The PCEHR: Moving forward

I can confirm that the Government is not going to build a massive data repository. We don’t believe it would deliver any additional benefits to clinicians or patients – and it creates unnecessary risks (~Nicola Roxon)

The PCEHR: Moving forward I’ve studied the PCEHR but I’m still not sure what the government has built and for what purposes. I was always under the impression that the PCEHR was designed to assist clinicians to improve patient care through better data flow. But this may not be the case.

The recent resignation of NEHTA’s top National Clinical Leads is an ominous sign. If the Department of Health does not start sharing ownership of the PCEHR soon and improve governance of the system, the PCEHR will fail. Here’s a quick rundown of the issues and how to move forward.

Legal issues

A first glance at the PCEHR Act 2012 seems to confirm that the PCEHR is built for clinicians, as its four purposes are clinical in nature:

  • To help overcome fragmentation of health information
  • To improve the availability and quality of health information
  • To reduce the occurrence of adverse medical events and the duplication of treatment
  • To improve the coordination and quality of healthcare provided to consumers by different healthcare providers

So far so good. But the Act is 93 pages long and I could find at least five other ‘non-official’ purposes of the PCEHR spread out throughout the Act:

  • Law enforcement purposes
  • Health provider indemnity insurance cover purposes
  • Research
  • Public health purposes
  • Other purposes authorised by law

And this is where the concerns begin. These ‘non-official’ purposes are not directly related to the care doctors provide to their patients. In general, one would say that patients and clinicians have to give informed consent before their health information can be used for research or other purposes. It seems like informed consent is missing here.

Contractual flaws

Combine this with certain clauses in the one-sided participation agreement and you’ll forgive me for thinking that the government, contrary to Roxon’s reassuring words, has built a massive data repository:  Once clinicians sign the agreement, they grant the Department of Health and Ageing a perpetual, irrevocable, royalty-free and license-fee free, worldwide, non-exclusive license (including a right to sub-license) to use all material they have uploaded to the PCEHR.

Those who think that you can always opt out are mistaken. Even if health care organisations or practices cancel the participation agreement, seven of the fourteen clauses survive termination, including clauses regarding liability. It is good to know that the government will continue to use the information after cancellation by a clinician or consumer for up to 130 years.

Another concern is the fact that the Minister may make or change PCEHR rules without legislation, and the Department of Health can change the participation agreement at any time without the need for input from clinicians. We thought the After-Hours and PIP contracts by Medicare Locals were a disaster, but this agreement is possibly worse.

Other problems

By now it is obvious that Clinical Leads and professional organisations have not been involved in many important decisions. There is a range of other issues, which I won’t discuss here in detail, including technical software glitches, the absence of MBS item numbers and lack of indemnity insurance cover for the fines related to the PCEHR. Under the PCEHR Act 2012, all clinicians are seen as employees, which could be a problem as many doctors may be employed as contractors for various reasons.

Moving forward

If the PCEHR can be used for data mining, legal purposes, insurance purposes, public health purposes etc, then that is fine, but, I would strongly advise the profession to stay clear from it. If however we agree, that the PCEHR is a clinical tool, then clinicians must be involved in all decisions.

What we need first of all is an open, well-informed discussion about the purposes of the PCEHR. What are consumers and clinicians exactly saying yes to when they sign up? A proper, transparent, independent governance structure with specific executive authority should be formed. This PCEHR Board should include members from professional and consumer organisations and act as a watchdog over the PCEHR. Any changes to the rules require a consultative process with AMA and RACGP before the Board can sign off. The current PCEHR Advisory Committee and Council are not fulfilling these criteria at the moment.

Consumers should know exactly what happens with their data after they have visited a health care professional and who has access to their information. The purposes of the PCEHR must be clear and agreed upon by all stakeholders. Clinicians own the rights of the data they create and upload, there is no need to grant the government a perpetual irrevocable license to use this data.

The PCEHR Act 2012 and the participation contract must both be reviewed and made 100% acceptable to clinicians. Appropriate indemnity insurance cover is a must, and 100% opt-out must be possible for clinicians and consumers at all times.

This will take time, but if we don’t start now there is no hope for the PCEHR.

This article has been published in Medicus, the journal of the AMA(WA)

8 thoughts on “The PCEHR: Moving forward

  1. Great summary Edwin of the current position of the PCEHR. I think that as you have stated that all stakeholders MUST be consulted from this point forward for the PCEHR to survive.

    Another key point from a consumers and clinicians perspective in the data mining world is data de-identification especially if it it is to be by 3rd parties. What are the rules, who monitors and audits the process etc.

    Interesting times ahead to see how the Coalition handles this.

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  2. Reblogged this on Dr Thinus' musings and commented:
    Nice summary – my clinic was one of the first, perhaps THE first, to technically be fully enabled to deal with the PCEHR – I fully agree with Edwin that it should not be used in it’s current format for the reasons stated in this and other articles. The risk is simply massive to Clinician and Patient and the benefits, in the current format, nearly non-existing

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  3. Edwin,

    re “I was always under the impression that the PCEHR was designed to assist clinicians to improve patient care through better data flow. But this may not be the case.”

    That seems to be one of the justifications for the PCEHR, however IMHO your skepticism is quite justified.

    The question I haven’t seen answered is this: Won’t clinicians use their local, hospital, state or other PCEHR feeder systems for clinical data?

    If so, what does the PCEHR offer the clinician? Especially when NEHTA/DOHA/DOHS specifically state that the data in the PCEHR is only a summary and may not be current.

    The phrase “white elephant” springs to mind.

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  4. Edwin,

    I can’t see how the PCEHR’s purposes (which you listed) can add up to a conclusion that the PCEHR is “built for clinicians”. While the purposes do have a big clinical component, they apply equally to patient use.

    ‘Health information’ is a precious concept for health literate patients. They generate it (they’re the source, after all), use it, and need it. Otherwise, how could they be active participants in their own care? They can improve the data that’s recorded about them (make corrections, prompt additions). An informed patient can even help to avoid an adverse event or treatment duplication.

    And the potential to improve health *illiteracy* is significant. Most people would never before have seen clinical information about them – even something as simple as what’s in a health summary.

    As you know, the PCEHR is not about the sharing of clinicians’ private working notes. It’s primarily about shared, summary information for clinicians and patients to complement existing practice. It’s hard to understand what it is because nothing like it has existed before (which also means it’s hard to get right).

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