In May 2010, the Federal Government announced it plans to spend $467 million over two years to introduce "personally controlled" individual electronic health records as part of a national health reform agenda.

Australia is nearly 18 months away from the scheduled delivery of a personally controlled electronic health record (PCEHR) for every citizen who wants one.

Like many in the healthcare industry, Doug Horsley is keen to learn how the PCEHR will work in practice.

Will it be a push to encourage Australians to upload their data to hosted offerings such as those available from Google or Microsoft? Will it be a centrally controlled database maintained at the state or federal level?

And if the individual truly has “personal” control over their record, how will a physician or clinician view it as a legitimate basis to recommend any treatment?

Horsley is Chief Information Officer at Australia’s largest Catholic not for profit private healthcare group, St John of God Health Care (SJGHC).

SJGHC operates four hospitals in Western Australia, seven hospitals in Victoria and two hospitals in New South Wales, as well as home nursing and pathology services in WA and Victoria, and Social Outreach and Advocacy services reaching out to people experiencing disadvantage in Australia, New Zealand and Asia-Pacific.

“As the primary health care provider, the GP arguably has more information than anyone else. After a patient is treated in a hospital, the specialist or the hospital then sends a discharge summary back to the patient’s GP – as a result, the GP becomes a vital link. The role of the GP could grow quite substantially if they use the PCEHR to be proactive in managing health,” said Horsley.

One of the great advantages in Australia is that over 95% of GPs have computers, and the National Electronic Health Transition Authority (NEHTA) is financially encouraging GPs into electronically transmitting information such as referrals to specialists and prescriptions or a request for a diagnostic test.

There is a wide range of electronic data connected with a patient, whether it is the electronic patient record, their medical images or associated administration files. It is not clear what will be the scope of the individual electronic health records to be stored federally in Australia.

UK opts for GP record

A review of a similar plan in the UK has determined "the core record should only contain a patient’s demographic details, medications, allergies and adverse reactions, and that these should continue to be copied from the GP’s medical record."

“One of the biggest challenges health has is the number of stakeholders that have an impact on outcomes - it’s probably the most complex industry vertical I have worked in or come across,” notes Horsley.

“All of the information is very siloed. For instance, if you have a procedure, then the specialist retains the information associated with it and may inadvertently hold on to that information, without necessarily sharing it with other health care team members.

“We have an IT strategy to progress toward electronic medical records and that’s been approved by our executive. However, I don’t believe there’s a solution in Australia that you can install like you could install a package for a manufacturer or a banking organisation – you can’t just go to the market and buy an Oracle or an SAP, it doesn't work that way.

“There are many good clinical packages out there but not one large package that fulfils all our requirements.”

A “Big Bang” approach - replacing hundreds of siloed legacy applications in a hospital with a single institution-wide application with centralised data - is not something that Horsley is keen to adopt.

“I don’t think that would work because of the amount of change management required from all our clinicians, doctors, specialists, nurses and the rest of the health care team.

“To me, the big challenge is managing change, no one is going to volunteer for change, because it brings risk and this will result in a lot of time being invested to make it work.

“In other industry sectors you can tell people their job is going to change, they're not going to fill in a form any longer and they have to visit a computer screen. That may not necessarily happen in health, as in the private health world, each surgeon, specialist, anaesthetist are their own boss. They determine if and when they will change and that is going to create a big dynamic.

“Doctors are time-poor as are most clinicians and nurses, so they need to walk up to a PC and be signed on and ready for action. We’d need to use 2-stage authentication, but it needs to be easy for them to enter or retrieve information.

“Our approach is more a best of breed approach so we can manage the change in any particular area and go step by step. Will it take longer? Yes. Has it got a bigger chance of success? I would say absolutely, because we are taking it one step at a time. It may be more expensive to tackle it one piece at a time, and you do have the challenges of integrating different data repositories and the issue of interoperability.

“The health sector, because of its history, has a lot of homegrown solutions that people are familiar with and moving to another standard is quite a challenge. Change management is going to be difficult but not impossible.”

St John of God Health Care is developing a pre-admission portal to provide patients with a means of submitting information to the hospital before they are admitted.

Horsley believes other patient portals can be developed, although it is unclear how these will relate to the PCEHR.

“We could provide pathology results through a portal, but a problem with this approach is you then need another portal for the radiology results and another for the oncology results. If you present that as a way forward for a doctor who is used to working with paper, they would see that as a major barrier to change because he may have to sign on to half a dozen different systems to get the information he needs. We need to make life easy for doctors to make this change happen, so portal technologies and the use of composite type systems is important to pull information together.

“Part of the challenge is who owns the data. We are a not for profit private hospital, so is it the specialist who owns the data or is it the patient? I am not sure we understand that right now. NEHTA are developing the discharge summary which is information relayed back to GP, such as what medication the patient is on, how the surgery went, but the patient doesn’t really see any of this. The patient might be given a letter from a GP to see a specialist, who in turn might ask the patient to get an X-ray, but it’s not the patient who manages the information, it's the medical profession.”

“Providing effective health care in progressive nations is proving more challenging and in today’s economy, nations need to address this accordingly or risk facing bankruptcy. Health, like other industries, are always seeking to invest wisely.

Incremental value

Mal Thatcher, Chief Information Officer at Brisbane’s Mater Health Services, believes that rather than the technology platform, the key issue is whether the architecture of the PCEHR will allow for incremental value from day one.

“It has to allow value to be delivered from day one with what the health sector has available to share, and then grow in value as providers and consumers increase their participation.”

A network of seven hospitals in southeast Queensland, Mater Health Services and its 7500 staff and volunteers provide care to some 500 000 people each year.

Thatcher is curious to know what incentives will be introduced to encourage providers to participate in a meaningful way, and what Australian controls will be implemented to ensure the data available within the PCEHR is current, accurate and timely.

“How will the implementation of the PCEHR better engage consumers/patients in their own care?” he asks.

According to a recent US survey, doctors’ use of e-mail with patients is the exception rather than the rule.

The Center for Studying Health System Change (HSC) found that overall, only 6.7 percent of all office-based physicians nationally routinely e-mailed patients about clinical issues in 2008.
About one-third of office-based physicians in 2008 reported that information technology for communicating with patients about clinical issues via e-mail was available in their practice. Of the physicians with access to e-mail, about one in five (19.5%) routinely e-mailed patients.
“Despite strong patient interest, physicians are not rushing to e-mail patients,” said HSC Health Research Analyst Ellyn R. Boukus.

While the survey did not ascertain why physicians do not e-mail patients, physician concerns about lack of reimbursement, the potential for increased workload, maintaining data privacy and security, avoiding increased medical liability, and the uncertain impact on care quality are commonly cited as reasons why physicians may be reluctant to use e-mail.

GPs at the forefront

Dr Mukesh Haikerwal, National Clinical Lead for NEHTA, said general practice is well positioned to support national e-health initiatives.

“With over 98 percent of GPs using computerised healthcare systems for clinical purposes and, 117.4 million GP consultations provided each year, GPs will be at the forefront of driving e-health in Australia. We know that GPs can provide a GP Health Summary for the vast majority of Australians, and this information will form the basis of data for electronic communication between healthcare providers and will be a key component for electronic health records,” said Dr Haikerwal.

The Royal Australian College of General Practitioners (RACGP) estimates that 53.5% of practices have migrated to a completely paperless practice, while 34% use a hybrid Electronic Health Record (EHR)/paper system.

There are many different practice management systems competing for the attention of local GPs and medical practices, but around four provide 90% of the installations and dominate the market.
Josephine Raw, General Manager, Practice Innovation and Policy at the RACGP, highlights a number of challenges to a national electronic health record.

These arise from the lack of compliance testing of GP clinical systems, poor integration and few standards for data collection, recording and measurement.

With the PCEHR only 18 months away from promised delivery, there are still many questions unanswered.

Will the individual health records be manually entered or transferred from existing electronic patient records held by GPs, medical centres, specialists and hospitals?

Doctors and hospitals use a wide range of different information systems for storing patient records. How will the PCEHR address the challenges of reconciling different database schema?

How will the process of uploading individual records take place, and at what stage will the individual be able to review the data that is uploaded? Who will automatically have access?

Will individuals receive notification before the data is uploaded? At which stage can they opt out, or must they opt in? Can they opt in later?

Who will be responsible for digitisation and the costs involved? Will it be mandatory to provide electronic records when the government requests? Will there be funding incentives from the federal or state government for medical facilities to digitise their records, as under the Obama administration in the US?

Will the funding cover the total cost of upgrading information technology to meet the requirement? In the US it has been estimated the cost of transition to electronic systems costs $US40,000 to $US45,000 for each doctor, nurse practitioner or physician assistant in practice, plus $US15,000 a year for maintaining the system?

How will a patient's individual record be accessed in an emergency? Must the patient give consent?

What are the regulations that apply to safeguard how the electronic information should be stored, transferred, and used to ensure the privacy of individually identifiable data related to a patient’s healthcare?