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Unfixable: time to ditch personally controlled e-health record scheme

Federal health minister Peter Dutton has commissioned a review of Labor’s troubled Personally Controlled Electronic Health Record (PCEHR) project. It’s unclear whether the review committee is to decide…

If the past year has taught us anything, it’s that this is not a fixable problem. Image from shutterstock.com

Federal health minister Peter Dutton has commissioned a review of Labor’s troubled Personally Controlled Electronic Health Record (PCEHR) project. It’s unclear whether the review committee is to decide whether to scrap the project altogether or to try and fix it. Hopefully it is not the latter because if the past year has taught us anything, it is that this is not a fixable problem. It needs to go.

The PCEHR project, which has cost A$1 billion so far, had earlier this year failed to meet a self-imposed target of 500,000 patients signed up by July 1. Of more concern was the lack of participation by GPs and the lack of any significant progress to meaningful use of the system.

The review committee will be chaired by Richard Royle, executive director of the UnitingCare Health group in Queensland. Royle will be assisted by Dr Steve Hambleton, president of the Australian Medical Association and Andrew Walduck, chief information officer of Australia Post.

The choice of CIO of Australia Post is curious given that Australia Post itself has implemented a project called Digital MailBox which has been as unsuccessful as the PCEHR. Or perhaps that is the point – Walduck may have a unique insight into recognising unsuccessful IT projects.

Promises vs realities

In principle, the idea of a shareable, internet-based electronic health record is a good one. For people in a situation where they can’t remember all the details of their medications or exact dates of operations, previous diagnoses and complications, an up-to-date summary of this information can provide critical information in the provision of hospital care.

But these scenarios are the exception and not the rule. In fact, there are unlikely to be any clear benefits from PCEHR – even if we were able to measure them. There is no research or other evidence that the PCEHR would have brought about any direct benefit to the population’s health, even if the impossible happened and it managed to sign up a significant portion of the population and achieved meaningful use.

The core of the PCEHR’s problems lie not with electronic systems, implementations, usability or the patient, but with the person charged with driving the system, the GP. It is the GP’s data that is being uploaded and it is ultimately the GP’s responsibility to ensure that the data is complete, accurate, timely and relevant. It is the GP who will be held responsible if anyone else acts on this data and something untoward happens.

It is the GP’s data that is being uploaded. Image from shutterstock.com

But, the GP does not have control over what happens to the record, who it is shown to, what the patient can show or hide and ultimately how another person decides to act on the basis of their information. The GP does not determine how that data is subsequently used by the government or what it is used for.

This is ultimately a very big ask of time-poor GPs who may never see any tangible benefits from these efforts but face very real risks. Under the current Australian fee-for-service remuneration scheme for GPs there is no way to convince them otherwise. Specifically paying GPs to add this information would not work either, as GPs would still have to be convinced that the time spent curating the information was more valuable than seeing another patient.

The expectation that patients will drive the demand is also fanciful given the low level of understanding of the benefits and risks of the PCEHR within the public.

Next steps

The review committee is due to run for six weeks and it is clear that – as has been pointed out by e-health blogger David Moore – this is insufficient time to achieve any meaningful understanding of what didn’t happen, let alone what is needed to fix it.

One can only imagine that a decision has already been made as to the outcome. But to move towards a workable e-health system in Australia, my recommendations are to:

1) Scrap the PCEHR to avoid any further effort and money being wasted. Some commentators have suggested that private industry should take it up, but this would only add commercial self-interest and a whole raft of other issues to an unachievable goal.

2) Redirect effort to implementing the standards and infrastructure that underpinned the PCEHR. This would be the health identifiers, secure message standards, authentication and underlying exchange of information. These features solve real problems being faced by health services today.

The adoption of patient health identifiers by pathology and radiology laboratories in particular would help ensure that results are correctly identified and sent to the right place.

Secure messaging standards are helping to drive more efficient exchange of information between health professionals and further support of these standards would increase the range of content exchanged in this way.

3) Bolster policy and legislation to enable the sharing of clinical information between providers at a local level. There are a number of products already on in use that provide the ability to share clinical information securely to health professionals that need access. The PCEHR provides little extra advantage over these systems.

Join the conversation

17 Comments sorted by

  1. Trevor Kerr

    ISTP

    There should be a little red flag that pops up on articles where the author has a glaring conflict-of-interest. Leaving that aside, David, how much of the project can be shunted off the books onto contracts? I don't think a complete stoppage is likely, since it would cause an unseemly rush for that budget allocation, and lobbyists at blows outside the Minister's office.
    I wouldn't be surprised to hear of the States wrangling over the carcase of PCEHR at next COAG.

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  2. Carol Daly

    Director

    The simple solution to rescue what is needed to provide 21st century medicine to patients is to legislate that my medical information is mine and does not 'belong' to the various doctors I happen to have consulted over the years.
    My body is mine and it is a legal fabrication that what has been done to it bElongs to doctors who rarely talk to each other.
    The number of medical accidents avoided by use of e health records is proven to be significant.
    My money in the bank does not belong to the bank because I use their services and they keep a record.

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    1. Richard W

      Engineer

      In reply to Carol Daly

      Carol
      I'm interested in this line of thought. Why are the medical professionals' records yours? These records are clearly distinct from your body so I don't quite follow that line of argument.
      Any records seem to me to logically be the (intellectual) property of the person who created them. In this case, the medical professional. They create it, they store it, they keep it. So if you want it as part of their service, you should negotiate with them. Feel free to ask each one if you can have it…

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    2. Chris Weir

      Analyst

      In reply to Richard W

      All very jolly Richard W, but you seem to overlook the main thrust of Carol Daly's comment.The number of medical accidents avoided by use of e health records is proven to be significant.

      In this day and age I would have hoped the consumer should have some control of their medical history and information particularly if it is misinformation and therefore the opportunity to correct it.

      Being an involuntary high user of medical services myself I agree with Carol; an example has occurred of my…

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    3. Brendon Wickham

      logged in via email @gmail.com

      In reply to Richard W

      Richard, they may be distinct from my body, but they are *about* my body. The principles of patient-centred care include empowering the patient to make informed decisions about their health and to know as much about their health status as possible. That includes medical notes. For more on this, have a look at the ePatient movement ("nothing about me without me").

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    4. Georg Antony

      analyst

      In reply to Richard W

      Medical records are created by medical consultants acting on behalf of, and paid by, their patients. (Payment through Medicare is from patients, through the tax system. Payment over the Medicare rebate is indisputably from the very patient.)

      Under any similar client-consultant relationship, the data is the property of the client.

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    5. Nicholas Orford

      logged in via email @hotmail.com

      In reply to Richard W

      Xray reports and path reports etc, are not intellectual property of GPs. It is not difficult to transfer those at least to Ehealth.

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    6. Nicholas Orford

      logged in via email @hotmail.com

      In reply to Richard W

      Richard W, Thats baloney. ehealth is not asking for full records. Just a summary and copies of specialist reports, xrays etc,. Reluctant doctors are protecting their practices at the expense of patients welfare.

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  3. Trevor Kerr

    ISTP

    "If you can't tell your boss's boss that the project's going to bomb, it's going to bomb."
    That's from http://civic.mit.edu/blog/mstem/clay-shirky-planning-shant-trump-reality, an account of Clay Shirky talking at Harvard's Institute of Politics about Healthcare.gov.
    As I've noted elsewhere, as a rank outsider, there are people who've been inside the guts of PCEHR and have been aware of the issues that have caused it to end up like this. But, if they haven't made records, at the time they tried…

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  4. Pythinia Preston

    writer

    They should scrap this bureaucratic e-health record nightmarish scheme. Doctors can barely read one record of a patient let alone their entire medical history. If you have 60 patients coming thru the door daily (sometimes more a few less) how can a doctor possibly find the time to look up previous records? And how safe are these records going to be? Patients are only driving the scheme thru fear and this is where we are going to be grossly manipulated.

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  5. Brendon Wickham

    logged in via email @gmail.com

    David, the only beneficial scenario you list is related to patient memory. Not only is this far from the exception (most patients would struggle to recall more than 50% of what a clinician has just told them - hence why experienced patients keep notes), but there are more benefits that a summary record can provide. For example, a system that is in regular use will have up to date information, saving GPs time from chasing up information from other sources.
    While GPs may not be the direct beneficiaries…

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    1. Pythinia Preston

      writer

      In reply to Brendon Wickham

      Why would patients struggle to recall more than 50 percent of what a doctor has said? a patient only gets 15 minutes, or 10 minutes of a doctor's consultation. That is why they are at the doctors to remember what ails them. A careless observation Brendon.

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    2. Brendon Wickham

      logged in via email @gmail.com

      In reply to Pythinia Preston

      I was being generous. There are a lot of studies on this topic. Some studies found that up to 80% is forgotten *immediately*. Google "how much do patients remember" for more detail on this.

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  6. Sue Ieraci

    Public hospital clinician

    Like most medications, electronic medical records have both benefits and side-effects - they are no panacea.

    Many people frequently cite eMRs as a potentially life-saving preventer of errors, but how many people know that they can also CAUSE errors?

    There are various mechanisms at play here. Some examples:
    - Increased work and time for the clinician doing the documenting (there is no doubt that writing on paper is the fastest documentation method for the operator)
    The Impact of Electronic…

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  7. Kemran Mestan

    Senior Researcher, equity and education at La Trobe University

    Today I went to a medical clinic looking forward to the benefits of the e-health record only to be disappointed that the clinic was not participating in the scheme. The doctor wasted time asking me general medical questions and entering my responses into her own database, even though that information was already on my e-health record. I then needed a blood test but she suggested i return to me other medical clinic so the results could be compared to an earlier test. Also, lower income people who use bulk billing and are less likely to have a regular GP can particularly benefit from e-health records. GPs receive public subsidies, they should be required to conform to the system that benefits patients.

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  8. Andrea Shoebridge

    logged in via Facebook

    I thought, and think, e-records is an invaluable idea - being living evidence of failing to remember medical events; I'm lucky to remember what decade, never mind what year and month, my several potential fatal events happened - but was surprised to hear recently that it had been active for a while albeit with little pick-up. A reason for that may be because few of us are aware of the facility, even those of us who knew it was coming. Perhaps I'll have to ask my dr for my records (which excludes events prior to my consulting this practice) and enter them myself

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  9. Nicholas Orford

    logged in via email @hotmail.com

    E Health had so much potential. At the very least it could save huge amounts of money by saving patients having to have repeat tests. However it is my experience that firstly patients dont know about the scheme and secondly doctors dont want it. Why dont doctors want it? Could it be because of self interest? Are doctors afraid of patients changing to another doctor and taking thier history with them? I believe that is a large part of the problem. How easy would it be for doctors to have a poster or leaflets in their waiting rooms for patients to read. How easy to transfer xray reports and path reports to the Ehealth system. They are already on most doctors data base. The practice manager simply has to key in those reports to Ehealth. They may complain about not having time. They are subsidised by the australian taxpayer in many ways, the least they can do is have their staff submit reports to Ehealth.

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