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04 May 2013

By Dr Mukesh Haikerwal, former AMA President and National Clinical Lead, National E-Heath Transition Authority

I was asked to write an article regarding the Personally Controlled Electronic Health Record (PCEHR), also known as the Electronic Health Record System.

I state up front that these views are my own personal views, based on my own journey.

This is the progress towards the brave new world of shared personal patient health information, the electronic exchange of patient information between practitioners using secure email - Secure Messaging Delivery (SMD) - built on nearly 20 years of increasing expertise in the use and deployment of clinical information systems (CIS) in the general practice sector, in particular.

The PCEHR evolved from the 2009 recommendations of the National Health and Hospitals Reform Commission, which in turn was informed by the Booz & Co. paper, E-Health: Enabler for Australia's Health Reform published in 2008, and Deloitte’s National E-Health Strategy report of the same year.

The PCEHR was funded in the 2010 Federal Budget for $446.7 million over two years. It built upon previous national infrastructure for e-health programs, the foundations of which were provided by the National E-Heath Transition Authority, set up by the Council of Australian Governments in 2005.

From these foundations arose the Healthcare Identifiers (HI) service, to identify all participants in the health care system – consumers and health practitioners alike. Unfortunately, that take-up of the system has been slow, even though it has been developed to obviate, or at least minimise, identification errors for patient information. To me, the HI service is the “flagship” product, underpinning any advance in health care technology.

There has been other continuing work, including the production of a National Products Catalogue (NPC) for health products, the Australian Medications Terminology (AMT) compendium, a consistent clinical terminologies system – Systematized Nomenclature Of Medicine Clinical Terms (SNOMED CT, a National Authentication System for Health (NASH) to provide access for participants to a national system and, most usefully, right here, right now, a system for confidential electronic clinical information transfer known as Secure Messaging Delivery (SMD). These are all components of a national electronic health system.

The current situation, in which health information is sent or received by letter or fax is greatly improved by the use of SMD. The receipt of pathology and radiology results in practice today uses a secure messaging delivery system that I term “Classic”. It uses a mechanism of authentication provided by the Department of Human Services/Medicare known as PKI (Public Key Infrastructure).

In time, this will be superseded by an enhanced SMD version that uses the HI service to identify patients and the providers communicating about their care, authenticated with a NASH that can be sent to any compliant software product, as they will “inter-operate”. Currently, a “Classic” SMD product can only share messages with providers with that brand (rather like a smartphone that cannot receive calls from a different type or brand of phone).

Proof of concept and deployment work is almost complete on arrangements that will allow all five main products able to exchange messages.

The PCEHR is a key enabling technology for health care, as it allows multiple practitioners to share clinical information about a patient, ensuring better coordination of care, less duplication and better health outcomes, as more pertinent information from ‘trusted’ sources occurs, guaranteeing “provenance’ of that information, upon which care pathways can then be based.

The “go-live” for the PCEHR system was 1 July last year, and since then there has been a gentle rise in the number of participants in the system, with more than 125,000 consumers registered.

The uptake of practitioners using the system was given a boost through the requirement that general medical practices participating in the electronic health Practice Incentives Payment scheme (ePIP) had to meet five eligibility criteria, including the ability to connect to the PCEHR system.

That process was fraught, as GP practices did not receive the multiple paper forms involved in applying for HI service organisation identifiers and NASH tokens until December, and were only given until 1 February to complete them. Of course, all this work had to be completed during what was the peak holiday season of the year.

The need is, however, that many more than the current 27 per cent of non-GP specialists, allied health practitioners and nurses, among others, need to get “e-enabled” for the system to have any chance of reaching the critical mass needed to achieve the goals of better, joined up care, enhanced by access to good, pertinent health information.

As a proponent of e-health to support the way I provide care, to streamline care by allowing access to key health information, and to potentially to make life easier and break down barriers, I connected my practice to the PCEHR system in December 2012.

As one of the 98 per cent of GPs using technology for clinical purposes, I have already experienced the benefits of the computer in my consulting room, which have improved, evolved and enhanced with time. These include dealing with the complexities of prescribing, receiving pathology reports, diagnostic imaging results and some specialist letters by Classic SMD. 

The biggest problem faced regarding both “in-hospital” and “out of hospital” IT systems is a lack of inter-operability, where multiple different systems are not able to talk to each other, they require multiple log-ins, and there is no common place to view and collate information.

The PCEHR is far from perfect. It has to develop more capability to allow it to enhance current care provided by practitioners with their own home systems. What can be said, and is not stated or recognised, is that despite the significant shortcomings, the very fact that the system is now able to be written to and read, from multiple GP, pharmacy, aged care and some hospital Clinical Information Systems (CIS), is a massive shift in inter-operability. It means there is the ability to gather and share information regardless of the CIS used, and disproves the idea that joined-up patient care is an unachievable goal.

So, there is now a vehicle which has been rolled onto the start line, and given a very gentle push.

There are a few drivers and a few passengers in the vehicle today, which is not perfect.

It does exist and has some function. It is no longer vapourware and a figment of someone’s imagination, spoken of but never seen.

It can be and must be “tweaked” – especially in these early days, as use increases and faults are visible. To that end, a Clinical Useability Program is being rolled out by NEHTA to address currently known difficulties with PCEHR, and to ensure product builds are made cognisant of clinical utility and useability, and that there is a mechanism to improve the methodology used for development of new products. This is part of how technology develops: from the crystal radio to digital, from the valve television to LED, from the Bell telephone to the coolest Smartphone.

In the same way as the customer base informed and drove these developments, it is up to the professions to now be part of the evolution of this technology.

We need to ensure that the health professions help design and build the technology they need and have called for, rather than having technology drive the way in which the professions do their work.


Published: 04 May 2013