Pharmacists and doctors: Let’s change the script

This week saw another low point in the communication and relationships between health groups in Australia. We must find a better way.

It began after the release of a report from the Queensland parliamentary inquiry into pharmacy, which recommends that pharmacists should be able to prescribe and dispense ‘low-risk emergency and repeat prescriptions’ and ‘low risk vaccinations’, subject to consultation with a ‘13HEALTH GP’ or checking ‘the patient’s medical record’ through MyHealthRecord.

Medical groups including the AMA and RACGP indicated they will not support the recommendations. This is hardly surprising as the results of the deliberations by the parliamentary committee led by Chair Aaron Harper MP are not based on mutually agreed principles or a collaborative care model.

Although the report repeatedly mentions a shared prescribing model, the recommendations, if implemented, will not result in effective collaboration. For example, checking the MyHealthRecord (which is not always available or complete) or calling a health-line can hardly be seen as supporting team care and collaboration with treating doctors. Cooperation between pharmacists and medical teams should be more than a box ticking exercise.

I believe we can do better than this.

Community pharmacists feel that their scope of practice is restricted and that they can contribute in a more meaningful way to patient care. Medical groups are concerned that more prescribers can lead to fragmentation of care and poor health outcomes, especially in the absence of meaningful collaboration.

Both arguments are valid and should be explored further. There is always a better way but this requires a willingness to work together and find mutually agreed solutions. Indeed, not an easy task, but we can’t leave this to a group of parliamentarians.

I’d also like to think we are able to move beyond strongly worded media releases, open letters, lobbying and political donations.

On a positive note, it was good to see that the Pharmaceutical Society of Australia (PSA) recently organised a low-key summit between medical and pharmacy groups to discuss patient safety. PSA president Shane Jackson said that the summit will seek to develop a set of principles to support respectful and collaborative practice between pharmacists and doctors.

Reaffirming these principles is a useful exercise and a good place to start. My colleague Dr Ashlea Broomfield and I spoke with Shane Jackson about collaborative models of care (listen to the BridgeBuilders podcast here). Although doctors and pharmacists may never agree on everything, which is absolutely fine, we must find a better way forward in the interest of our patients.

It has begun: Australians will soon have a digital health record

By the end of the year Australians will have an online digital health record, unless they opt out of the system. The details of the move towards opt-out will be released soon.

The Australian Digital Health Agency (ADHA) is ramping up its activities to prepare for the change to opt-out. The large-scale operation will involve extensive stakeholder engagement, a nation-wide communication and advertising campaign and increased support for consumers and clinicians.

For consumers who have not opted out at the end of the defined three-month period later this year, a My Health Record (myHR) will be created. The record will be activated when used for the first time by consumers or clinicians.

A clean slate

ADHA has opened a new call centre, launched a revamped website myhealthrecord.com.au and is now present on Twitter (@MyHealthRec).

Staff levels of the call centre – transferred from the Department of Health to ADHA – will increase from thirty to two hundred and will operate around the clock during the opt-out period.

The record will initially be empty apart from two years worth of retrospective MBS and PBS data. Consumers have the option to remove this data.

Pathology and imaging reports are uploaded into the MyHR one week after the test date. Some sensitive tests, such as HIV, may not be automatically uploaded depending on the various State or Territory legislation.

Clinicians and consumers will have the opportunity to stop the upload of results and other reports if desired. Consumers can restrict access to or remove reports from their MyHR.

No stone left unturned

No stone has been left unturned in finding ways to make Australians aware of their right to opt out: a wide scale advertising campaign will use various media including radio, social media, billboards and cinemas.

Materials such as waiting room brochures, tear-off pamphlets and reception cards will be made available to providers. Medicare will be sending out brochures to Australians. Consumer organisations have been engaged to help with awareness.

It is expected that the adoption and active use of the MyHR will vary across Australia as a result of the availability of already existing digital health solutions in various states and regions.

For example, in areas where discharge summaries are not always easily made available by hospitals, the uptake of the MyHR may be higher.

Opt-out procedure

Currently there are about twenty million Australians without a MyHR. Based on the trials it is expected that only a small percentage, about 2%, will opt-out.

It looks like the opt-out procedure will be relatively simple and can be done via an online self-service portal or by phone through the help desk. Hard copy opt-out and ‘election-to-not-be-registered’ forms will also be available through post-offices, and will be made available to hard-to-reach populations.

Although care has been taken to make sure there is no coercion not to opt-out, those who do will receive a notification that their medical information may not be accessible during emergencies. They will also be asked to give a reason after they have opted out.

The MyHR website will shortly contain information about the opt-out procedure. It is also expected that the FAQ section will be expanded to assist consumers in making a well-informed decision.

Risks and challenges

The MyHR offers clear benefits as clinicians will have increased access to information such as shared health summaries, discharge summaries, prescription and dispense records, pathology reports and diagnostic imaging reports.

However, every digital solution has its pros and cons. It has been decided that the risks associated with the MyHR will not be explicitly discussed on the website.

Behind the scenes however, risk mitigation has been one of the priorities of ADHA. This obviously includes the risk of cyber attacks and public confidence in the security of the data.

Change management

Another challenge for ADHA will be to manage expectations – before, during and after the opt-out period. The reality is that the MyHR is not a be-all and end-all, and is still on a development journey.

As a result of the troubled past of the digital record there is a large group of skeptics. It appears that so far ADHD nor the Department of Health have been able to get this group on board. The usual promotional material, touting benefits, is unlikely to change anything. A more effective approach would involve addressing the concerns, issues and perceived obstacles.

Primary Health Networks (PHNs) will assist in spreading the message. The PHNs involved in the opt-out trials reported high levels of success in engaging providers.

Other parties including the Royal Australian College of General Practitioners (RACGP) will provide peer-to-peer education, which may help to balance the message, address some of the concerns and manage expectations.

Edwin Kruys is a member of the My Health Record expansion program steering group.

The information in this blog post is intended for informational purposes only. It may not be complete and is subject to change. Please refer to offical ADHA sources for MyHR updates.

Where did our health data go?

Data is like garbage, you’d better know what you are going to do with it before you collect it ~ Unknown

It took a while, but the Department of Health is now inviting submissions about the various ways digital health information in the national My Health Record (MyHR) should, and could, be used.

By law information in the MyHR can be collected, used and disclosed ‘for any purpose.’ This ‘secondary use’ of health data includes purposes other than the primary use of delivering healthcare to patients.

The consultation paper is not an easy-read and I wonder how many people will be able to make heads or tails of the document – but then again it is a complex subject.

Nevertheless, secondary use of health data seems to make sense in certain cases. As the paper states:

“Secondary use of health data has the potential to enhance future healthcare experiences for patients by enabling the expansion of knowledge about disease and appropriate treatments, strengthening the understanding about effectiveness and efficiency of service delivery, supporting public health and security goals, and assisting providers in meeting consumer needs

Risks and red flags

There are risks. For example, I would be concerned if insurance companies or the pharmaceutical industry would get access to the data or if the information would not be de-identified.

The consultation paper also mentions performance management of providers, and driving ‘more competitive markets’. These are red flags for many health providers because there is little evidence these purposes will benefit patient care.

For example, performance management has gone wrong in the British Quality and Outcome Framework pay-for-performance system and has resulted in:

  • only modest improvements in quality, often not long-lasting
  • decreased quality of care for conditions not part of the pay-for-performance system
  • no reduction of premature mortality
  • loss of the person-centeredness of care
  • reduced trust in the doctor-patient relationship
  • loss of continuity of care and less effective primary care
  • decreased doctors morale
  • billions of pounds implementation costs

According to the consultation paper it is ‘not the intention’ to use MyHR data to determine remuneration or the appropriateness of rebate claiming by healthcare providers.

Interestingly, a similar discussion is currently happening around the changes to the quality improvement incentive payments (PIP) to general practices and the proposed requirement to hand over patient data to Primary Health Networks without, at this stage, a clear data framework.

Research & public health

It seems reasonable to use the information in the MyHR for research or public health purposes with the aim to improve health outcomes. The access, release, usage and storage of the data should obviously be safeguarded by proper governance principles.

A good idea mentioned in the paper is a public register showing which organisations or researchers have requested data, for what purposes, what they have found by using the data and any subsequent publications.

I hope the MyHR health data will never be used for e.g.:

  • commercial purposes including by insurance companies
  • performance management or pay-for-performance systems
  • sharing or creating identifiable information for example via integration with other sources
  • low value research

The My Health Record is far from perfect but still has much to offer. Unfortunately it has an image problem and its value proposition will need to be clearly communicated to health professionals. There are also several loose ends that need fixing, such as workflow challenges and the medicolegal issues around uploading and accessing of pathology and diagnostic imaging reports.

Knowing exactly what MyHR data will be used for and by whom will be an important factor for many in deciding whether to participate and at what level. ‘Where did our health data go?’ is a question health professionals and consumers should never have to ask.

You can complete the public survey here. Submissions must be received no later than midnight Friday 17th November, 2017.

A new hope for the My Health Record?

It looks like we’ve entered a new chapter in the Australian digital health story. After several rocky episodes it seems the force is with us and Australia’s digital health record system is on the road to recovery. At the same time there are challenges ahead.

When it comes to the national electronic My Health Record (formerly PCEHR) there is no shortage of scepticism among health professionals. Many have disengaged after unsuccessful encounters with earlier clunky versions of the system.

A lot of work has been done to make the interface easier to use. Accessing the system and uploading a shared health health summary has now become a fairly simple process – as it should be.

Towards opt-out in 2018

The My Health Record will get a massive boost in the middle of 2018 when the system changes to opt-out. Currently Australians have to actively sign up if they want a digital shared health record but next year every Australian will have a record – unless they opt out.

Earlier this month the Council of Australian Governments (COAG) approved Australia’s new digital strategy which carries the title ‘Safe, seamless and secure: evolving health and care to meet the needs of modern Australia‘.

The strategy outlines plans between now and 2022 for secure messaging between providers and with patients, telehealth, interconnectivity and interoperability, electronic prescribing and dispensing, test beds for new digital health technologies, development of health apps & tools and workforce training and upskilling.

Digital health strategic priorities
Digital health strategic priorities 2018-2022. Source: National Digital Health Strategy

The Australian Digital Health Agency (ADHA) has indicated it wants to co-design an implementation framework with the broader healthcare sector.

ADHA CEO Tim Kelsey said on Norman Swan’s RN that it is not just another strategy document: “I want to reassure people that this is going to be about delivery and people should hold me and the agency to account for delivering actual real benefit.”

Kelsey also admitted that at the moment the My Health Record doesn’t have as much clinical value as most doctors would want, but that a record of dispensed PBS medications is currently available. More clinical content will be coming soon, such as radiology and pathology.

Challenges ahead

The strategy document acknowledges some of the issues doctors have with regards to security, safety and use of the data: “They [doctors] need assurance that the digital systems they use support them to meet their obligations to keep their patients’ health information secure and private, and that health data will be used safely and appropriately to improve patient outcomes.”

Doctors have also voiced concerns about the medicolegal risks that come with accessing a patient’s My Health Record, for example when diagnostic tests and images will be available that may not have been reviewed and actioned by the requesting clinician. Clear guidance is required on how the reports are to be handled and who is responsible.

Most clinicians will not have an issue with de-identified data in the My Health Record being used for research or public health purposes, but transparency around secondary use of data will be welcomed and would encourage engagement with the system.

Uploading of shared health summaries is happening in general practice but concerns have been raised about the quality of some of the data. The current incentive payments seem to encourage volume. However, if the uploaded clinical content is not useful, others may not engage or upload data from their end. A classic case of the chicken and the egg.

New hope

It seems the Australian Digital Health Agency has sorted out many of the governance issues and is becoming a more transparent, engaging enterprise. An effective implementation strategy will genuinely address the barriers to engagement with the MyHealth Record and not just sprout benefits. I believe there is hope for Australia’s digital health record.

The rise and fall of the medical expert

Has the election of Donald Trump signalled a new era? Expert advice and scientific evidence seem to be taking a backseat while populism and an anti-elite ethos are gaining momentum. In Australia this may further fuel non-scientific opinions and scepticism towards medical expertise and science in general. Trumpism is, of course, not new. Australia has had its fair share of health policy based on little or no evidence.

Throughout history experts and scientific evidence have often been viewed with suspicion. The election of Donald Trump is a case in point. “Donald Trump’s lack of respect for science is alarming,” said the Scientific American.

Indeed, Trump is doing nobody a favour by, for example, spreading the incorrect and unproven message that vaccines cause autism. Apparently seventy percent of Trump voters believe this is true, despite the existence of extensive scientific safety data demystifying the dangerous misperception.

In Australia there are also signs that medical expertise is undervalued. The funding withdrawal for several primary care research initiatives are illustrative of the common perception about objective sources of information.

A classic case of dismissing medical expertise is the My Health Record (formerly PCEHR). The first big cracks in this government project started to appear in 2013, when the medical leads decided to resign en masse. More recently we have seen similar issues with the Medical Home project, which had full support from the profession until it was radically changed.

Then there are the changes to legislation around medical cannabis, which have created a perception of easy access for patients. Although there are plenty of anecdotal reports from people who have experienced symptomatic relief with cannabis for a range of conditions, doctors are still waiting for the research to provide information on indications, efficacy, safety and quality of cannabis products.

Science vs everything else

Vested interests

“Most people are happier with experts whose conclusions fit their own ideas,” write Clarke & Lawler in The Conversation. “But the Australian suspicion of authority extends to experts, and this public cynicism can be manipulated to shift the tone and direction of debates.”

When trying to inform government policy, experts are up against lobbyists who often represent large corporate commercial interests. An example is the campaign by some of the large corporate after hours home visit services which seem to be mainly concerned about their profitability.

I’ve received reports from these services (who mostly employ non-GPs) delivering repeat prescriptions after hours – which is of course inappropriate use of tax-funded health services and is concerning, especially as Medicare funds are scarce at the moment.

The facts are clear: since the bulk-billing National Home Doctor Service in the ACT arrived, home visits rose from 1588 in 2013-14 to 20,556 in the last financial year. This trend is happening at a national scale and there is no reasonable explanation for the explosion in urgent home visits.

What we need is an ethical and efficient after hours service that works seamlessly with day-time medical services.

Another example where profit comes first is Pathology Australia, representing several big corporates, who transformed their public ‘don’t kill bulk bill’ to a backdoor deal with the government to reduce the rent they pay to family practices for co-locating profitable pathology collection rooms.

Vested interest campaigns have eroded confidence in experts and scientific evidence for a long time – and not just in the health industry (see video below).

Replacing experts

Other trends seem to indicate that experts are regarded as expendable and should be replaced by others – because it is deemed cheaper or more efficient. Examples are physiotherapists prescribing opiates in emergency departments, radiographers reporting on scans and non-medical staff performing gastroscopies.

Who thinks I should fly this plane?

There are situations where tasks can be safely delegated within a supervised team environment. However, the evidence that task substitution leads to better health outcomes or lower costs is minimal. The reality is, as always, more complex – think about the Canberra nurse-led clinic that did not ease pressure on the hospital but instead increased emergency department presentations.

The retail pharmacy sector is lobbying intensively to get their non-scientific business proposals approved by governments across Australia. Their justification for taking over parts of general practice is to ‘relieve pressure on busy GPs’. Again, this is misleading, incorrect and not supported by medical organisations.

Research suggests that it’s all about the business of pharmacy and that the sector shows little interest in working cooperatively with GP teams: only one-fifth of pharmacies participating in a Victorian experiment had contacted the GPs of the patients involved.

This is disappointing as we’re desperately trying to reduce fragmentation and work better together in the interest of our patients. At the same time there are many ways in which pharmacists could add value.

Having more options as health consumer sounds appealing but doesn’t necessarily make us healthier or happier. Sometimes less is more. For example, the Royal Australian College of General Practitioners (RACGP) recommends against a range of popular screening tests because of lack of evidence and the potential of harm for patients, not to mention the added costs to the health system.

The RACGP has also published a list of tests, treatments and procedures doctors and consumers should question. This is not always easy to explain to patients, but at the end of the day it’s the right thing to do for all parties involved.

Expertise: a subjective thing?

Annabel Crabb said in the Sydney Morning Herald: “Expertise is now a subjective thing. You can discover much about people’s deep ideological beliefs or prejudices simply by observing what advice they accept without question, and what they take with a grain of salt. Sometimes there is little logic to the position.”

The best defence is a good offence and when medical experts object to proposals or policy based on opinion instead of science, they are usually accused of defending their territory or ‘turf’ – which distracts from the real message of course.

Expert opinions and scientific evidence are not a fix for all our problems. There are other factors that need to be taken into account. However, as populist movements like trumpism are gaining momentum, the anti-elite ethos may further fuel non-scientific opinions and scepticism towards medical expertise and science in general. This is a real health risk and we should look at why this is happening and what we can do to improve things.

Follow me on Twitter: @EdwinKruysDisclaimer and disclosure notice.

Video: Why aren’t people listening to science?

Brand new eHealth strategy doomed to fail

consultation

I had an interesting experience recently. I participated in a webinar organised by the Department of Health. It was supposed to be a consultation of GPs about the uptake of eHealth.

It went something like this: “We want to gain feedback from GPs about how we can get you to use the eHealth. This is how we’re going to do it; we’ve already organised training and we’re kicking off after the Christmas break. But before we start this session you must know that we cannot consider other options or timeframes.”

I was speechless. Literally – as I was not allowed to speak. I could only send little text messages via the closed online question platform. I was unable to see the feedback from other online participants.

Meaningful use?

For years health providers have repeated the same message over and over: if you want to make eHealth successful please take us with you.

The government is talking about new incentive payments to practices, ‘refreshed’ training programs and opt-out instead of opt-in, but there is little mention about improvements that make health providers want to use the PCEHR (now called ‘My Health Record’).

I find it concerning is that the current plan only encourages uploading of documents. What should be facilitated is safe and more efficient care for our patients. At the moment it seems to be all about the number of uploads to the system. I cannot help but wonder what higher level performance indicators are at work here.

Any incentive has to be effective at provider level to create a behavioural change. In other words, we must encourage individual practitioners to use eHealth, not just organisations and practices.

It is no surprise that the government failed again to enlist support from the profession. In its submission to the Department of Health, the RACGP wrote:

“(…) the RACGP cannot support the proposed mandatory requirements for the uploading of a specified quota of clinical documents to My Health Record. Meaningful use is not just uploading information to My Health Record, and nor is uploading information an acceptable starting point for meaningful use. Meaningful use relates to safety, quality, communication and healthcare outcomes – not merely numbers.

Unresolved issues

E-health experts have warned that the system is still unsafe. For example, some software programs merge medication dose and instructions. Others have warned that the uploaded clinical information does not always arrive in the My Health Record database.

Then there are the unanswered medicolegal issues. For example, we still need clarification about some of the basics, including the purpose of the system. This is essential if we want to encourage meaningful use of eHealth.

As I wrote in MJA Insight, I would be happy if the data in My Health Record was 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  system operator is currently authorised to collect information in individual health records for law enforcement, health provider indemnity insurance cover, research and public health purposes, and as required or authorised by law. This process should be more transparent with a better explanation of what it means for both patients and providers.

Removing the need for provider participation agreements seems like a good idea as these documents are very one-sided. But it is not clear to me what this will mean for the liability of organisations, practices and individual practitioners.

A failing strategy

I find it challenging to have a meaningful discussion about incentivising uptake of eHealth when there are so many unknowns. It’s like trying to sell a house that’s still being built and everyone knows there are construction issues. Pushing people to live in the house does not make it a safer or a better building.

The RACGP warns against hastily implementing incentives and advises the department to wait for the outcomes of the Primary Health Care Advisory Group review, the MBS review, and the opt-out trials which are due to start.

Once the identified problems with My Health Record have been addressed and resolved, the RACGP believes that uploading of patient information to My Health Record would be best supported by a practitioner incentive payment (SIP) or an MBS rebate.

It will be interesting to see the response from the department to the criticism. I’m afraid that history will repeat itself: they’ll go full steam ahead, only to discover in one or two years time that the strategy didn’t work. What do you think?

Follow me on Twitter: @EdwinKruysDisclaimer and disclosure notice.

Rebooting the PCEHR: Opt-out and a new name are not enough

Rebooting the PCEHR

Health Minister Sussan Ley has announced that “the Abbott Government will deliver a rebooted personalised myHealth Record system for patients and doctors that will trial an opt-out, rather than opt-in, option as part of a $485 million budget rescue package (…).”

I like the word ‘rebooted’, as it implies a fresh start and that is certainly what the Australian e-health records system needs. ‘MyHealth record’ sounds better than PCEHR too. But many questions remain, including the most important one: will clinicians use the renamed system once it’s opt-out instead of opt-in?

The legal stuff

Clinicians have concerns that have not yet been addressed.

For example, at the moment the information in the PCEHR may be used by the Government for data mining, law enforcement purposes and ‘other purposes authorised by law’, for up to 130 years, even after a patient or provider has opted out.

When healthcare organisations or practices cancel the PCEHR participation agreement, seven of the fourteen clauses survive termination, including liability of providers.

Other concerns are that the Minister of Health 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 doctors or patients.

Improvements

If the Health Minister is serious about engaging clinicians, here are some of the issues that must be resolved:

  • The purpose of the PCEHR (myHealth Record) must be clear
  • The legal framework should be reviewed, and any changes must be agreed upon by consumers and clinicians
  • If consumers want to opt out at any stage, they should have the option to have their data removed from the system
  • If providers opt out at any stage, their liability should end as well.

And that’s just the beginning. Here’s to hoping that the $485 million will be spent wisely.