Dr Hambleton, Speech at E-health Conference
E-HEALTH CONFERENCE
MELBOURNE
TUESDAY 30 NOVEMBER 2010
Clinicians driving change: Supporting patient care
Good morning …
It is a great pleasure to represent my medical colleagues at this very important and timely Conference.
The promise of e-health has been on the horizon for many years.
While the full potential of that promise is yet to be delivered, it feels like we are just a little bit closer to making e-health a reality.
The very fact that we are here today discussing the practical steps we need to develop the personally controlled electronic health record shows how close we really are.
I would like to acknowledge the efforts of Dr Mukesh Haikerwal in pushing the e-health agenda.
In his charming way, Mukesh has been tireless and determined in bringing together all of the relevant players over the last few years.
His involvement has had a significant impact on the e-health agenda and its progress.
Doctors are excited about the prospect of sharing patient information electronically with each other and with other health care providers to improve patient safety and the quality of care we provide.
Many GPs now hold accurate and comprehensive information about their patients that has been progressively built up over more than a decade.
But at present the only way we can share it is by printing it.
Even then, it may or may not be with the patient when he or she arrives at the next doctor - and even then, at best it is subject to transcription errors.
Today I am going to talk about what my medical colleagues think must be done to get the first stages of the electronic health record up and running, and ensure that it is done in a way that will best assist doctors in caring for their patients.
We need to strike a balance between clinical safety and consumer expectations in the design and use of the electronic health record.
To succeed, the e-health record must be easy to use, support what doctors already do, and not disturb time-honoured clinical methods.
We doctors talk to our patients, take a history, perform a medical examination, assess supporting information, order investigations if needed, then make a diagnosis for the patient and decide on a treatment plan.
That is the hard part about what we do.
It takes years to learn and even longer to get good at it.
If doctors can rapidly access relevant data via the electronic health record, it will support this process. But irrelevant data will get in the way.
During my consultations with my patients, I find that most of them have a reasonable understanding of their health circumstances - and they are usually very honest with me about what’s going on with them.
But commonly - despite our best intentions - doctors don’t always have all the clinical information that we need to provide the safest, most clinically appropriate care.
This is where information obtained by other health practitioners in relation to my patient during other episodes of health care could ensure that I don’t miss the critical issues that could impact on my treatment decisions.
Here is a ‘live’ example from one of my patients last week.
John told me that he had a number of times called an ambulance to his home because he had severe abdominal pain - RUQ 10/10.
On the first two occasions, his pain had gone by the time the ambulance arrived, and he was not transported.
He had a health summary from me with him detailing his cardiac history, his diabetes, his AAA, his past history of cholecystecomy.
He also had retained gallstones in the bile duct after the above surgery and needed an ERCP and sphincterotomy to solve the problem.
The next three times he was taken to Royal Brisbane Hospital Emergency Department where, once again, they were in possession of his paper history.
The pain invariably went away within a few hours of arriving at hospital.
His diabetes and vascular disease were proving to be a distraction.
The CT Abdomen showed nothing more than his AAA, and the US of the liver was normal.
This information trickled in to me some days after his hospital visits.
The first discharge letter contained the blood results, which showed a rise in his liver function tests that were consistent with obstruction of the bile duct.
The second and third letters from A&E did not include the above but, when I asked for them to be faxed, it was clear that on each occasion that there was acute pain the liver enzymes rose.
For the non-doctors in the room, it was clear evidence of bile duct obstruction.
This was enough evidence to convince another gastroenterologist that he needed another ERCP and, sure enough, there were two more gallstones.
There were five blood tests on three different pathology computers.
A CT scan of the abdomen and an ultrasound of the abdomen were also needed to make the diagnosis.
The patient had no way of recalling the sort of detail that I needed to make the diagnosis, or even of being sure what tests had been done.
For example, the negative cardiac enzyme tests were just as important.
I was the only one who had all of the information available.
The diagnosis would have been made much more quickly if we all had all the detail in ‘real time’.
It was time consuming for me and inconvenient for the patient - maybe even life threatening.
This is just one example where the sharing of a patient’s information between health care providers could make a real difference to the quality, safety, and cost of the health care that I could deliver.
At the most basic level, doctors should be able to access from electronic health records important information such as:
- pathology results;
- diagnostic imaging results;
- discharge summaries; and
- current medications and adverse events.
This is basic information, yet critical to patient care.
When I talk to doctors, and when I think about my own practice, I am struck again and again by what a difference it would make - even in the case I have mentioned - if we had an electronic health record.
The record could facilitate the sharing of this most basic yet critical patient information between treating doctors and other health providers.
It would deliver a very loud bang for the buck.
Clearly, I am talking about a very small but fundamental part of the much grander plan for a personally controlled electronic health record.
Let’s start with the basics and get it up and running.
Let’s start with electronically shared patient summary information that cannot be altered by the patient, and which is accessible to all doctors.
I am not suggesting that the personally controlled aspects of the electronic health record are not important.
The point I am making is that, if we are to get take-up of the electronic health record by doctors, the doctors need to be able to trust the reliability and accuracy of the information the record contains so that they can act on it.
Most patients would recognise the need for treating doctors to be confident about the information that they have before them.
I can’t think of any of my patients who would object to me being able to have access to information about where they have recently been hospitalised, or when they needed to see another doctor.
In fact, many are surprised when I don’t have that kind of information at my fingertips already.
How many patients have turned up at their GP before the specialist’s letter or before the discharge summary has arrived?
In fact, the Menzies-Nous Australian Health Survey published last week found that: “Most people believed their doctor and all the people treating them should have direct access to their health record.”
The AMA has thought very hard about how doctors will integrate the personally controlled electronic health record into the way they practise medicine.
At the AMA, we are talking about the sharing of summary patient information electronically between treating doctors.
We don’t talk about sharing all of our patient information - just the key information that other doctors need to provide safe, quality patient care.
And that is what we do already – when I refer my patient to a specialist, I don’t send their entire file. I just send the key information that I think the specialist needs.
The AMA supports the premise that the sharing of accurate summary patient information between treating doctors is critical to the success of e-health.
This is information that sits beside a personally controlled record.
It is essential that this record contains reliable and relevant medical information about individuals.
It is important that it aligns with clinical workflows.
It must integrate with existing medical practice software. Otherwise we are faced once again with the transcription errors I spoke of earlier.
It is also very important that the personally controlled record has appropriate security measures to protect patient privacy.
We believe that if the system is to be truly national and consistent, it must be governed by a single national entity.
We believe governments must fund the system and support its take-up with appropriate incentives, education and training.
Progress in these areas would provide benefits to patients through efficient and accurate communication between GPs, other specialists, hospitals, and other health providers.
Over time, once the initial capability to share the summary patient information across healthcare settings is rolled out, there is significantly more information that could go on the summary.
It could include information such as prostheses, implants, ECGs, referrals, advance care directives, health care plans, and team care arrangements to name but a few.
Clearly, as the information on the record starts to get more complex, patients will inevitably and very reasonably want more rules around who can access all that extra information.
Privacy of and access to those parts of the record will be very important.
This is also the point at which I think the personally controlled aspect of the record is very relevant.
A personally controlled record that patients would operate alongside the summary information shared by doctors could prove to be a great motivator for many patients to become more involved in their own health care.
In my experience, when my patients take responsibility for their health and work with me, we usually get the best outcomes.
Most doctors don’t like ‘Dr Google and there are good reasons for that.
But it is undeniable that the advent of the Internet has produced patients who are more informed and perhaps a bit more prepared when they come to see me.
I actually prefer it when patients with ongoing health concerns take an active interest in informing themselves about their conditions and in actively engaging with me about the steps they can take to manage their condition better.
I think there are generational issues here with some patients older than me who are reluctant to use the web all that much.
I find that patients about my age are quite willing to go after information and to inform themselves.
Now there are young people who can’t stop pulling down information.
The challenge with them is to direct their gaze to useful locations and to stop them getting sidetracked.
I think that the personally controlled record will encourage and empower patients to take more responsibility for aspects of their health care.
The opportunity to create their own record about how they are managing their health will help patients to keep track of their conditions and medical history.
This should dovetail into home monitoring for things like diabetes and blood pressure.
This, in turn, will lead to patients being able to truly engage with their health care provider to provide better management of their health.
However, we need to strike the right balance here between the health care provider’s need to provide safe patient care and consumer expectations about the role of the information they control in the record when health care is delivered to them.
It is not realistic to expect that doctors will turn to information put in the personally controlled record by the patient as the definitive source of information on which to base clinical decisions.
Doctors will always take a history, do an examination, and make an assessment and diagnosis putting different weights on different types of information.
We cannot just rely on what is in the personally controlled record.
Often, diagnoses or previous conclusions need to be challenged. Just like my patient I mentioned earlier.
I have never ever seen a patient with retained gallstones after ERCP and sphincterotomy, but that is what the evidence said.
To get it right we need all the evidence though.
Even now, doctors have concerns that patients might be reluctant to share some information with them.
Patients may think that once information is on the record – somewhere, sometime – that information might be accessed inappropriately.
Patients are already concerned about how treatment decisions might affect them in other aspects of their lives.
I recently saw a patient who wasn’t sure whether he wanted to be prescribed anti-depressant medication for fear that somehow down the line it could ‘get out’ and affect his employment as a teacher.
These kinds of concerns will become even more important to patients when diagnoses, treatment decisions, and medications are shared electronically.
So, if we look at a world where there is a personally controlled electronic health record - where information may be in ‘The Cloud’ and therefore truly accessible - it is entirely understandable that those concerns for patients will intensify.
Unfortunately, if patients have the ability to remove or ‘make private’ facts that are part of their summary information, they might do so - for all kinds of reasons.
And if they choose to do so, then the record may becomes useless to a doctor because the doctor could never rely on it.
For example, when prescribing medication, if the anti-depressant was hidden, the real possibility of a serious adverse medication interaction could exist .
If Tramadol is prescribed, then it could precipitate a serotonin syndrome if the patient was taking an SSRI (Selective serotonin reuptake inhibitor).
Once the personally controlled record is up and running, if there is just one serious adverse medication event like this, then e-health will not have delivered on its promise.
If the summary information was not available to the treating doctor, then the whole venture will have failed.
Failed the patient. Failed the doctor. Failed the health system.
The summary patient information needs to be accessible to all doctors.
It should only be able to be changed by doctors who understand the implication of what is recorded – and this can certainly be done in consultation with the patient.
Conversely, the addition of some information into the electronic record by a patient could also pose a clinical risk - if the doctor were to rely upon it.
For instance, many patients believe they have allergies to drugs, but they are simply side effects.
While they are important, they do not have the same clinical impact. For example, Augmentin - nausea, muscle aches with statins.
If we think about these examples, it is clearly not true that the personally controlled electronic health record will entirely remove the need for patients to tell their history to every new health professional they see. But it will streamline it.
Doctors and other health providers who are committed to safe, quality patient care will need to have that conversation and practise their craft, no matter what is in the record.
As I said earlier, it is essential that doctors can rely on the summary information including:
- pathology results;
- diagnostic imaging results;
- discharge summaries; and
- current medications and adverse events.
As we develop the personally controlled electronic health record, we need to consider that e-health in primary care will drive most of the health system benefits.
Those benefits will be most apparent in the acute care setting. Most of the costs, however, will be incurred in the primary care setting.
With this in mind, the Government must invest in e- health at the primary care level or the momentum will stall
The right approach, the right information, and the right investment in e-health can deliver real benefits to patient care and to the efficiency of the health care system.
The AMA and the medical profession stand ready to get behind e-health and make it the reality that the Australian health system needs.
30 November 2010
CONTACT: John Flannery 02 6270 5477 / 0419 494 761
Geraldine Kurukchi 02 6270 5467 / 0427 209 753
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