The Danish health IT solution: small-scale brilliance

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.”

E-mail consultations

Dr Daniel Byrne
Dr Daniel Byrne about the Danish e-health system: “The live medication list was too good to be true.” Image: Linkedin.

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.

Patient access

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.

Miles ahead

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.”

Why doctors still can’t email your health record

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.

A no-brainer

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 benefits 

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.

GP2GP benefits
Image: Clinicians will have immediate access to their patients’ Electronic Health Records. This will ensure genuine continuity of care. It will also mean improved safety. There will be fewer transcribing errors because the need to key in information from paper records will be massively reduced. Clinicians and staff will benefit from the time savings. Source: HSCIC.

Potential issues

“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.

The benefits of consumer online access to health records

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:

Pros

  • Improved participation and responsibility
  • Increased consumer’s knowledge of their health care plan
  • Better self-management
  • 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

Cons

  • 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
  • Increased workload

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:

Culture change

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

Improving transparency 

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?

Blocking social media at work is not the answer

Restricting social media usage at work is sometimes done out of fear. “We don’t want our staff to be distracted.” And: “They shouldn’t waste their time on social media.” Other understandable reasons may include perceived cyber risks or the cost of excess data usage.

An organisation that blocks social media sites may send out one or more of the following messages:

  1. We don’t trust our staff
  2. We don’t really understand what social media is all about
  3. Even though consumers are using social media for health purposes, we’re not really interested

In most cases decision makers are probably unfamiliar with social media and may see it as a threat.

Why staff should have access

Here are five reasons why health care staff should have access to sites like LinkedIn, Twitter, YouTube, Blogs etc:

  1. Social networks are powerful learning tools for staff
  2. Social media are increasingly used as health promotion tools (such as embedded YouTube videos)
  3. Shared knowledge accessible via social media will assist staff in finding answers and making decisions
  4. Interactions with peers and thought leaders can increase work satisfaction (and will contribute to staff retention)
  5. Participating in social media and other new technologies will raise the (inter)national profile of an organisation

When it comes to cyber security, I believe there are alternatives that are more effective than blocking social media access including upgrading and updating operating systems, updating antivirus software, improving backup procedures, clever password management and online safety training for staff.

A simple social media staff policy also goes a long way.

3 reasons to avoid Skype for telehealth

Is Skype safe for a clinical consultation? In June last year, the Royal Australian College of General Practitioners said in their publication RACGP advice on Skype: “There is currently no clear evidence to suggest that Skype is unsuitable for clinical use”.

This year however, new information came to light suggesting that Skype, owned by Microsoft, may not be as safe as we thought. Here are three reasons why you should be careful to use Skype as a professional video conferencing tool:

  • Skype is not encrypted from end-to-end. Microsoft can intercept information transmitted via Skype.
  • Skype tells the world where users are by exposing IP addresses. This allows criminals to target cyber attacks.
  • The US National Security Agency (NSA) can listen in and watch Skype chats with their data collection program Prism.

Interestingly, Skype’s privacy policy states:

Skype is committed to respecting your privacy and the confidentiality of your personal data, traffic data and communications content.

But this, it seems, needs to be taken with a pinch of salt. The Guardian reported that Microsoft “worked with the FBI this year to allow the NSA easier access via Prism to its cloud storage service SkyDrive, which now has more than 250 million users worldwide.”

The big question of course is: If US government agencies are listening in on our video chats, what other governments and organisations are collecting our online data?