Major Adoption Of Digital Health Is Still Somewhat Of A Fantasy In The Real World. What Do We Know Now?

Agencies like the Commonwealth’s Australian Digital Health Agency (which has just lost it CEO in unexplained circumstances) have a mantra that essentially suggests that if we can get full adoption and use of Digital Health tools by clinical professionals (doctors nurses and the like) that we will suddenly arrive at some sort of clinical Nirvana where there are dramatic improvements in the quality, safely and connectedness of care delivery all of which will be to the ultimate benefit of the patient and their lives.

They point out that all sorts of major transformations and improvements have been seen in areas from banking to logistics and transport and it can thus only be a matter of time before the same improvements in quality and efficiency will be seen in healthcare.

If this were true then surely, by now, we would have working exemplars where most of the problems have been definitively been solved and all that is left is to dot the ‘i’s and cross the ‘t’s and roll out a highly successful model globally.

That process is also yet to begin because, to be frank, no one has got there yet!

If we look around the world we see all sorts of things happening and we see evidence of real benefit on a significant scale from Digital Health to be rather hard to find.

In the U.S. we see harm, clinical errors and clinician burnout and frustration on an unexpected scale and we see consumer frustration with the lack of access they have to their own clinical information. Worse they often find the different clinicians they visit cannot access their records from other clinicians leading to frustration at the least and real harm at worst.

Interestingly some smaller Scandinavian countries, Scotland and New Zealand have made more progress but are still working on issues while it seems clear that what they are doing does not scale well as England continues to struggle after near 20 years of effort.

This brings us to Australia. We need to break Australia into three areas.

In the Public Hospital Sector we have had decade long processes to get basic clinical and administrative systems in place with some sort of success in NSW and Victoria with considerably less success in all the other States. This has been associated with considerable clinician annoyance and alienation. The private Hospital Sector is about 5 years behind the public system.

In the GP sector – and to a much lesser extent for specialists – basic record keeping, billing and other admin functions are commonly computerised with some communication functions also in place at a practice level. Inter-practice information flows are still very limited.

Australia also has a one-of-its-kind health information repository – the My Health Record – which collects all sorts of clinical and administrative information into a huge document repository. The thought is that this repository will be looked up on the off chance it has some useful information and that the time spent looking it up will be repaid. To date there is no evidence I have seen that this is actually happening. Despite just on 90% of the population having a record at least half are still empty and many others contain old and ageing data as best one can find out. No usage statistics of any value are published by the Government, but it is known that while automatic contributions to the repository continue to mount the same cannot be said for clinician curated content. The system has failed in over six years of operation to attract much clinician usage or interest.

Importantly, as far as I know, there are anecdotes but no compelling evidence that the investment and work so far has been worth it.

It would be fair to say that globally, advanced economies struggle to progress Digital Health initiatives and that issues that were widely discussed a decade are still seeking solution. In developing countries some basics have made a little progress and need to be fostered to come to richer fruition.

Having watched on since 1987 I have to say I have concluded a number of things.

1. Successful computerised support of clinical practice is very much harder than was imagined 30 years ago and is still being worked on.

2. Small scale initiatives can often work very well but seem very rarely to scale.

3. The track record of large centralised government solutions is abysmal – none have really succeeded.

4. Unless clinicians see value in the use of technology for themselves and their patients adoption is an extremely hard slog without significant financial incentives – as have been used in Australia.

5.Trying to turn skilled clinicians into data entry clerks does not end well.

6. Simplistic thinking about what will and won’t work for clinicians and patients seems always to reveal the problem being address is very much harder than it seemed initially.

So, in summary we are not there yet, the problem of obtaining real value from Digital Health is a truly wicked one but maybe, just maybe the next five years will be different. Some think so and I guess time will tell.

David.

It Seems My Old Clinical Speciality Is Wondering About Using The #myHealthRecord. Oh The Shame Of Publishing ADHA Propaganda Unfiltered!

This appeared a little while ago. The document is date 1^st Feb, 2019. It seemed pretty excited.

A MyHealth Record message for anaesthetists

AUSTRALIAN DIGITAL HEALTH AGENCY

In February, a My Health Record (MHR) was created for every Australian who chose not to opt out of the system. The Australian Digital Health Agency’s rollout of MHR to healthcare providers was initially focussed on GPs, pharmacists, pathologists and diagnostic imaging services.

The Agency is now looking to engage more specialists – including anaesthetists.

What does this mean for anaesthetists?

MHR is a secure, online health summary where clinicians involved in a patient’s care can access their health information. Information available may include a patient’s medical history, medicines view (incorporating prescription and dispense records), allergies, adverse drug reactions, immunisations, hospital discharge summaries, pathology results, diagnostic imaging reports, event summaries, advance care plan and custodian information.

It is an additional source of information to support clinical decision making — and does not replace other important information such as the medical records held in a clinical information system, or essential clinical conversations with a patient and other healthcare providers.

Clinicians decide who would benefit the most by using MHR such as those on multiple medications, complex and chronic patients or patients who travel or are older. Therefore, it will not necessarily be used for all patients.

At this early stage of implementation, a record requires initial activation by its owner or their clinician and may contain little or no information. As more provider organisations connect and healthcare interventions occur, the information gathered in a person’s record will grow.

To date more than 15,000 healthcare provider organisations, including specialists, GPs, community pharmacies, pathology and diagnostic imaging services, public and private hospitals, and residential aged care facilities have connected.

The MHR system gives clinicians access to their patients’ records, however harsh penalties apply for inappropriate or unauthorised use. Patient control is at the core of MHR where they can set access controls to limit who can see their record and the information it contains.

Additionally, Australians have a choice whether they want a MHR and can choose to permanently delete their entire record and any backups at any time in their life. Parliament recently passed legislation to strengthen the privacy protections in My Health Records Act 2012 including:

Benefits for anaesthetists

MHR aims to support improvements in the safety, quality and efficiency of Australia’s healthcare system by allowing timely access to information stored in one place

Dr Marie Bismark, joining two other specialists to discuss My Health record on video, said in relation to working in private practice:

“I think you can feel quite isolated from decisions being made by other specialists. You don’t have that multidisciplinary team environment as you do in a hospital ward and it almost becomes more important to know what decisions are being made and what medications are being prescribed by other people involved in the patient’s care.” MHR makes this information available.

What next?

Anaesthetists can access MHR as an employee of a health care organisation connected to the system. To find out more anaesthetists can request a digital health education session by contacting the ASA office or the ANZCA or the Australian Digital Health Agency at clinicalpartnerships@digitalhealth.gov.au.

Further information on MHR and getting connected can be found at www.myhealthrecord.gov.au or by contacting the Helpline on 1800 723 471. For more information and assistance.

Here is the link:

https://asa.org.au/wordpress/wp-content/uploads/Policy/MHR-anaesthetist_article_.pdf

Let me first make it clear this screed comes intended for practice managers and seems to be at least partly put together for the ADHA.

The page is here:

https://asa.org.au/practice-managers-education/

The Aust. Society of Anaesthetists also has a position  paper which seems to be much later according to the .pdf – dated 14/10/2019.

Here is the link to the page – it is Item 17 and has been revised.

https://asa.org.au/asa-position-statements/

It paints a slightly more reticent view – to say the least!

Position statement – ASA PS17

My Health Record (MHR)

Preamble

The ASA supports the notion of an electronic health record that is ‘fit for purpose’, reliable, accurate, adequately resourced, consumer focussed, equitable, universally accessible, easy to use, maintains people’s privacy and safeguards against the misuse of data. The current 2018 My Health Record, (MHR), has attempted to address some of these concerns. The ASA will continue to collaborate with stakeholders to resolve the outstanding issues that present a barrier to the successful implementation of an effective e-health record.

Introduction

The practice of medicine in Australia has evolved organically from generic practitioners and bush hospitals to specialised generalists in primary care, specialists, sub-specialists in secondary and tertiary centres.

Healthcare services are distributed geographically across rural, regional and metropolitan centres reflecting Australia’s population mal-distribution and across the public and private sectors. This healthcare practice is supported and augmented by pharmacists, nurses, allied health professionals and diagnostic technicians. The net result is often uncoordinated care occurring in silos that may be duplicative, unnecessary, wasteful and potentially harmful1.

Having access to an accurate e-health record could theoretically improve this fragmentation of care. In 2012 the Personally Controlled Electronic Health Record (PCEHR), was introduced to improve health outcomes by sharing health information and increase consumer engagement through an ‘opt-in’ approach2. Low community uptake prompted further research, education and promotion culminating in the relaunch of MHR in 2016.

Potential advantages of an ideal e-health medical record

Reducing fragmented care

Medical information often exists in silos. This information should follow the patient3, to allow healthcare professionals to provide timely, safe and appropriate care. This is particularly relevant for those with special needs, complex multisystem disease, chronic disease, the elderly and disadvantaged. Multiple medications may introduce the potential for drug interactions, allergic and adverse drug reactions. An up-to-date drug reconciliation tool would significantly reduce these potential errors particularly when patients are transitioning from one setting to another or changing geographical locations. Having an accurate current medical record assists with discharge planning and handover of care.

Safer care in emergencies

Emergency access to reliable, current medical information may be lifesaving.

Improved efficiencies

Uncoordinated care is wasteful. It often results in duplication of investigations and referrals. This is expensive and may result in increased exposure to risks.

Consumer centric

Allowing patients to have input into their medical record, how the data is managed and who has access to it, empowers them to take an active role in decisions about their care. It increases awareness, choice and control4.

Advanced care plans and advanced care directives

These may be reliably located in the e-health record.

Increased engagement

Centralizing the consumer’s information may stimulate healthcare providers to offer more acceptable, appropriate and useful products and services.

Area for research

De-identified data may be used by legitimate authorised entities to conduct quality improvement research, planning and policy development

Potential disadvantages of the My Health Record 2018

Incomplete, inaccurate record

Allowing consumers to alter their record potentially devalues the clinical integrity. Health professionals may not be able to reliably provide the best care for their patients if it is based on inaccurate information. Consumers may have an asymmetry of medical information that may compromise their ability to make the best decision regarding what to exclude4. When the MHR has been modified by a patient this is not visible. It should be made clear if a record has been altered by a patient even if the content of that change is not.

Access

Many health professionals, including many specialists, do not have access to the software required to engage with MHR5. Combined with ‘on going’ compliance obligations this presents a significant barrier to specialist participation. Incomplete healthcare provider participation below a critical mass, reduces the universality and overall value of the MHR. Adequate resources must be invested in the platforms that support and maintain the integrity and access at the bedside (ideally on a mobile device) of the MHR data.

Privacy and security

The potential for centralised personal data to be corrupted, stolen, used and stored inappropriately remains a valid concern for all stakeholders. Proposed government measures go some way to protect patient privacy. No IT system will ever be totally reliable yet this has not prevented the developments in e-banking or e-travel. There needs to be assurance that should such a data breach occur, the FederalGovernment assumes full responsibility. There needs to be consultation with the medical indemnity industry and some assurance on the limited liability of doctors utilizing MHR.

‘Opt-out’ may not be fully informed consent

PCEHR went from ‘opt-in’ to ‘opt-out’ in MHR to achieve a greater critical mass of consumer participation with benefits of scale, greater interconnected participation and the potential for transformational change6. However, consumers must be fully informed and have a degree of e-health literacy that permits them to make an informed choice about how to engage, and to what degree, with MHR.

Implementation barriers

There needs to be more effective targeted education and promotion to ensure MHR is acceptable and useful to healthcare providers and patients7. Evaluations of MHR have demonstrated low levels of usability amongst those with reduced e-health literacy8. Low levels of awareness and how to utilise the full capabilities of the MHR, may discriminate against the ‘digitally naïve’. This may include the most vulnerable people with chronic, multisystem disease, the elderly, those with mental illness, non-English speaking and from lower socioeconomic backgrounds.

Conclusion

The ASA supports an e-health record that meets the clinical and consumer expectations. This includes respecting and protecting patient’s privacy while maintaining the integrity of the clinical data. The implementation of MHR will require more resources to address and support these concerns.

References

1.     Hambleton S, Primary Health Care Advisory Group (2015), ‘Better outcomes for people with chronic and complex health conditions’, Commonwealth of Australia Department of Health, accessed January 28th, 2019. http://www.health.gov.au/internet/ main/publishing.nsf/content/76B2BDC12AE54540CA257F72001102B9/$File/Primary-Health-Care-Advisory-Group_Final-Report.     pdf

2.     Commonwealth of Australia, My Health Records Act 2012, accessed January 20th, 2019. https://www.legislation.gov.au/Details/ C2012A00063

3.     Bartone T (2018), ‘My Health Record could save your life one day’, The Sydney Morning Herald, published July 23rd, 2018.

4.     Wells L (2018), ‘An important overview of the pros, cons and questions about My Health Record’, Croakey, published June 6th, 2018, accessed January 20th, 2019. https://croakey.org/an-important-overview-of-the-pros-cons-and-questions-about-my- health-record/

5.     Miller AC, ‘My Health Record important, but let’s fix the problems’, AMA, published October 9th 2018, accessed January 20th, 2019. https://ama.com.au/ausmed/my-health-record-important-let%E2%80%99s-fix-problems

6.     Van Kasteren Y, Maeser A, Williams PA, Damarell R (2017), ‘Consumer perspectives on My Health Record: A review’, Flinders University, South Australia, accessed January 28th, 2019. https://www.hisa.org.au/slides/hic17/sci/vanKasteren.pdf

7.     Bartone T (2018), ‘Advocating for the best My Health record’, Australian Medicine, published August 9th, 2018, accessed January 20th, 2019. https://ama.com.au/ausmed/advocating-best-possible-my-health-record

8.     Walsh L, Hemsley B, Allan M, Adams N, Balandin S, Georgiou A, Higgins I, McCarthy S, Hill S (2017), ‘The E-health literacy demands of Australia’s My Health record: A heuristic evaluation of usability’, Perspectives in Health Management, 14 (Fall), accessed January 28th, 2019. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5653954/

This seems to me to say if the #myHR did and was as described on the tin it could be a good thing, but at the present there are too many holes that need remedy and investment. The paper for Practice Managers is pure propaganda whereas the position paper is a sensible considered document which sees the spin.

Thus, again we see the clinicians pretty careful, not that oversold on a solution that isn’t!

David.