“When I graduated, my medical notes were an aide-memoire to help me treat my patients. When I joined a group practice, I realised that my notes helped my colleagues and me treat our patients. Since computerisation, my notes and health summaries have helped me to write better referrals so that colleagues outside my practice can assist me in treating patients more effectively. Now that I can share an up-to-date health summary on MyHR, I realise that my notes can help my patients to achieve better outcomes from the health system, even when I am not directly involved.”
Five years ago, in 2014, I wrote about OpenNotes because I thought it was a new and fascinating concept. I soon discovered that giving patients access to health records triggered strong emotional reactions: patients loved it and many doctors thought it was one of the scariest ideas ever.
Fast forward to 2019, and about 90% of the Australian population has access to the national My Health Record (MyHR). According to the Australian Digital health Agency over 80% of general practices and pharmacies, 75% of public hospitals, and 64% of private hospitals have registered.
It took a while, but Australia has sorted out most of the digital teething problems. A large part of what doctors do every day – from writing prescriptions to requesting tests – is now recorded and can be viewed by patients, other health professionals and researchers.
This is only the beginning. Secure messaging is one of the next big topics on Australia’s eHealth agenda. By 2022 patients and healthcare providers can communicate and share more health data than ever before via interoperable, secure digital channels.
Nobody is expecting this to be an easy journey, but I’m looking forward to the destination! Welcome to the ‘open era’ of health information.
When his wife attended a conference in Copenhagen, Adelaide GP and RACGP board member Dr Daniel Byrne took the opportunity to find out why Denmark is one of the world leaders in the use of e-health.
One of Australia’s problems is the reliance on paper documents. For example, almost every healthcare organisation designs their own referral forms and we still fax and post a lot of documents. In Denmark a ‘one-letter solution’ was introduced years ago: one electronic form used by thousands of health organisations.
“No patient ever left the surgery with any paper,” said Dr Byrne. “It seemed very well organised with a great e-health network. No faxes were used as everything is connected via secure networks – prescriptions, referrals, pathology and radiology ordering, even email consults.”
There are no incentives for Australian GPs to communicate with their patients by phone and email, whereas Danish GPs are paid to to take calls from patients every morning. They are also paid for e-mail communications with patients.
Dr Byrne: “The email consults are excellent. The patient has to send their email via a government secure email system. Every citizen in Denmark has a government email address – maybe similar to our MyGov system.”
“Only simple non urgent requests are done by email. I think the GP has three days to answer. The payment was around $10 per email for the GP and this seemed to work fine. If there is a bit of to and fro with a patient via email the GP asks the patient to come in for a proper consult.”
Shared medication record
National databases exist for medications and laboratory results. Dr Byrne: “The live medication list was too good to be true! Click on the medication list in any GP software or hospital system and within 2-3 seconds up pops the same real-time live medication list.”
“The GP I was with could see the prednisolone dosing schedule for a patient with polymyalgia from hospital and then just take over future prescriptions. Everyone is working off the same list. I am sure it is not perfect but a pretty good starting point compared to our nothing.”
It appears the system encourages continuity of care. After hours medical services use the same computer system as GPs and hospital discharge summaries arrive electronically at the GP surgery within two days. Scripts are sent electronically to the patient’s preferred pharmacy.
Compared to many other European countries Denmark has a high public satisfaction with the health care system.
An interesting aspect is the access patients have to the system. Via the Danish National Health Portal patients can access hospital discharge information, laboratory results, the live medication list and waiting list information.
Patients can electronically schedule GP appointments, send e-mails to their GP and renew prescriptions. They can also see who has accessed their health records.
All doctors are allowed to access the health records, but other health professionals require patient consent first. Danish law does not allow the interconnection of IT systems across sectors, such as health and taxation.
With a population of 5.6 million Denmark is one of the smaller European countries, which may make it easier to roll out e-health. The system is not perfect and there are always issues, such as interoperability.
Overall Denmark seems to be miles ahead of many other countries, including Australia where we still rely heavily on the fax machine. Dr Byrne: “In Denmark it is illegal to fax anything as the system works on a national ID number that has to be kept secure.”
This is good news. Doctors and patients are often confused about the rules regarding the collection, use and disclosure of information on a PCEHR.
An example of ambiguities includes doctors being advised not to use PCEHR data when providing third-party reports. But what happens to PCEHR information that, over time, has been incorporated in local databases? And are doctors allowed to access a PCEHR in the patient’s absence?
What’s the purpose?
This lack of clarity reflects a bigger problem — the absence of a clearly articulated and shared goal underpinning the national e-health system.
In the absence of an agreed purpose, rules and systems can become arbitrary or misguided, restrictive and lacking in consistency. Doctors, patients and policymakers first need to agree on the main purpose of the PCEHR.
Ultimately it is a tool intended to improve the provision of care: patients disclose their personal data to doctors and, in return, receive more effective and personalised care. I would be happy if the data were used for other purposes such as disease surveillance or even feedback on my clinical management but, in the end, it is the patient’s record and they must have a say in it.
A proper consent procedure is essential for any use of PCEHR data outside individual patient care. It appears the PCEHR system operator is currently authorised to collect information in individual PCEHRs for law enforcement, health provider indemnity insurance cover, research and public health purposes, and as required or authorised by law.
This should be more transparent with a better explanation of what it means for both patients and clinicians.
Patients should also understand the pros and cons of setting advanced access controls, especially now an opt-out system is on the cards. Adequate support will be required for specific groups including the elderly, people with a disability or mental illness, and some 14–17-year-olds.
The right to be forgotten
At the moment, PCEHR data are required to be held for up to 130 years. An interesting concept to consider is the “right to be forgotten”, which has been introduced in the European Union Court of Justice to give people the right to remove data from search engines under specific circumstances.
This concept is applicable to e-health. Patients, for example those with a mental health diagnosis early in life, may want to have part or all of their PCEHR record erased at some point (not just deactivated) to avoid stigmatisation or other repercussions — rather like the expunging of juvenile criminal records to give young people a fresh start.
Liabilities & incentives
Removing the need for participation agreements seems like a good idea. The Department of Health proposes that the liability provisions in the agreements be disposed of, rather than transferred to the legislation.
It is unclear what this would mean for the liability of doctors and health care organisations.
It seems new incentives will be paid to doctors who upload records to the PCEHR on behalf of patients with care plans. Although this will be welcomed by most doctors, it excludes other patients who don’t have a care plan but who would also benefit from a PCEHR.
Linking payments for chronic disease management to the uploading of documents is complicated. If it is introduced without other improvements to the PCEHR system, it could create more resentment among doctors and may lead to poor-quality uploads
What happens if patients do opt out of the PCEHR? Will their doctors be paid less to look after them?
And what if a patient who would benefit from a PCEHR declines to have a care plan, or the doctor provides chronic care without creating care plan documents or health assessments? In that case, there would be no incentive for the doctor to upload data to the PCEHR.
An upload incentive across the board would avoid these issues.
More criminal penalties?
The government is also considering introducing more criminal penalties, including jail terms, additional to the monetary civil penalties that already exist for data breaches. If we want to increase participation and engagement by doctors, I’m not sure that more penalties will help.
The challenge is to make e-health an integral part of health care, and align its purposes and values with usual clinical practice.
Training & education
Astronomer Carl Sagan said: “We live in a society exquisitely dependent on science and technology, in which hardly anyone knows anything about science and technology.” If e-health is to succeed we need to invest in information and communication technology skills. We must train the next generation of e-health designers, builders, managers and users to ensure our e-health system is safe and effective.
This article has previously been published in MJA Insight. Many thanks to Ms Jen Morris, Dr Karen Price and Dr Michael Tam for their valuable feedback and suggestions on the draft of this article.
In the 2015 Budget the Federal Government has allocated significant funding to improve the electronic health record system for all Australians. The personally controlled e-health record gives patients a lot of control, but many healthcare providers are still concerned about the medicolegal risks embedded in the system.
I had the privilege to speak with Dr Steve Hambleton, former AMA president and Chair of the National E-Health Transition Authority (NEHTA), about some of the concerns voiced by doctors and consumers.
It appears there are various sticks and carrots in the pipeline to get more healthcare providers on board, but there is no sign that for example the heavy-handed PCEHR Participation Contract for providers will be changed.
The good news is that Dr Hambleton expects the current national infrastructure will help other providers and products – different to the PCEHR – to emerge in the near future.
Here is the transcript of our conversation:
Are you enjoying your role within NEHTA?
“I think I am now!”
I assume you are happy with the allocated funding of $485 million for e-health over 4 years in the latest budget?
“Yes absolutely. I think it does two things: It restarts the momentum of e-health in this country, and the Federal Government has now sent a signal to the State Governments and the e-health community saying: ‘we are serious about e-health and we want to get an outcome; we want to get some returns.’ If you think about it, we’ve really had no momentum since about September 2013.”
The budget indicated that NEHTA will cease to exist as suggested in the Royle report – what will your role be after the transition?
“I hope to be able to contribute in some way, but there are no announcements about it as yet. NEHTA can now complete its task of setting up the infrastructure and I guess the Australian Commission for E-Health, if it goes forward as proposed, can take it to the next step of more meaningful and better use of e-health.”
What is the difference between NEHTA and the proposed Australian Commission for E-Health?
“I think the main difference will be in the governance, not so much the strategic direction. We recommended in the Royle review to put users and people who can meaningful influence the direction of e-health on the governance board, so the influence is there at the highest level.”
According to the PCEHR Act 2012 the PCEHR has four purposes: to help overcome fragmentation of health information, improve the availability and quality of health information, reduce the occurrence of adverse medical events and the duplication of treatment, and to improve the coordination and quality of healthcare provided to consumers by different healthcare providers.
It appears however there are least 5 other purposes of the PCEHR spread out throughout the Act:
Law enforcement purposes
Health provider indemnity insurance cover purposes
Public health purposes
Other purposes authorised by law
Especially the last one seems a catch-all category. There seems to be a lack of information about what happens with our patients’ health information in the PCEHR. What are your thoughts on this?
“We should probably engage with the minister now to gain a better understanding of where they want to go with e-health, but if we simply mechanise what we’re doing with paper records we really can’t reach the benefits of electronic health. We have to analyse the data we’re creating and use that to improve care and understand outcomes.”
“For example, when a new drug is released into the community we want to know: does it actually deliver the same outcomes as when the drug trials were run? We need to make sure that the healthcare we are providing does make a difference and does get an outcome, so we do need to analyse the data. Whichever way we go, the performance of the system is going to face more transparency as time goes on, and I think the profession is beginning to understand that.”
“We need to analyse individually what we do in our practices; all the colleges are now saying: ‘as part of continuous professional development we want you to reflect on your activities within your practice and show us how you modify your activities to get a better outcome.’ That will apply to GPs, specialists, hospitals, and the systems need to be analysed as well. We can’t do that unless we have a common dataset and I think that’s what e-health gives us.”
We need more information about what the government will and won’t do with the data because the PCEHR act 2012 seems to allow for almost anything.
“I think that’s probably a question we should put to the minister. We need to hear what’s in their heads. I don’t have any knowledge about what’s in the government’s mind.”
The data is kept by the government for 130 years, is that right?
“My understanding is that’s correct yes.”
Do you think patients are aware of this?
“I can’t answer that question, I couldn’t tell you what patients are thinking but certainly from the day-to-day interaction with patients it’s surprising to see how many people think we’re already sharing information about them and use that to try and improve the situation.”
Even if healthcare organisations or practices cancel the PCEHR Participation Agreement, 7 of the 14 clauses contain paragraphs that survive termination, including liability. Although practices may have signed up to access the incentive payments, they may be concerned about the fact that the contract has clauses that, once signed, will be perpetually binding.It makes sense to adjust the contract to entice clinicians to participate, doesn’t it?
“My comment would be that we’re bound by good medical practice in any case, no matter what we do in relation to our patients. Decisions that we make are expected to be in their best interest. And putting my AMA-hat on, our interaction with e-health should be no different and shouldn’t require any different concept than when we are interacting with patients in other ways.”
“E-health is a different way of interacting and recording data and I guess that’s why we’re well-educated and insured and act in the patient’s best interest. If you look at good medical practice and say well that’s the guidance that we’re all subscribe to, than this should apply to any interaction including e-health.”
But 130 years seems like a long time.
“We’re expected to keep paper records for a period of time and every time I try to get information about this, you know, nobody will give you a clear answer when you can dispose of them. Theoretically it might be seven years since you last used them but if you talk to a medical defence organisation they say: ‘well if you keep them longer that would be good.'”
“I’ve got electronic health records in my practice dating back to 1995 and you wouldn’t think of destroying any of those. I think it’s one of those areas that you think: is this information permanent? I mean, in 130 years is it going to be in a form that’s usable? I guess it’s one of these things we don’t know the answer to.”
How do we get doctors to use the PCEHR?
“Doctors have been sitting back asking: ‘well why should I engage with e-health when it’s not certain if the government is actually going to support it?” There has been a lot of uncertainty. We now have a strong signal from the government that e-health has a future and that we have a national infrastructure that we’re going to use.”
“Then we need to say to doctors: ‘well what is the benefit here?’ The primary beneficiary is the patient. The information collected that they can manage will provide the next doctor they see with accurate and up-to-date information. Specialists and public hospitals can get quick access to the curated information.”
“The reality is it’s going to make our lives easier and make our search time shorter and provide us with rapid access to accurate information. Opt-out ofcourse means that when you look for a PCEHR there’s one there; if the patient has been in hospital there will be a discharge summary; if you want to upload something it’s not complicated and you don’t have to sign people up. It will be more efficient.”
The budget mentioned revised incentives, can you tell us more?
“Nothing specifically, but I have no doubt that the practice incentive payments program will look at incentivising doctors to use electronic health records. Their software has to be SNOMED compliant, they need to have secure messaging protocols and be able to send messages between doctors and patients and utilise the e-health infrastructure. I think that’s going to happen.”
A problem with practice incentive payments is that they go to practices, not to doctors who are interacting with the PCEHR.
“It depends on how practices have set themselves up but you’re quite right. The Royle review recommended that there should be a link between annual health assessments, care plans and utilisation of e-health. This would be a direct reward for doctors if they interact with the e-health infrastructure. The government has indicated that it is going to try and implement the major recommendations of the Royle review.”
GPs could interpret a link between care plans and e-health as the government forcing them to use the PCEHR, because if they wouldn’t their income drops.
“It is by no means a definite outcome. It is something the PCEHR review commission thought would be worthwhile. The Primary Health Care Advisory Group [of which Dr Hambleton is chair as well] will consult with senior members of the profession to see what they think. I think it is pretty clear that people with high needs and chronic diseases would benefit from better electronic communication.”
I agree that certain people with chronic diseases could benefit from e-health. Many GPs however are weighing up their own risks of participating against the benefits to their patients, and that’s where some of the concerns come from.
“Yes, I think we should all look at issues like that. I suppose we will be looking to our indemnity providers to give us some guidance. The AMA has put out a guide for the use of the PCEHR which gives pretty good guidance. But if e-health reduces the risks for our patients and improves the care to our patients everybody is going to support it; if it does the opposite then they won’t.”
“I just want to make one more point. We focus on the PCEHR, and I understand why, but so many people have called me out and said: ‘we’ve spent a billion dollars on the PCEHR!’ but actually we haven’t. The national infrastructure that underpins the PCEHR is really critical for a successful e-health strategy.”
“Think about the individual health identifier, the individual practitioner identifier, practice identifier, SNOMED CT, Australian medicines terminology, secure messaging protocols and also a national product catalogue plus a national health services directory.”
“All of this basic infrastructure is built and can be used by other providers, different to the PCEHR, and that’s the exciting future. I think other products will emerge, which of course doesn’t mean that we shouldn’t make the PCEHR easier to use. We should. We’ve got to make it easier.”
Tricky medicolegal cases
I asked Dr Hambleton to comment on a few real-life cases. In some instances the doctors involved contacted their indemnity insurers but unfortunately insurers were not always able to provide advice. In his comments Dr Hambleton refers to the ‘AMA guide to using the PCEHR’ which can be downloaded here.
A patient saw another doctor in the same practice who did not upload the latest information to the PCEHR, and the patient subsequently complained to their own GP.
“There is no compulsion to upload anything to the PCEHR. A patient can ask the doctor to upload something but the doctor is not required to do it. The doctor may say: ‘I’m not your nominated healthcare provider but you need to see your own doctor to get another shared health care summary uploaded’. These sort of things need to be talked about in practice protocols and discussed with the patient.”
There was a practice that accessed the PCEHR when the patient was not present, and the patient threatened to sue the practice.
“Patients do provide standing consent for access to their records by registered healthcare providers, so they can assist with their healthcare.”
“I think we have to talk to the AMA or the indemnity providers, but accessing the PCEHR for reasons other than the patient’s healthcare probably is not appropriate access.”
One patient demanded that the GP did not mention essential information available in the PCEHR for a report to an insurance company. The GP was unsure what to do.
“That’s very clear. If you have to write a medicolegal report it would not be appropriate to access the PCEHR, as it’s the patient’s record. If you’re writing a medicolegal report doctors can only access their own records, unless the patient has given permission to access their PCEHR. Practices need to think about protocols that describe who accesses the PCEHR and why, and have systems in place to make sure this happens.”
Misleading, missing or incorrect information causes mistakes or harm. Many doctors are unsure how they can assess if information available in the PCEHR is reliable or not.
“I think this is a really important comment as well. You can’t assume that any information in the PCEHR is absolutely accurate. If you are using that information you often have the patient in front of you so when you are taking a history, check if the information is accurate or not. No information is ever going to be complete and we shouldn’t expect that the PCEHR contains complete information.”
“Patients have the right to say, for example, ‘please don’t upload the fact that I had a termination’. Patients should understand that we don’t have to use the PCEHR and if we do, it should be weighed up like any other object of information we get.”
By looking at the PCEHR billing information providers can find out where patients have been, eg other doctors, even if a patient has asked the other doctor not to upload anything to the PCEHR. Are we supposed to have access to this information?
“Well, supposed to and allowed to are two different things. When patients consent to the PCEHR use, they are basically providing standing consent for access to the information that’s there. They have given consent but they also need to understand what consent means.”
“Patients have a lot of control: You can shut it down to one doctor or you can shut it down to only the doctors you give the access code to, and patients can switch the controls on and off.”
Some doctors are concerned that information they upload may be deemed not 100% accurate, in which case they would be in breach of the PCEHR Participation Contract.
“We are trying to provide the best available data. We will be judged by the standard of what a colleague reasonably would have done in the same circumstances. The intention of a shared health summary is to provide the next practitioner with a guide to manage the patient. If you think about it: there is not much difference between uploading a health summary to the PCEHR and writing a referral to a colleague using that exact information.”
“It is part of good medical practice to continually review the information that’s there, and for example delete previously prescribed antibiotics from the current medication list, and look over the past medical history we’re providing to other doctors to see if it is still relevant and useful to the patient’s medical care. It is certainly true that if you upload reams of information you may confuse the next provider.”
In the ‘Blogging on Demand’ series you get to choose the topic. If you have a great idea you want the world to know about, feel free to contact me. Northern NSW GP and technophile Dr David Guest feels that one particular low-cost health-IT solution from New Zealand, called GP2GP, is worthy of more discussion and would make a big difference in Australia.
I admit it’s odd: Every time a new patient presents, the receptionist will see to it that a huge pile of paper notes ends up on my desk, often held together by paperclips or elastic bands.
I usually move the pile over to one side and look at it for a couple of days to see if the documents will disappear which, so far, hasn’t happened. Then, during a lunch break, I bite the bullet and trawl through the record, under while entering the data into the computer: allergies, medications, history, family history etc.
Important documents are scanned and shredded. When a patient at any stage decides to leave the practice, the receptionist prints the record and faxes it to the next GP. When it’s a large record she will make sure it’s held firmly together by paperclips or an elastic band before it goes to the post office in a big envelope.
Getting computers to solve this problem for us is an issue in Australia, because our IT systems don’t communicate. But in New Zealand and the UK they have found a way to transfer health records electronically. It’s called e-mail. Well, not really, but there are similarities.
Simply put, GP2GP is a software application that securely transfers an electronic health record from one practice to another, and automatically stores information in the relevant sections of a patient’s record.
Dr Guest: “Although I support the PCEHR one cannot help but feel frustrated by the slow pace of change and the limited functionality it provides. In recent times I have become much more interested in simple low-cost achievable IT solutions.”
“It would be great to emulate the UK and NZ ability to transfer medical records from one practice to another. Auto-populating medical lists, health summaries, allergies and vaccinations will save time and reduce medical errors. New Zealand has reportedly done this for less than a million dollars. Given the lack of progress in Australian health IT, it seems a no-brainer to replicate this.”
“Patients have a reasonable expectation and entitlement that information can be easily transferred to their new practice
RACGP e-health spokesperson Dr Nathan Pinskier says: “Australians legitimately change their GP and general practice for a number of reasons, for example because their GP retires, practices merge or people relocate. Approximately 10% of Australians move home each year. Patients have a reasonable expectation and entitlement that personal healthcare information held by their current general practice can be easily transferred to their new practice.”
“Transferring data via a physical medium, like discs and USBs, is problematic as they only work well between compatible systems. The PCEHR allows for the sharing of some clinical documents via a point to share environment, however this requires the patient and both the old and the new general practices to be registered with the PCEHR.”
“Furthermore the documents that may be available for transfer may not always be the information required by the new general practitioner, as documents can be restricted or removed by the consumer. The PCEHR is after all, by definition, the consumer’s personally controlled healthcare record.”
Dr Guest: “The elements enabling this transfer of data already exist in Australian electronic health records software. Most products can export their data in machine readable formats such as XML. They can also import an XML-file produced by their own software from other practices. There needs to be agreement on a standard structure for the XML-data and this is what NZ and the UK have achieved. We should use their format and then enforce it.”
The process of posting paper records and manually entering data is inefficient. Patients First, the New Zealand not-for-profit organisation responsible for introducing GP2GP, states on its website: “This results in a significant safety risk each and every time a person changes their GP.”
Indeed, when doctors or staff enter data manually, there is the potential to make mistakes.
“Having this knowledge at their fingertips will lead to improved clinical decision-making
According to Patients First, there are many benefits:
“With GP2GP, general practitioners will have detailed knowledge of their new patient’s current medication, allergies, current problems and past medical history. Having this knowledge at their fingertips will lead to improved clinical decision-making so that the right care can be provided at the right place and at the right time thus reducing the risk to patient safety during the handover of care.”
Lastly, a benefit that has been claimed is a reduction in the number of duplicate tests.
“The major issue is developing an agreed set of standards for both the content and technical requirements for point to point transfer that can be implemented by any vendor,” says Dr Pinskier. “The RACGP Optimus project has made significant progress in relation to defining the content, however there is no national program to address and fund the technical transfer work.”
Some have argued that there is no business case for software vendors to develop GP2GP in Australia. In New Zealand and the UK the project received Government funding.
The reduction in workload may not be as substantial as we would like. GP Emma Dunning pointed out in New Zealand Doctor Magazine that doctors still need to review the imported data:
“Where I used to be demoralised by the huge pile of paper notes awaiting my attention, I am now demoralised by the stream of tasks on my taskbar, in red, saying ‘GP2GP notes imported, review’. My lightbulb may never be green again!”
A 2011 pilot study from the UK found that the record transfer system was valued, but that there were issues with the quality of the records, which required significant resources to rectify. The New Zealand version also experienced teething problems.
Urgent national priority
Nevertheless, the adoption rate in the UK is 62% (2013), and in New Zealand 93% (2014) with 30,000 transferred records per month.
“I think it is excellent and it saves a lot of time
GP Dr Richard Medlicott, who is a member of several e-health task forces in New Zealand, is content: “Personally I think it is excellent and it saves a lot of time. It’s even better since we increased the file limit from 5 MB to 20 MB. I can’t see any reason you wouldn’t use it.”
According to Dr Pinskier making our systems talk to each other has become an urgent matter: “To support efficient healthcare delivery and continuity of care, we need an agreed mechanism for the safe and efficient transfer of clinical information. One would argue that this is now an urgent national priority.”
It seems GP2GP could be a cost-efficient improvement in Australian healthcare, but the question will be: who pays?
Thanks to Dr David Guest for the topic suggestion.
Where are we at with the PCEHR? I asked four leaders in the field about their thoughts: Has it been a success or a failure? Can it still be improved and if so, how?
Dr Frank Jones, President of the Royal Australian College of General Practitioners: “The concept was always good, but it failed to engage with front line medical professionals and was hijacked by lawyers. I am also really unhappy with the government’s plan to upload results if not viewed by the requesting doctor after seven days – a disastrous situation!”
“The other thing that is never talked about and that people outside GP-land are unaware of, is that GPs can already access their practice patients’ notes, anywhere, anytime. GPs leading the way again – in many ways this has diminished the value of a PCEHR at a front line GP level.”
“Lets get the basics right first: Initially we need the information such as active relevant medical issues, allergies and OTD medications.”
In its present form a failure
Dr Brian Morton, Chair of the AMA Council of General Practice: “In its present form as a GP I would have to say it’s a failure. There is no recognition nor remuneration for GPs to spend the time to prepare and submit the data which must be done with the patient present. Professional clinical input to the design process has not been given the status needed to make PCEHR workable and relevant to medical practice.”
“Privacy and consumer political correctness have over-ridden safe principles of health care. The very poor uptake of the PCEHR is evidence of this. If we are to reap the benefits then recognition of the cost of data entry needs to be made.”
“Remove and prevent data which is not clinically relevant for care, for example Medicare billing data, as medical assumptions cannot be safely made based on a billing event. Identify clearly in the record that data has been removed or data hidden; the ability to over-ride the control of this is inadequate for safe care. Start the use of PCEHR with small and focused data entry such as active medical history.”
“Make a Medicare item number for the initial entry of data and an item for review yearly by the patient’s usual GP. Enable the functionality of automatic loading of diagnostic imaging & pathology data to the PCEHR when it is received and reviewed by the requesting provider. For example in our software: when it is transferred from inbox to patient record.”
A clear disaster
E-health blogger Dr David More says: “It is a clear disaster as it has failed to be utilised by, and successfully engage with, either clinicians or patients to any significant degree after what is over two years since initial implementation.”
“It should simply be abandoned and a new eHealth Strategy based on serving the needs of clinicians in information sharing and use developed. Patient engagement should be at the level of providing useful e-Health services to such as e-mail, repeats, referrals, results and record access via local practitioners.”
Dr David Glance, Director Centre for Software Practice, University of Western Australia: “I would say that the PCEHR is effectively dead – there is some interesting commentary here. The liberal government has not killed it but they haven’t supported it actively either. Nor have they put forward any other strategy. So given the financial climate we are in now, I don’t expect that to change.”
“I fundamentally believe that Australia has a basic structural issue when it comes to implementing central strategies around eHealth. We are still lagging in electronic record adoption in our hospitals and public health services and to a lesser extent within the specialist community. Until that changes, any shared electronic health record will always have gaps and be less than useful.”
“Clearly NEHTA needs to be disbanded and something else put in its place. It was self-serving, bureaucratic and pretty hopeless when it came down to it.”
“With regard to opt-in/opt-out, I would say that opt-out is always a better option with a far easier access mechanism than was implemented for the PCEHR. But given how awful the implementation was, the point was moot. Talking of the implementation, given what we know about user interface, you would have thought that the interface to the PCEHR could have been a lot better than it was.”
The start of Doctor Amir Hannan’s career was a rocky one. In 2000 he took over the surgery from convicted murderer Doctor Harold Shipman. On their first day, Amir and his colleague found that Shipman’s children had removed all furniture, phones and computers from the practice. Equipment had to be borrowed from other surgeries.
The practice has long since been turned around into a thriving GP clinic with a strong focus on eHealth; for the past 7 years patients have had online access to their electronic health records.
Around the world there are several projects going that allow patients to get access to their records, and Amir Hannan is one of the trail blazers.
He did his medical training at Manchester University and then trained as a General Practitioner in the north-west of England. I got in contact with him after he posted a comment on my blog post about OpenNotes, and he was kind enough to talk to me about his amazing pioneer work.
Amir is passionate about the project: “I am motivated by the desire to do the very best for patients and staff by bringing out the best in all of them. Empowering them, empowers me. When they benefit, I get an immense sense of achievement. It becomes infectious and helps me to overcome any challenges I may face.”
The practice administration and clinical system he uses in his practice is called EMIS, widely used by GPs in the UK. Amir: “EMIS also provides a secure online facility for patients, called ‘Patient Access’, which allows patient access from a range of internet devices.”
What are the benefits?
Amir says the system offers many advantages:
“Benefits include a more open relationship with patients, which enables patients to feel more in control. They can book appointments online, order prescriptions online, update their contact details and access the full records if they wish. This helps patients to read what the doctor or nurse has said, see test results or letters as soon as they arrive back in the practice, check for any errors or missing data and help with completing medical and insurance forms.”
“It improves the relationship between patient and clinician, leading to a partnership of trust.
“Information buttons provide links to trusted information so that patients do not have to do a Google search. You can do all these things via smart phone, tablet or PC.”
“It improves the relationship between patient and clinician, leading to a partnership of trust. Patients use it intelligently saving their time and doctors’ time to make the system safer and more efficient.”
“Patients can send secure messages electronically, write into the surgery on paper and their comments can be added to the record or they can complete an Instant Medical History which we have recently introduced. We do not encourage email as it is not a secure means of communication and our replies could be seen by other family members which may compromise the patient’s right to confidentiality.”
“We need to do further studies to prove patients accessing their records and, most importantly, understanding them, do in fact enjoy better outcomes such as improved blood pressure control, diabetes care or reduced time off work. Anecdotally patients seem to have better compliance of treatment and we have many testimonials from patients describing their positive experiences. Such evidence may become available as more patients sign up.”
What are the risks?
Amir feels his patients are more in control of their health and care and, at least anecdotally, there seem to be some benefits. But are there any downsides?
“We take security and privacy very seriously. The software requires patients to register using their pin numbers for the service and then use passwords to get access to their records. This seems acceptable to the patients. We have not had any data breaches to date. We offer advice for patients to help them understand these issues better.”
“Very few patients ring the surgery because they do not understand something and we have not been sued for anything as a result of giving patients access to their records. In fact we are still waiting for our first complaint and that’s after offering the service for over 7 years. Currently over 2650 patients, 23% of our registered patient population, have access to their records. Records sharing is safe and does not increase litigation.”
“Every encounter afterwards can lead to patients learning more about their symptoms and how they can do more for themselves.
“It does take some time for patients to sign up for online services, and we do have an explicit consent process. Patients are asked to get their pin numbers from the receptionist, look at some of the support material which explains what records access is, and then complete an online questionnaire which confirms their understanding of the issues. Their request then has to be processed which takes about 10 minutes per patient.”
“It is a journey of discovery for patient and clinician so that every encounter afterwards can lead to patients learning more about their symptoms and how they can do more for themselves. Paradoxically, this seems to lead to a reduction in anxiety because patients, carers and family can check what has been said, see that the practice has done what it agreed to do, gain a better understanding of their health and improve their health literacy – patients worry less as a result.”
Amir’s practice offers the service for free to patients, although there is no funding in the UK to support practices to engage with their patients online. Amir: “Our implementation using the practice-based web portal has required the practice to provide its own resources. The current strategy locally has been for the market to drive innovation, which has failed completely. Funding will need to be made available to encourage innovation and enable stretched practices to invest in such tools to gain maximum benefit and to scale this.”
The UK Royal College of General Practitioners has published a guide titled ‘Enabling patients to access electronic medical records. A guide for health professionals‘. Amir recommends this to anyone who is interested in setting up a similar system.
“My hope is that one day all people in the world will be able to do this. This is the future of healthcare and it is happening now! See how others are doing it, such as in the UK: PatientView or in America: Kaiser Permanente and OpenNotes.”
“I use my twitter account to share experiences with others.
“It is not easy and it takes time, resources and effort. Build links with others and collaborate with them to share experience and knowledge. Build a practice-based web portal such as ours, which helps to engage with patients and provides a mechanism of informing, signposting, engaging and empowering patients and their carers. Engage on twitter and social media – there is a great deal of interest. I use my twitter account to share experiences with others.”
“Listen to your patients and staff. Work with them and develop a strategy and a plan. Most importantly get on and do it. Don’t procrastinate or worry about what might happen – instead think about the opportunities and consequences of enabling patients to access their records and understand them.”
Consumer access to electronic health records may not be far off. In the not-so-distant future people will look up their file from home or a mobile device. They will also be able to add comments to their doctor’s notes.
In its current version the Australian PCEHR allows limited access, but the US OpenNotes record system has gone a step further by inviting consumers to read all the doctor’s consultation notes.
Pulse+IT magazine reported that 18 percent of Australian doctors believes consumers should be able access their notes; 65 percent would prefer limited access and 16 percent is opposed to any access at all.
What are the pros and cons? Here are some of the often-mentioned arguments:
Improved participation and responsibility
Increased consumer’s knowledge of their health care plan
Consumers can read their notes before and after a consultation as reminder
Consumers can help health practitioners to improve the quality of the data, eg by adding comments
Consumers can better assist practitioners in making fully informed decisions
Consumers may interpret the data incorrectly creating unnecessary concerns
Increased risk of security breaches and unauthorised access
Unwanted secondary use of the data by eg insurance companies or governmental organisations
Practitioners may need to change the way they write their notes
An article in the New England Journal of Medicine reported that OpenNotes participants felt they had a better recall and understanding of their care plans. They also felt more in control. The majority of consumers taking medications reported better adherence. Interestingly, about half of the participants wanted to add comments to their doctor’s notes too.
Most of the fears of clinicians were, although understandable, ungrounded:
The majority of participants was not concerned or worried after reading what their doctors had written (many just googled medical terms and abbreviations)
Consumers did not contact their doctors more often
A minority of doctors thought OpenNotes took more time, others thought it was time-saving
According to the OpenNotes team transparent communication results in less lawsuits. I couldn’t find any information about the security risks of the system.
Overall, consumers were content: 99% percent preferred OpenNotes to continue after the first year. Doctors were positive too, see this video:
Consumers have the right to know what information is held about them, and they have the right to get access to their health records. Online access therefore seems to be a logical step to exercise these rights. Although the PCEHR allows consumers to see a summary, the consultation notes cannot be viewed. OpenNotes is about sharing all consultation (progress) notes between a consumer and his/her practitioner.
I believe there are 3 trends happening that will push this development:
The culture of sharing data online
The increasing consumer participation in health care
Evolving digital and mobile technologies
The 3 main reasons why it will not happen overnight:
An attitude change towards full access takes time
Security and privacy concerns
Lack of incentives for software developers and practitioners
Online access to electronic records (viewing and commenting) will boost transparency. It will change the interaction between consumers and practitioners and may even improve quality of care. I’d love to see more trials and experiments in this area. What do you think?