intrigued I thought I should have a look and see what was going on and I found that recent activity was indeed in evidence.

Those who have been following the HealthConnect saga will be aware that it has been Tasmania, the Northern Territory and South Australia where projects have been initiated. In South Australia (SA) there are two streams of activity. The first is an extension of the Broadband for Health Project for SA with some extra support on implementation of security.

The second, and more interesting, is the planning of a project (to go live in November 2006) to provide a basic Shared Electronic Health Record (SEHR) (accessible by the GP, Patient and other Carers) to assist in the communication and sharing of patient specific health information to better co-ordinate and deliver care.

The SEHR and messaging environment is to be provided by Ozdocsonline. They can be found at Ozdocsonline.com.au.

What a very good idea I hear the loud cries – and I cannot but agree. As always, however, the devil is in the detail.

Before discussing that detail, let us briefly consider what attributes we would expect from a Commonwealth / State Government funded Shared EHR Project. I suggest we would expect at least:

1. The use of an open, rather than proprietary, SEHR and messaging platform.

2. Adherence to the national technological standards directions being defined by NEHTA.

3. Interoperability and synchronisation between the GPs local Electronic Health Record and the SEHR record to the extent that both contain the same information to ensure patient safety.

4. At least a HeSA level of security for information flows between the systems of the various users of the SEHR to ensure clear accountability on the part of all users regarding the information stored in the SEHR.

5. Use of the necessary coding and terminology sets to ensure information was captured in a comparable and computable form.

6. Access to the service would be free to the patient (ideally).

What is proposed is that the Ozdocsonline portal will become the central, and proprietary, access point from which patients and their carers will contribute and retrieve information – largely in the form of free uncoded text. The shared record will consist of some key demographic information and then a series of entries (which are either unstructured encounter documentation or itemised action plans) which, it is hoped, over time will become a useful record.

Now, while I am a long time supporter of the idea that progress will only be made in e-health if the various actors just get on with it - this proposal frankly seems a bridge to little!

Among the issues I also see around the planned operation of this proposal are:

1. The patient is apparently charged a fee every time they leave the practitioner a question, prescription repeat request and so on. (Ozdocsonline collects the funds and remits to the GP monthly).

2. The practitioner will need to record information twice – in their computer system and in the on-line system. This may slow the GP down just a little and lead to quite slow adoption.

3. The use of clear text e-mail to let the various actors in the operation know the other has made a referral, a change or whatever. This has the possibility of leading to a deluge of e-mail and further delay for the GP, as well as providing some information, some may not want disclosed, to others.

4. The proposal does not meet the expectations for a publicly funded SEHR trial given the learnings already made in this area so far (e.g the importance of information coding, the importance of client GP systems etc).

It is clear to me that this plan – as presently evolved – is seriously underdeveloped and quite inconsistent with even the broadest outlines of where e-health in Australia should be heading.

I find it amazing that the funding for Development of the Web Based Community Care Plan Management Tool Ozdocsonline is coming from the iTOL program in the Department of Communications, Information Technology and the Arts, rather than the Commonwealth Department of Health. Maybe that explains why the special health privacy and standards issues have not been addressed as one might have hoped.

The motivation for this project is excellent, and if well executed it could make a difference. However, sadly the currently plan for its conduct is, I believe, badly flawed and needs serious review.

David

Danish Nirvana – Happiness and e-Health

A few days ago the University of Leicester published the following survey of some 80,000 people from around the world. Participants in the various studies were asked questions related to happiness and satisfaction with life. The Leicester study also looked at health, wealth and access to education. The results were as follows:

The 10 happiest nations in the world are:

1 – Denmark
2 - Switzerland
3 - Austria
4 - Iceland
5 - The Bahamas
6 - Finland
7 - Sweden
8 - Bhutan
9 - Brunei
10 – Canada

They also reported that Burundi, Zimbabwe and the Democratic Republic of the Congo are the unhappiest nations on the planet.

As a matter of pure co-incidence I had been researching e-Health interoperability and had come across a report on the status of e-health in the very same Denmark.

See the following site for details and a copy of the full documentation covering many countries (including Australia – which receives a report suggesting much planning but little actual delivery as of May 2006.) http://www.srdc.metu.edu.tr/webpage/projects/ride/

I now know why the Danes are so happy (other than having our Princess Mary and a new prince) and why Australia (and the US) do not make it into the top 20. Their e-Health works!

A few statistics make the point pretty clearly.

1. 97% of general practitioners now use EDI, and almost all hospitals are now able to send electronic X-ray results and hospital discharge letters. This is unique coverage unknown in any other country.

2. Electronic patient referrals for hospital treatment and to specialists have not yet been used on a massive scale, nor has the use of laboratory requests so far become particularly widespread. However, in the local-authority area, the number of local authorities that exchange EDI with the hospitals has risen from 12 to 92 during the course of the MedCom IV period (2002-2005).

3. The range of services used by 80+% of GPs include:

• Discharge Letters and Reports
• Outpatient Letters and Reports
• Casualty Letters and Reports
• Image Diagnostic Letters and Reports
• Admission and Radiology Referrals
• Pathology Results (All types)
• GP Prescribing
• Billing (Most Services)

Referrals are now being progressively rolled out.

At present the network (termed MedCom) is EDI based but it is being migrated to an XML based web services environment over 2006.

It seems to me this is proven technology that works and would make a huge difference to clinical care in this country. It would also be easily replicable in a sensible time frame and would be consistent with what is known of NEHTA’s planned directions.

Someone from the Government needs to undertake a detailed study visit (it’s a nice place in Autumn) and then get on with actually doing something here!

David.

E-Prescribing in Australia – Is there a New Plan?

Your humble scribe had another of those “choking on his Wheaties” experiences this week. Suddenly ‘out of a clear blue sky’ it was announced, following the recent Australian Health Ministers Advisory Council (AHMAC) meeting, that there was to be an end to paper prescriptions and we were to move to full electronic prescribing with electronic transmission of the prescription to pharmacists. The pharmacist is to obtain an electronic copy of the patient’s prescription by swiping the patient’s Medicare Card. (One imagines that ultimately Mr Hockey’s Access Smartcard will provide the same – but rather more secure – functionality).

This is hardly a new idea. Way back in 1996, your scribe and a colleague wrote a report for the Commonwealth Government which recommended that planning for such a system commence. We had concluded there was a compelling business case to implement e-prescribing even then. Some notice seems to have been taken of the suggestion as early this century we saw the commencement of the MediConnect trials in Tasmania and Victoria. These trials showed that e-prescribing could be done but that further work was required to make it all work well in order to achieve widespread adoption. There were also some issues around the potential costs of a national implementation being seen as quite high – as an isolated program.

It is noted in passing that e-prescribing is being widely trialled and implemented elsewhere in the world with much activity in the US,UK, Canada and Europe.

Here is the text of the announcement.

“Electronic Prescribing and Dispensing of Medicines.

Australians are set to receive improved healthcare following agreement today by all Australian Health Ministers to remove the legislative barriers to electronic prescribing and dispensing of medicines.

From 1 March 2007 the amendments will allow for all stages of the prescribing process to be completed electronically and provide an alternative to the present paper prescriptions system. Scripts will be able to be initiated electronically by prescribers, electronically signed, then transmitted securely and uploaded into the dispenser’s system without the need for re-keying. This will ease the burden created by paper-based prescription processes and allow healthcare professionals to spend more time with patients and their needs.

There are an estimated 400,000 adverse drug incidents that occur in Australia each year according to the Australian Council for Safety and Quality in Health Care's Second National Report on Patient Safety. Electronic prescribing and dispensing will help eliminate those incidents that occur due to poorly handwritten paper prescriptions and transcription errors.

The regulatory amendments to provide for electronic prescribing and dispensing will become effective on 1 March 2007. This gives all States and Territories sufficient time to make their own consistent legislative and regulatory amendments.”

This description makes it clear that what is envisaged is a national “store and forward” network where the doctor creates the prescription, sends it to a central repository from where it is retrieved by the pharmacist into their dispensing computer. Presumably the patient will also be given a written prescription (hopefully with a barcode containing all the prescription information in scannable form) as a back up and to handle the situation of the computer repository being unavailable.

The number of questions this AHMAC announcement raises are legion. Among them are the following:

Who is going to own and operate what will prove to be a rather large national network? (Will it be Medicare, another part of Mr Hockey’s empire or will it be outsourced?)

What standard(s) are to be used for secure messaging and prescription transmission and are there currently any GP systems with such capability?

What terminologies will be used, given that the Australian Medicines Terminology is still in an embryonic stage of development – not due for at least 12-18 months?

What levels and capability of electronic decision support will be offered at the prescribing point and at the central repository to reduce prescribing errors? (The reduction in error rates, and possibly the ability to bias towards the use of generic medication, is the key justification for the introduction of e-prescribing).

Where will the Government be sourcing the required guidelines and prescribing databases to ensure the prescribers get the most current evidence-based information?

Is the Government (or some agency) going to undertake certification and proof of functionality testing of GP client systems, to ensure they work as safely as possible and have up-to-date drug reference databases etc?

How are prescriptions, which are transmitted but not collected, to be handled? (e.g. the situation where the patient decides not to pay for the drug, or is given the prescription on the basis of “if you get worse get it filled”).

Who will have access to the commercially valuable prescribing data-base the system will create and under what circumstances?

Where do NEHTA, the medical colleges, the pharmacists, the Pharmacy Guild and consumers fit in all this. Have they been consulted?

Are hospitals expected to produce discharge prescriptions electronically?

What review has been undertaken of all the work done here and overseas to ensure we get the safest and most secure system possible from end to end (i.e. from the doctor developing the prescription all the way to the patient being handed their medication and appropriate clinical and safety advice)?

I suppose I could go on but in the absence of the AHMAC providing publicly available detailed minutes there seems little point. All we have – from the Government and AHMAC – is that which has been provided in the above announcement.

Before wrapping up, I must say I think a properly developed and considered national e-prescribing implementation would be a very good thing and would save a significant number of injuries, indeed lives. It does of course need to be undertaken in the context of that National e-Health Plan we have all yet to see.

However, it seems to this observer that, despite some rumours to the contrary, this hare has a good deal further to run and a good deal more work to be undertaken before something useful makes it to the light of day. Pity about that. It all seems far to “spur of the moment’ to be real.

David.

E-Mail Security and Clinical Practice – What’s Sensible?

In The Australian last week an article appeared reporting that a large teaching hospital in Melbourne has been using standard e-mail to send discharge summaries to GPs. Further it was reported that this had been approved by the hospital following a decision by the hospital's privacy committee that the benefits of rapid communication outweighed the risks to patient confidentiality.

The questions this action poses are interesting and, to a degree, contentious. What they boil down to are essentially - What place does standard e-mail have in daily clinical practice? – Should its use be constrained? - What alternatives exist to achieve the outcomes sought by the hospital (rapid communication of important information to the relevant GP)?.

The essential facts are these.

Firstly traditional un-encrypted e-mail is simply an insecure communications medium. Even more worrying is that it is a very persistent (long lasting) medium where, with enough effort, months or years down the track e-mail can be retrieved. Why - because e-mail seldom goes directly from sender to recipient (it typically passes through one, two or more intervening servers all of which often keep a copy) and anyone who has access control to that server can read any e-mail on it.

Secondly the recognition that e-mail is insecure has provoked privacy organisations and general practice organisations to consider – How should email best be used?.

Thirdly, the ubiquity and ease of use of e-mail, makes it imperative that rather than apply blanket bans or approval a reasonable, responsible, balanced and pragmatic approach to e-mail use, between hospitals and GPs, and between patient’s and GPs, should be developed. I and many others have been using e-mail in one form or another for almost two decades. To-date I have had no problems although others have, ranging from e-mails being leaked to the press to marriages being threatened by receipt of misdirected or accidentally copied or forwarded e-mail.

For GPs it seems clear that the guidelines developed by the General Practice Computing Group (GPCG), and available from their website, provide a sensible and well thought out approach for the use of e-mail when communicating with patients . The essential elements of this approach are to treat e-mail as official correspondence, get informed consent as to the risks of disclosure from the patient before using e-mail, do not use e-mail for any urgent matters, have a properly worded disclaimer on the footer of any patient e-mail and do not include anything in e-mails that could potentially embarrass or upset a patient. A practice policy as to security of e-mail, filing of e-mails in patient records and response time back to the patient are also sound and needed steps.

GPs who are concerned can, of course, set up various technology based secure links with regular patients – but such approaches are not really generally applicable given the effort required by both parties and the cost. Better would be an agreed national approach to secure e-mail for GPs to communicate with patients rather than the present – albeit obviously interim - situation we have at present.

The circumstances for hospitals are a little different in my view. They should obtain informed patient consent and carefully review any content sent for potential patient compromise – if it would cause the patient distress, or if the information were to appear on the front page of The Australian, it should not be sent. Ideally, however, large organisations should take advantage of the availability of a range of secure, encrypted clinical e-mail messaging services (such as Argus, Medical Objects, HealthLink and others) and use one of those services to send information back to their referring GPs.

In all cases it is the sender of the e-mail who must get informed consent from the affected individual before any unsecured e-mail is sent.

Over time we can hope that the work being undertaken by the National E-Health Transition Authority (NEHTA) will lead to the emergence of secure clinical messaging services where no possibility of breach of patient trust and confidentiality is possible.

David.