Concept of Operations: Relating to the introduction of a Personally Controlled Electronic Health Record System
B.3 Experiences with PCEHR Systems in Australia
Prior to 2010, a number of shared electronic health record systems have been developed. Consideration of shared electronic health records in Australia started with the National Electronic Health Records Taskforce (NEHRT) in 2000, which was commissioned by the Australian Government to consider the potential for a network of electronic health records. The recommendations of the NEHRT led to the creation of the HealthConnect program and work on a range of trials on PCEHR progressed initially through HealthConnect and MediConnect programs in Tasmania, Queensland, New South Wales, South Australia, Western Australia and the Northern Territory. In 2005 it was recognised that for eHealth to progress further in Australia, key infrastructure and standards were required, and NEHTA was established.
Since the HealthConnect days, a number of regional Shared Electronic Health Record (SEHR) Systems have continued, including:
- GP Partners in Brisbane Health eXchange — GP Partners, one of the divisions of general practice in Australia offers a variety of services to GPs within its remit. One of these services is a health information exchange, offering connectivity between 166 of the 800 GPs in the area, six local hospitals, allied care providers and residential care facilities. The GP Partners Health eXchange offers automatic notification to GPs when a health record is checked or updated with results from an investigation by another care team member, and is integrated into GPs’ Clinical Systems to minimise the disruption to GP workflows [GPP2008].
- eHealth NT Shared Electronic Health Record — The Northern Territory Department of Health and Families has been progressively implementing a SEHR across the NT. In rural and remote communities implementation activities are being coordinated with the accelerated rollout of the Primary Care Information System (PCIS). In urban communities, activities are being focused on aboriginal medical services and clusters of urban private general practices. Feasibility is being assessed for expanding the SEHR into regions of Western Australia and South Australia. A major new initiative is the implementation of a current health profile, updated automatically when the individual attends their principal primary care GP or health centre. Future plans include provision to store and update Healthcare Management Plans and the capacity for an individual to access their SEHR via the Internet [NTH2008].
- Goldfields Esperance GP Network — The Goldfields Esperance GP Network has implemented a Regional SEHR. The SEHR is part of the GoldHealth Network and is used to support Kalgoorlie-Boulder patients and currently connects local general practices, specialist practices, aboriginal community controlled health services, a major regional hospital, a district hospital, and an aged care facility.
- Healthelink in NSW — Healthelink is a SEHR operated by NSW Health in Maitland (Hunter Valley) and Western Sydney. As of November 2009 it had over 90,000 individuals enrolled and allows health information to be shared between GPs, Community Providers and Hospital-Based Providers. NSW Health is currently reviewing the future of this program in light of the PCEHR System.
- Smart Health — Smart Health Solutions provide a SEHR alongside other chronic disease information management and secure online solutions. Smart Health has existing SEHR implementations at Royal Adelaide Hospital, The Alfred, New England (Armidale, Tamworth, Inverell and Moree Hospitals), St Vincent’s and Mater Health (Sydney). Additional implementation sites are also proposed or under development.
From the earlier HealthConnect trials, a range of independent evaluation reports have been produced. The findings documented in these reports are brought together in the overarching ‘Lessons Learned Report’ [DOHA2005a]. In addition to the needs for national infrastructure and standards, the major lessons learned include:
- A SEHR System is technically feasible, but the underlying infrastructure and connectivity (including the availability of CISs particularly in hospital, access at the point of care and network and communications infrastructure) limited the success of most implementations.
- While community pharmacists and GPs are currently better positioned technically to move towards SEHR than hospitals, specialists and other private providers, there will be change management and business process challenges for all.
- While the full process of registering individuals for a SEHR is too time-consuming for most healthcare providers, the trust between healthcare providers and their regular patients means that individuals will be strongly influenced in their decision to participate by the attitude of their healthcare providers towards eHealth.
- Succinct and audience-specific information should be provided before registration, with further information available to those seeking it.
- A Health Summary with key clinical information should be established as early as possible and appropriately funded/resourced.
- Consent models need to be simple and practically workable at the point of care.
- Individuals preferred voluntary participation based on an ‘opt-in’ model for participation.
- Individuals prefer to provide some form of ‘standing’ consent to nominated healthcare providers to have ongoing access to their record (rather than consent at every episode of care).
- The most popular consent model for when a healthcare provider sends an individual’s health information to a SEHR was for the healthcare provider to assume consent unless the individual says ‘no’.
- Some individuals may never be sufficiently comfortable to participate, even with the most stringent controls.
- Most healthcare providers were concerned about the completeness of the SEHR if individuals withhold information.
- Drivers for Adoption and Change Management:
- A critical mass of both individuals and healthcare providers is needed to deliver benefits efficiently. It is important to complete the care chain wherever possible — gaps in the electronic health record reduce the healthcare provider’s perceptions of the utility of the record.
- The key to provider healthcare participation will be demonstrable benefits and seamless interaction (such as the creation of Event Summaries) through integration with their normal business processes. Use of their clinical system is preferred over a separate web based Internet interface.
- Where it meets an existing business need, healthcare provider engagement and change management is significantly easier.
- Successfully engaging healthcare providers and the provision of effective change management support is a critical success factor. Clinical champions and the Divisions of General Practice are key change management facilitators.
- Governance and Stakeholder Management:
- There is a need to effectively engage stakeholder groups at both national and local levels that will facilitate strong governance and engagement with the national approach.
- The roles of funder and stakeholder need to be separated in the governance arrangements.
- Early and ongoing vendor engagement is required to test, deliver and maintain functionality.
A number of lessons learned are also reported in an evaluation of the NSW Healthelink system [KPMG2008]. The report highlighted that building a SEHR is technically feasible and that there is support from both individuals and healthcare providers for such systems. However, the report also highlighted that uptake was slower than expected due to a number of reasons:
- Healthelink had not yet reached a critical mass of patients, and therefore did not yet contain sufficient information for its potential to be realised.
- The process of accessing and using Healthelink was not yet seamlessly integrated into clinicians’ routine system processes. This reflects the decision of NSW Health to contain the degree of sophisticated functionality as part of its pilot risk management strategy.
- Healthelink has experienced difficulties with some independent vendor software products that were not originally designed to accommodate a SEHR. This will remain an issue until the software products used by GPs are able to accommodate the requirements to transmit information to a SEHR.