Opinion: Reflections of a general practitioner on carbon versus silicon-based IT

I may be one of the last of a disappearing generation of working GPs. I graduated in 1970, having taught myself to touch type in my sixth year of medical school (which may have been the most useful thing I learned that year.)

I observed the growth of medical computing from that perspective: typed letters, dictated hospital admission notes, the birth of the personal computer, the use of computers to write scripts, then with increasing sophistication to take over clinical recording.

There was a stage where, for safety’s sake, one had to maintain both computer and handwritten records. A personal computer on the doctor’s desk, another on the reception desk – if connected – that was a ‘network’. There were 10 clinical systems available, all with frequent upgrades, all competing against each other, all ‘buggy’.

Solo practice was unworkable. One needed at least six doctors in a clinic to justify the cost of prompt, competent IT network support. But as things settled down, I felt increasing annoyance at the attempts of some to substitute complex, convoluted, algorithmic IT processes for the well-established, competent, human intellectual routines of medical assessment and clinical care.

What I hear today in IT is a belief that magnified complexity, fuzzy logic and artificial neural networks will competently – ultimately completely – surpass the human intellect. We are still blinded by the computer chip, and still have not fully tested and extended the capabilities of the human brain. I first learned to use my ‘neural network’ at home, then in school, in medical school, and still, even now, in clinical practice.

I concede it is an ancient ‘carbon based’ system. Its neurons nevertheless are miniscule, when compared to the size of a transistor. They require much less power. Sourced from a much wider gamut of energy sources. And, importantly, clinical care functions on a person to person basis.

Who pays the piper?

Reading Adam Powick's opinion piece in Pulse+IT recently, I found myself deeply disturbed. I am concerned at his expectations of clinical responsibility, and of the ‘clinical technology’ he considers should be available for his care.

I am intrigued by and question his list of expectations. Mr Powick states:

  1. I want access to a complete, secure and up-to-date electronic record of my health conditions and interactions with the health sector
  2. I want to own and share this dataset, not have parts of it hidden from me by my service providers
  3. I want to have my key health indicators proactively and remotely monitored and I want to be alerted when there is a discrepancy that needs attention
  4. I want to access first-level diagnosis electronically from my home at a time that is convenient to me (and this is rarely during normal working hours)
  5. I want my drug prescriptions to be automatically fulfilled and delivered to my home
  6. I want to have transparent access to consumer ratings of doctors, drugs, treatments and clinical facilities (i.e. a ’tripadvisor’ for health)
  7. I want to book all of my healthcare appointments online
  8. I never want to fill out another paper form again or repeat 
my details as I navigate the health system
  9. I want access to reputable, best practice healthcare 
information
  10. I want periodic, tailored, full-service health check-ups – if it 
is good enough for my car, it should be good enough for me.

I ask the following questions in response:

  1. Will the ‘doctor-shopping’ narcotic addict have the right to massage and curate their ‘electronic record of their health conditions’ and the list of past prescriptions in that record? What an easy way to present oneself to the next doctor as ’squeaky clean’. Would Mr Powick ‘share’ information about circumstances of mental illness, or of a diagnosis of a sexually transmitted disease, that properly is part of his clinical record? Would he leave this information in his eHealth record indefinitely? But once there, who has the right to expunge it?
  2. How will ‘key health indicators be proactively, remotely monitored’? Which ‘indicators’ is he talking about?
  3. What is ‘first level diagnosis’? Before any diagnosis necessarily comes a specification or indication of an anomaly, then sequential assessment by patient history, examination, then pathology and imaging tests. Is Mr Powick expecting that this service will be provided – at a full level of competence – by practitioners and diagnostic services working after hours? Just for his convenience?
  4. Who will pay for the delivery of his ‘drug prescriptions’? How will they be delivered? What safety and security concerns must be met in this ‘delivery’?
  5. What are and who determines the ‘consumer ratings’ of doctors, drugs, treatments and clinical facilities? Who determines what is ‘reputable, best practice healthcare information’? Will this be an enormous expansion of the TGA? Or will it be done in a less professional, objective and impartial manner, by assessors paid, one way or another, in kickbacks?
  6. The last periodic, tailored, full service check-up on my car cost me over $400, and cars commonly do not require pathology tests, nor imaging. Would Mr Powick pay $400 for the clinical part of his assessment, in addition to the price of the panel of pathology tests he would consider appropriate and whatever the cost of a total body MRI (best resolution, no radiation) to detect any dangerous anomaly at the earliest possible stage? How frequently? If not, for how much of this should Medicare pay?

For those who, like Mr Powick, admit to being “a little on the portly side”, what is the financial obligation of Medicare to care for him? His health is, and always has been, his responsibility. Does Mr Powick expect Medicare – the taxpayer – to carry the costs of increasing medications, doctors’ visits, expensive technologies, procedures and operations?

Is it impertinent for Mr Powick now to be taking 'a more personal interest in how well our health system really supports consumer needs’ when his health system has needed him to have taken a more personal interest in optimising his own health?

This is an achievement that has not required, and still does not require, any great or sophisticated technology of eHealth.

About the author:

Dr Glenn Rosendahl is a GP who has practised in Australia, Canada, the US, Norfolk Island and the Solomon Islands, and has worked with Aboriginal people in Queensland and the Northern Territory. He has also been a prison medical officer and cared for patients in immigration detention. He currently works as a locum on the Gold Coast.

Comments  

# Shiva S. 2018-01-30 11:43
Dear Dr Glenn,
I do agree with every comment you made. This integration of all systems and electronic patient records/electro nic medical records are becoming more and more popular these days. As a biomedical engineer with IT backgrounds I should be justifying these activities instead I am really concerned.
This integration business is booming and every stake holder in the business is rubbing their hands to make more profit. All standards and protocols apart the manufacturers are making subtle changes in their product to make them unique so that once you buy their product you have no choice but to keep buying their add ons at inflated prices. I have seen products costing more than double their original cost of purchase to keep them updated and maintained over the life of the product even without any special addons.
All these capital costs are driving the cost of quality medical care for the patient instead bringing the cost of care down as originally thought or claimed.
Unfortunately the current trend is integration regardless of the cost and the fact is we are spending more and more on these integration efforts instead of the actual treatment and care.
Ultimately we are investing more on these newer technologies and systems without actually understanding / realising the so called benefits promoted by all the vendors.
In my opinion we all need to stop and do a reality check and decide on what we actually need?, what we can afford? what are the critical requirements? what are the real benefits? not to mention seek the answers for every questions you have forwarded in you article above.
Thank you for posting this hot topic and highlighting the requirement for the reality check.
Best Regards.
Shiva. S
# Jane S. 2018-01-31 15:37
Like Dr Rosendahl, I am also disturbed. However I am mostly disturbed by the apparent inability or unpreparedness of Dr Rosendahl to address the issues raised by Mr Powick. These are systemic problems, not personal. If more medicos could hear the needs of their patients and give an objective, non-defensive response, maybe consumers would be happier with the healthcare ‘service’ that is frequently dished out to them.

Like Dr Rosendahl, I too have lived and worked all over the world, and I have seen how many other systems accommodate patients’/custo mers’/clients’ personal and medical needs to a much greater extent that here in Australia. I have a normal BMI, I exercise regularly, I have never smoked and I do not drink more than a ‘unit’ or two of alcohol a week. Like Mr Powick, I view my health as mostly my responsibility.

However, for Dr Rosendahl to comment on a patient’s weight is avoiding the issue, it is a red herring. It does not address the issue of a patient’s non-access to their personal health information, their usage (or abusage) of Medicare, or their willingness but consequent inability to participate meaningfully in the maintenance of their health.
Similarly, discussing Mr Powick’s weight does not address the lack of respect or consideration for patient time spent ringing for and choosing an appropriate appointment option, (dare I say usually?) waiting in the surgery to see a doctor once there, repeating the fiasco for second or further appointments to receive pathology results and/or to have repeat computer-genera ted prescriptions issued. Addressing these simple issues demonstrates respect for other people by freeing up appointments for more needy patients, saving patients’ time and Medicare expense. It also allows medics to do what they are trained for (ie diagnosis) rather than unnecessarily spending time on administrative tasks.

When I say health is mostly my responsibility, I think my responsibility is to look after my body and mind to the best of my ability, and to attend a surgery on a regular basis. Medicine is not my training, so I pass the remaining responsibility to someone who is trained in that field. I think my doctor’s responsibility is to be open and honest with me, to keep abreast of the current literature and maintain practices accepted as safe and modern. I expect my doctor (or like Mr Powick, an e-record scanning technology) to alert me to any anomalies found during visits, and to help me prevent or minimise potential health harms. I would also like my doctor to help me understand his/her chosen treatment preferences, as well as those discarded, for whatever reason. I am frequently thwarted by both individual doctors and the system when taking that responsibility.

My health details are often hidden from me: they are currently not collected in a single place (even when I have requested that my records are held in an e-health record). Several practitioners have refused to add them as they did not consider the fee paid by the Commonwealth for doing so to be adequate. I understood Mr Powick’s first request was to allow him access to a summary of what healthcare professionals (HCP) in general claimed from Medicare when servicing his medical needs: it should be relatively easy to supply them to both the consumer/patien t and HCP from existing records (akin to a bank statement, where every detail is available at a click for around 7 years). This record permits a level of accountability for HCPs (no unnecessary/und elivered services or charges) and patients (eliminates the possibility of doctor or pharmaceuticals shopping as visits claimed and prescriptions filled are all visible) and is a recording system for both patients and doctors.

As for who will provide ‘reputable, best practice healthcare information?’– NPS (National Prescription Service), NHMRC (National Health and Medical Research Council), and others already provide independent, not-for-profit and evidence-based information on prescription medicines and clinical practice guidelines, suitable for medics and/or patients. Suggesting that provision of this information needs an ‘enormous expansion of the TGA’ otherwise it will ‘be done in a less professional, objective (did you mean subjective?) and impartial manner, by assessors paid, one way or another, in kickbacks’ is either ignorant or disingenuous.

From a patient’s/custo mer’s perspective, there is a lack of availability of comparative medical costs, currency of HCP continuing education attendances, benchmarking, and ‘trip advisor’ type information about potential healthcare service providers in general. How can one make an informed decision about or take personal responsibility for health care if there is no access to relevant and appropriate information about either one’s chosen practitioner or the products and services recommended or provided?
I do not think Mr Powick is asking for anything unreasonable, or anything that is not expected from other non-medical service providers.

Jane S.
# Glenn Rosendahl 2018-01-31 22:06
I thank Jane S for her response and critique. And I understand her frustration. The vast majority of my colleagues to not practice the way I do. Most will deal with only one problem in a consultation, and give it from 6 to 10 minutes. Explicitly, that is the way their appointment book is planned. A second consultation is inserted in each 15 minute slot as the day builds. The reason is simple. Bulk-billed, with 35% of the fee deducted for clinic costs and administration , each consultation nets only $25. Lawyers expect to bill $300 an hour, and they have no ‘clinical costs’. You say “Several practitioners have refused to add [clinical details to a e-health record] as they did not consider the fee paid by the Commonwealth for doing so to be adequate.” It IS grossly inadequate. There is no additional fee, simply an entitlement to claim $45 if it is more than 20 minutes work - still only $135 (max) per hour. (This includes sick, holiday, education leave, professional costs, malpractice insurance premium and superannuation) And the task itself is complex. Having completed the consultation, one must show the notes to the patient (on the screen) negotiate with the patient what will be uploaded, what will be changed, what will be deleted. (The patient can take whatever time they choose to consider this.) When that is decided, log on (using a complex time consuming log-on process), download the text, add the patient’s formal authorisation, then log off. All that - essentially - at no additional Medicare cost. Really?

There is matter of which patients are unaware. Most medical records these days consist of the detail of prescriptions written, and of pathology and imaging requisitions. The information of history and physical examination, of the diagnostic logic and resultant conclusions is very sparse - or present in a personal acronym jargon. Or templated out of generic resources of medical algorithms. The purchasing power of the Medicare fee is less than 50% of what it was 30 years ago - compared to the cost of living. Less than 30% when compared with average weekly earnings. Most of my colleagues do not ‘touch type’, and as they began practice, their notes were simple a hand written ‘aide memoire’ - a single line, beside a date, on a card. Recent graduates understand, from the beginning, just how paltry are the monetary rewards of general practice. The need to ‘make haste’. Write detailed notes covering all the concerns of the patient in a consultation, the history taken and the examination undertaken, analyses of imaging report and pathology results, conclusions reached, a management plan, including prescribing rationale, detailed referral letters so specialists and allied health - you have got to be joking! For $25 for up to 20 minutes, and $45 beyond that. And we have yet to upload a clinical summary to the the Medicare cloud!!!

The issues raised by Mr Powick ARE systemic - as are the problems I identified in my critique of them. Clinical notes - to now - have been the property of the doctor. Like the contemporaneous notes of a lawyer. If I find inconsistencies in what I am told, that suggest the patient has a hidden drug use, insurance or worker’s compensation agenda, I have an obligation to my clinical ethic to annotate my file with those perceptions. Mr Powick wants the file to be his, my role is to be his scribe (at my expense) to create notes to his satisfaction. There being no other record.
It was Mr Powick who drew attention to his weight. His own statement, and his implicit attitude, made it an issue. For reasons of brevity, in my essay it was truncated. In full he wrote:

“…a little on the portly side due to an aversion to strenuous exercise and a (in)famous inability to walk past a nice dumpling, pizza, burrito, stir fry or glass of red wine. I have gout, which I am told is genetic, but then again I haven’t met too many skinny, teetotal gout sufferers over my time. I am starting to feel the first signs of arthritis…”

The issues I raised are not irrelevant.
1. A responsible attitude to one’s health care.
2. The cost of that care.
Are taxpayers to pay for a citizen’s irresponsibilit y? The answer, at present, is - YES.
I have no argument with on-line pharmaceutical information (if you know what information to trust), but clinical practice guidelines are always dated, and rarely reflect a consensus view. As for the reputations of clinics and hospitals, they have websites - written and controlled by them. Every doctor in Australia has registration information in the AHPRA website - you can look it up. As to what they do, and how well they do it, there is an increasing gamut of information out there - commonly significantly massaged - indirectly or directly - by the practitioner. Or do you expect AHPRA to closely ‘objectively’, ‘independently’ rate every Australian doctor?

Does the doctor, the patient or the government control the medical file? There already is a complete listing of all PBS prescriptions in the Medicare cloud. Which means there already is an implicit complete listing of all patient’s significant medical conditions - that are treated pharmacological ly. Medicare controls this listing with iron-clad security. For example, it details the names of all patients who have recently been treated for Hepatitis C. Do we use this data as the basis for a general eHealth Record? Add all the other information to it? How secure then is the data? Inadvertence is one problem. Two ex-public service filing cabinets sold at a second hand store in Canberra… I am sure the ABC has handed the top secret files back. But can you expect all the doctors, nurse practitioners, pharmacists, allied health - to be more careful than that - every time, all the time?
Then there is deliberate hacking…
Do you want your file published on WikiLeaks?
# Ian Mcknight 2018-02-04 13:27
I'm not qualified or inclined to comment on the length and breadth of these things, but a couple of things in Dr Rosendahl's post do require a response. The whole "scare factor" thing of mentioning WikiLeaks etc really needs to stop. In this day and age people should absolutely be risk-aware, but what is often missing from the "anti" brigade is a rational and balanced evaluation of the likelihood of the risk, and a total disregard of the common every-day good that WILL eventuate by these improvements. If we focused on the worst case scenario for everything we did, would we ever get in a motor car? Would we bank online? Would we go out in the sun, go on an airplane? We do these things because they enhance our lives or at least save us time, and we know that if we behave with appropriate levels of care, 99.9% of the time we will be fine.
It wasn't that long ago when there were shock-horror reactions to practices even being connected to the internet.. Apparently armies of intrepid hackers would divert their attention from NASA or other military or financial targets, and target General Practice, presumably so they could share Mr's Miggins pap smear details with the world. Well, it didn't happen ! Even with almost every general practice being connected to the net all day, every day, I can remember hearing of only one ransomware attack on an australian medical facility in the last few years. And that particular cyberthreat was something that all modern businesses and indeed private homes had to be aware of. On the subject of a rational assessment of risk, I am still yet to hear of any GP ending up in court as a result of their use of the My Health Record (formerly PCEHR), despite all the nightmare scenarios being described by some GPs since 2012.

On the subject of the MYHr, I really must take issue with your description of uploading a Shared Health Summary, which starts with the sentence, "And the task itself is complex..". Well it absolutely isn't, or at least need not be. My first though was that you were using non-compliant software, but some quick online research makes me think that you are probably using the fully compliant Best Practice program. So it must therefore be that you have not been properly trained or informed in the use of the MyHR, and there are some misunderstandin gs as a result of this.
Let me clarify a couple of points:
1) A patient who sign's up for the MyHR gives consent to the fact that providers who are involved in their healthcare may read information on the record and contribute information to it. It's kinda the whole point.
2) The patient can ask you not to include a certain item from their history, and if they do you should honour that. This is the extent of the negotation, and you meet their request with a mouse-click. There are no free-hand notes being uploaded, there are allergies, significant history issues, medications and immunisations, all removed with a mouse-click if required.
3) There is no downloading of notes or recording of formal consent required as you indicated. If you are actually registering them for a record, then there is consent required, this itself can be a 2 minute exercise, and as of sometime this year, the government will "turn on" everybody's record with an opt-out option.
4) If you are uploading a summary to an existing record, "the complex log-on" is clicking on a button in Best Practice. If you can't do this, then your software is not set up or maintained properly.
5) I would respectfully suggest, that if your electronic patient record is tidy and well organised, the uploading of information to the MyHR can be extremely quick and efficient. I have had one GP brag to me that their best effort is a health summary upload in 90 seconds. I'm not at all saying that summaries can be done this quickly, but I am saying that her description of what is generally involved, is more accurate than the one you relate.
6) Lastly I would say that in terms of any discussion between you and the patient around shared electronic health records, the patient would be influenced and possibly led by your demeanor. So if any of this seems painstaking for you, it may be that the patient is picking up on your reluctance, scepticism, mistrust of the system etc. You may well be setting the tone for an awkward or lengthy conversation.
I write the above, having supported GPs and nurses in clinical system use for nigh on 15 years. I have trained in and promoted the MyHR for the last 5 years or so. I know there are reservations, often well founded ones, but I would urge sensible risk evaluation, and I have to respond to some of the commentary around "clunky" interactions with the system. If you are using a mainstream General Practice software program, you have a very good interface with the MyHR.
# Glenn Rosendahl 2018-02-04 17:24
With respect, there are risks. And quite separately from these, is the matter of ‘time’. I must confess, I have never uploaded a file to MyHR. I have not been asked to do so. I have been neutral. And it would appear to me that some practices are assiduously already discouraging patients. If a file reads on its face: ’Not to be uploaded to My Health Record’, I suggest a conversation has already occurred. And when MyHR is ‘implemented’, that file will remain empty. The patient has already ‘opted-out’. I suspect those practices that did upload in the ‘test run’- in good faith, expecting a financial reward, and found, if they got the money, it was then demanded back - really have no further interest in the facility. They got their fingers burned. But I am not writing from personal experience. I considered the ‘test run’ was unconscionable. There was a clear conflict of interest - never acknowledged by government, therefore never acknowledged by the participating doctors. If I, as a doctor, will be in receipt of a monetary reward for enrolling a patient in MyHR, then I must disclose that to the patient as a factor in my encouragement of them to ‘join up’. This is an absolutely elemental ethic.
I am fascinated that all I have to do to ‘log on’ is press a button. I must do more than that to access my own bank records. The bank does not give me any access to anyone else’s records. Whereas, with information given me verbally by my patient, I can access their record. Does that mean, that if I record that information, I can re-access their record subsequently? If I inappropriately have access to that information of a patient I have not seen, I can access their record as well? The mind boggles. There is information on patients’ records potentially far more embarrassing than Pap smear results.
I take explicit issue with you. I consider that - not from a medical administration perspective, but from a personal medico-legal perspective, every patient must specifically and explicitly consent to what is uploaded to their MyHR file. And it would be best if there was a formal way for each patient to document that acknowledgment. Otherwise, what defence do you have to a subsequent claim that ‘I did not consent to that information being uploaded’. And the threat of legal action.
However, you do present a partial exculpation. Apparently one is only uploading “allergies, significant history issues, medications and immunisations”. Will there be pathology and imaging reports that we upload, or that are uploaded from their source? And what are ‘significant history issues?’
My analysis of Medicare’s own data is that 50% of item 23 consults take less than 7.5 minutes, 50% take more. With a 2 minute time for logon, upload and log-off, that is a more than 20% cut in the bulk billed remuneration for each consult.
There was, and is, a much more simple - and safer - alternative. Keep the patient’s medical file on their smart-phone. It would require some technology, but would not be difficult to do. But no, the government wants everybody’s incomplete medical synopsis up in the Medicare cloud in the sky.
# Ian Mcknight 2018-02-04 20:08
Not saying that there are no risks associated with medical record keeping and communication in both the electronic and non-electronic spheres, I'm just advocating a balanced assessment of the risk and likelihood of risk weighed against tangible everyday benefits.
It makes sense that you have not uploaded a MyHR, as your description of what is involved didn't ring true. Also, with the greatest respect, I'm struggling to see you as "neutral" on this topic.
Let's clarify the test you spoke about. The MyHR/PCEHR has been available since 2012-2013. The government financially incentivised practices to have their systems ehealth capable, and then around May 2016, changed the incentive to what it is today, namely that practices upload a really small number of health summaries per quarter in order to qualify for the incentive payment. It is a tiny number when calculated on a per GP basis, but does serve to prove that the practice does have an enabled and maintained system. Obviously patients have to have a MyHR for it to receive a health summary. There was no test that I am aware of, other than in late 2015, an Opt-Out Trial was commenced in Northern Queensland and the Blue Mountains. I have never heard of a practice meeting it's upload obligations and then having to pay money back, because the patient opted out of the system.
I'm wondering if the fundamental ethic you refer to extends to all the other financial incentives accessed through the MBS when delivering patient care. Do you point out to the patient the Medicare payment to the practice for care plans or health assessments?
My description of one button access to the MyHR, was of course directed to what you as the time poor, practicing GP has to do. For this to work for you as I described, several security related things will have been put in place by your practice management, namely.
1) Installation of a compliant software program.
2) Application for and Installation of various PKI certificates which enable login security and encryption.
3) Application for and installation in the software of a unique identifying number for the practice. HPI-O number
4) Sourcing and installation of your individual ehealth specific number HPI-I
5) Changing your software permissions to enable MYHR access and or patient registration
6) The patient's health Identifier HI, downloaded by the practice software.
All this happens as a result of your practice management staff, so that you can access the record with a click. And again, with respect, it feels like your position has changed from "it's too complex" to "if it's that easy, it can't be secure".
We can go back and forwards on the consent issue. My statement around people who sign up for a record stands, but it is worth mentioning that when someone does sign up, there are 5 or 6 types of information that they consent to have displayed in the record. They can change these consent levels at any time, and yes it does require a level of knowledge on their part to know that they can modify consent. For example, they can consent to having immunisation information being displayed in their record. I would bet a large amount of money, that you are not aware that a MyHR also contains information sourced from the Australian Immunisation Register. Very useful, I would have thought, but would you really have the register contacting the patient every time they had an immunisation to get specific consent. Similarly the MyHR can contain prescribing and dispensing information from the NPDR, surely you can see the impracticality of trying to gain specific consent for every prescribe and dispense transaction.
With pathology results, work is well underway to enable labs to upload pathology results direct to the MYHR unless the patient has withdrawn consent for this. This would typically happen 7 days after the result was sent to the patient's GP. The first lab in NSW has recently gone live doing this.
As far as "significant issues" go, I was referring to the Past History screen in Best Practice, which will optimally contain a summary of the patient's major health issues. At least that's the case with my practice customers, (hopefully).
Glenn, this initiative seeks to save time, money and sometimes live's by making key information available in an accessible repositry. It does this whilst trying to cater to the needs of a heavily privacy concious citizenship. There are numerous audit trails, numerous privacy options for the patient and penalties for clinicians who deliberately misuse the system. It's a more than fair effort at helping the non-regular clinician treat the patient they are meeting for the first time.

The smart phone option really doesn't bear scrutiny when you consider the variety of phones, operating systems and how often people change them, let alone the generation that don't use them at all. It doesn't stack up against a universal repositry that can be accessed by many. You will be pleased to note though that there is an app for accessing the MyHR, called healthi. There will be more in the future.
Glenn, I actually write this largely for the benefit of other readers who may read your thoughts and assimilate them into their own opinions. One of the biggest barriers to take-up of this so far has been the circulation of incorrect, semi-correct or badly generalised information. As a final note,as part of what I do, I have a pdf document on using the MyHR with Best Practice. I'm more than happy to send you a copy if you want to let me know your email address.
# Glenn Rosendahl 2018-02-06 17:39
Ian, in good grace I respond again. But I do disagree with you.
1. I have no obligation to ‘try to be neutral’ on this - or any - topic. I am entitled to have a point of view, and to state it. I would like my opinions to be seen as relevant and informed. Who is to assert that another’s opinion is neutral or biased? For a commentator to assert that - used to be called ‘begging the question’ - although in today’s discussions such descriptors are commonly found in the preface, and are commonly the norm. It is for each reader to make up his or her mind, what they think, having read the matter.

2. My information so far has been from what I have read, and understood. Essentially, since 2012 I have been a locum: Immigration Detention medical care, Aboriginal Health Care (Alice Springs, Capalaba, Mareeba) ‘coal face practice’ in Emerald and Stanthorpe, Qld, and now in my 6th clinic on the Gold Coast - none of these, so far, have picked up on the MyHR in the formal sense - so in reality I have never had any clinic expect that I would upload these files.

3. I wonder why? Particularly in bulk billing clinics, time is of the essence. The government grudgingly finally acceded to allowing billing an item 36 if the consult - including the upload process - took over 20 minutes. I have read significant comment in the recent medical media about practices having to repay the incentive, apparently because insufficient successful uploads had been done.
I suggest your listing of what is expected in a clinical summary is incomplete. The Medicare patient brochure expects: a summary of your medical history, conditions and treatments - which obviously you must create. You wrote: “There are no free-hand notes being uploaded.’ I disagree, I believe that is exactly what is expected. Detail comparable to what is in the following: ‘Hospital discharge information’, ‘Specialist letters’ - which are also to be included. [See Consumer Brochure: My Health Record, Australian Digital Health Agency]

4. Even more detail is expected in creating ‘Health Assessments’. [See MBS Online]
‘A health assessment is the evaluation of a patient’s health and wellbeing. General practitioners (GPs) use it to help decide if a patient needs: preventive health care education to improve their health and wellbeing [items: 701 - $59.35 less than 30 mins; 703 - $137.90 30-45 mins; 705 - $190.30 45-60 mins; 707 - $268.80 60+ mins.] There is the explicit expectation of ‘comprehensive information collection, including history, examination (physical, psychological), interventions and referrals, and ‘providing a preventive health care strategy for the patient. The expectation is that all this is ‘written up’ and included. You are being paid GP rates for doing the work of Specialist General Physician. To be uploaded into the patient’s My Health Record. Paid even less, in two year’s time. Then to be paid as part of the ‘capitation fee’ for patients enrolled in your practice ‘My Health Home’.

5. There is a real difference between Medicare payments for clinical care, be it consults, care plans and health assessments - and enrolling patients into MyHR and uploading health summaries. Patients expect us to create clinical notes, that will be kept confidential within the practice. They are pleased that the government pays for part or all of this as part of their care. However to persuade the patient to upload some or all of this information into a government controlled, ‘cloud situated’ database is a completely different circumstance - each of us has an obligation to satisfy ourself that the database is secure, and set up appropriately - before we upload our patient’s clinical information onto it. You have written: ‘A patient who sign's up for the MyHR gives consent to the fact that providers who are involved in their healthcare may read information on the record and contribute information to it. It's kinda the whole point.’ My opinion is that such global consent is incompetent. You assert that once having given consent, the patient implicitly ‘opts-in’ all future information downloads (from anyone) without any further warning - of whatever information - unless they explicitly opt it out. Is the patient fully aware of that? Have they been made explicitly aware of that? (If I was offered this opportunity, with that caveat, I would say ‘no’.) If significant information arrives after the consultation, what do you do with that? Yes, you may need to recall the patient. What do you do if they do not front up?) I would prefer to have this information on my phone.

6. And what is the process by which imaging or pathology information disclosed to and discussed with the patient - that the patient then states they refuse to have on their record - is prevented from being ‘automatically uploaded’ a week later by the imaging or pathology entity? What is the process by which that refusal is communicated to the reporting entity? Who’s responsibility is it to see the refusal is actioned?

7. What if the information is personally - or socially - critically significant? A positive gonorrhoea, Hepatitis C or HIV result? Formal disclosure of ‘doctor-shoppin g’? If the removal of that information makes that file unreliable, then all MyHR files are implicitly unreliable. (You hold that information in the clinic’s file, the patient - at least until now - is not entitled to have it expunged.)

8. Who is accountable if the MyHR file is unreliable? The doctors who have contributed to it in the past? The patient? Medicare? You, the treating doctor, because you trusted the file? We now have the case, just reported in the UK, of Dr Dr Bawa-Garba, who may have seen, but did not properly understand the significance of a few numbers in a pathology report. The patient died. The doctor convicted of manslaughter, and permanently ‘struck off’. What if information is in the clinic file, but not in MyHR? Who is accountable for its absence?

9. One does not need a MyHR file to know what is on one’s immunisation register. I have just (belatedly) signed up for a ‘my gov’ account (to get money back from Medicare). That process immediately gives me access to my immunisation register.

10. In the practices where I have worked since 2013, if I had wanted to enrol patients in the MyHR database, practice management would have expected me to do the legwork, for each patient. Almost two decades ago, when I gave up solo practice, I knew I was also giving up the services of a medical secretary. Front office staff in a 6+ GP practice take bookings for appointments - and when patients are booked at 6 an hour (or more) for each doctor - that is all they do. In a bulk-billed practice, that is all the practice can afford for them to do. Your list of tasks, from 1. to 6. is the GPs personal responsibility. For essentially no additional payment. I am not ‘setting the the tone for an awkward or lengthy conversation’. If my patient wants a MyHR file, I will charge them private fees. What it costs me to create it. And then upload. It will be ‘opt-in’. Simple as that.
The practice I am moving to, does charge private fees. I may reconsider this, in that circumstance.
I presume you charge private fees as well.

But if the patient wants a MyHR, I will discuss the pros and cons fully. Possibly with a written pro-forma that discloses all the relevant issues, that I ask them to read in the waiting room, before I see them. Perhaps you can present us with such a ‘pro forma’ you would consider relevant, competent and complete. (Nevertheless simple and minimalist - the least that needs be said.) We can then discuss it.

My concern is that the questions I have raised, now well over a decade - these very questions - have been treated with contempt. Shoulders are shrugged. ‘These questions are trivial. These are discussions that are not worth having…’
# Ian Mcknight 2018-02-07 02:21
Ok Glenn, and I will try and be briefer,
1) Entitled to opinion absolutely. But there is an ongoing battle for hearts and minds around this important issue, and if you say something in this public space that I feel is incorrect, or exaggerated, I will attempt to set the record straight. The key issue I addressed is the working and functionality of the MyHR, and whilst I am no GP, I have educated dozens of clinicians in it's use.
2) That's a shame.
3) Absolutely there are many practices who were prepaid the incentive payment and had to pay money back as they didn't upload enough summaries. This is vastly different from what you originally suggested, namely that practices were penalised by the fact that they uploaded summaries for patient's who subsequently opted out. Completely different circumstances.
No I am not wrong about what is expected to be included in a Shared Health summary upload. There are numerous sources on the net including instructional videos, that show you what a shared health summary contains. It is absolutely driven by the GP software. My statement around this is 100% correct. As I mentioned I have educated many on this and demonstrated the process, I'm not quite sure what else I can say to convince someone who has never done a single one. I reiterate this is talking about the Shared health summary specifically, this is the only document GPs are currently incentivised to upload. There are other documents that are possible, like Specialist letters, but in a lot of places there is more to be done on the specialist side.
4) Not possible to upload Health assessments to MyHR currently. If it is intended in the future, the act of upload will be a couple of extra clicks added to the document that you were creating anyway. The same with specialist letters. I have no opinion on whether you are paid enough to do Health assessments etc, but I get the feeling a lot of GPs would concur with you.
5)"Patients expect us to create clinical notes, that will be kept confidential within the practice", I actually think patient's have greater expectations than this. Sorry, but If I was your patient, I absolutely would want you to contribute to a shared electronic health record. I would absolutely, (especially if I had serious health issues), want you to help any future clinician that I was dealing with have quality information available at time of presentation. Not several hours later when the practice opened. As far as confidential records within the practice goes, I guarantee you there are practices where multiple branches share the clinical database. Do you think every patient at those practices realises that their records are actually not kept in that building, but rather on a server in a building that many of them would have never set foot in? Does every patient realise that in some practices everyone has the same password, or that their faxed referal letter can be read by anyone at either end who is walking past the fax machine. Your original article was a response to a "patient" who had expectations far beyond what you describe here. "each of us has an obligation to satisfy ourself that the database is secure, and set up appropriately", I know what you are getting it, but from a technical point of view I'm not sure you are qualified to comment on cloud based database security, in the same way as an Internet security expert is not qualified to comment on clinical issues beyond the reach of the layman.
You don't like the consent model here. It is what it Is, all I can do is describe it and attempt to correct you if you state it wrongly. I have no strong opinion on whether it is right or wrong, but I will say that this is an attempt to generate a solution that is workable in a practical scenario. The lengths that you are suggesting we go to around specific consent on every occasion, would generate far more work for clinicians..... .....when you are saying the current model is already far too onerous. To be honest you can't have perfect privacy and perfect timely health care, the two will never meet. You can have good privacy and protection and better communication around health care, and that's what we are shooting for. I'm actually certain patient's in majority would opt for the best most timely care they could get, given the choice.
You are right that a lot of patient's would have a MyHR and not in any way, be expert in tweaking the security and consent parameters of their record. But if they (or you) want to educate themselves about it, there is plenty of information online at the relevant sites.
6) The latest release of BP for instance has a tick-box on the request form that specifies if the patient doesn't want the path result uploaded to the MyHR. MD and the other applications will follow suit I'm sure.
7) I know what you are saying, and It's been said by others. I still fall on the side that says some information is better than no information,... . which apparently is what most clinicians have 80% of the time when meeting a patient for the first time. If the patient was allergic to "x" 5 years ago, they are still allergic. If they had a heart condition 2 years ago, they still have a heart condition. But you right, you can identify troubling scenarios to which there is no complete answer. Now can you identify good scenarios where ordinary patients all around australia every day can receive more timely and accurate care through the instant availability of information? As I said previously, a balanced view of pro's and con's, risk and reward is what is required. Not just a total focus on the "nightmare scenario" and a total disregard for obvious everyday benefits. There is no perfect system.
8) I don't know, see my previous point.
9) I didn't say it was the only way you could get Immunisation Register data, I said it was a useful feature of the MyHR that you weren't aware of, and I asked you if the Immunisation people should be made to ask the patient for consent to send it to the patient's record, each and every time they updated it.
10) Sympathies over time and legwork re enrolling patients. I know plenty of practices where signing patient's up is done by the nurses. This works well as they are often then in a less time restricted encounter. Often then the patient sees the GP who uploads a health summary. The IT part of it is very quick to do, but absolutely there may be some conversation around it that may take time. The Gov is making it Opt-Out this year, so there will be no need to register patients at some point. Re private fee's, I'm not a doctor, just a humble support and training guy!
Re Pro Forma, practices were all sent reasonable brochures aimed at patients. If your practice has never pushed the issue, you should have plenty left :-) There is a copy here, https://myhealthrecord.gov.au/internet/mhr/publishing.nsf/Content/469F70E39D3B7628CA257F8A0008E39B/$File/All%20you%20need%20to%20know%20Brochure.pdf
Hope I haven't been guilty of "Shoulder Shrugging", certainly the mountain of preceding text represents an attempt to answer some of your questions.
# Glenn Rosendahl 2018-02-07 11:34
Ian,
Firstly, I thank you for your comments. I, as you say you are (and I respect your honesty) want to clear up misconceptions and enunciate concerns and issues that have been glossed over.
[New enumeration]
1. Can you give us your relevant CV. For how long, and in what way have you been involved in developing and promoting MyHR? Have you in the past been - are you now - in receipt of income for such activities? You did say: ‘I’m not a doctor, just a humble support and training guy!’ But I think we are entitled to know more about you, since it appears you make your income in ‘support and training’ in the MyHR. Indeed, it would appear you have a vested interest. We are entitled to ‘disclosure’! (You can find me, any time you wish to look, on the AHPRA register of practitioners. Since you are advocating very strongly for the present embodiment and use of MyHR, I think it reasonable we know who you are. (I certainly will not hold that against you!)
2. Thank you for your clarification of what is expected, and what is not expected, in the Shared Health Summary. I am intrigued at the administrative expectation (that you have not conceded) that GPs will ‘curate’ the MyHR for the rest of the ‘medical system’. Since I last corresponded, I have had my second ‘ablation procedure’ for AF. (I have a pacemaker.) The private hospital still works on paper records. (Three procedures, and my file is physically voluminous!) The local public hospitals (the word ‘University’ is in the moniker) send out discharge summaries through ‘Medical Objects’, days, or a week or more, after discharge. I expect they will expect us to upload them to MyHR, as they will not have them finished at discharge, so are not in a position to give the the patient a copy, nor ask their permission to upload the information onto MyHR - and would not give the time to do so. That would mean the full - unexpurgated - statement being sent to the GP, the redacted copy to MyHR. With both copies being held in the patient’s hospital file, and some explanation for the difference. No, give the job to the GP. That also moves the cost from the State Health budget to the Commonwealth’s. I expect there will be quiet, but strenuous and continued resistance from specialists, against them uploading their letters directly to the MyHR. We GPs will be expected to do all this work for 65% of $39 ($25) for the first 20 minutes, 65% of $70 ($45) for from 21 to 40 minutes - on top of the time spent for the patient’s clinical consultation. I may not have known the detail you have now explained to me - but have you understood the parsimonious bulk-billed budget we are working with? That you expect the doctors you train to use the MyHR to accept? You did write: ‘I have no opinion on whether you are paid enough to do Health assessments etc, but I get the feeling a lot of GPs would concur with you.’ I expect your role and formal work is such that you may not express an opinion - administrative or private. The government is getting very close to ‘civil conscription’ in this matter, and it is that Constitutional protection that prevents it from enforcing this role. That may change with the expectations already written - to retain the capitation fee - for patients to be enrolled in the Medical Home. (Due partway through 1919)
3. You say ‘ I know plenty of practices where signing patient's up is done by the nurses. This works well as they are often then in a less time restricted encounter. Often then the patient sees the GP who uploads a health summary.’ In some of the practices of which I have knowledge, the patients signed up were children, and healthy young adults. The health summaries were a breeze. I expect they filled their quota. But the work to be done to create summaries for older patients with lots of problems - one simply could not ‘cost justify’ the time. And there was no administrative obligation to do so.
4. Since you have never practiced medicine, you have no practical experience of our onerous responsibilitie s - of our ethical and medico-legal obligations. When we see a patient for the first time, it is incumbent on us to interrogate the patient for their allergies and drug reactions, their current medications, and their complex and chronic illnesses - before we discuss the reason for their attendance. Unless every GP, in sequence, has competently updated a patient’s MyHR as they attend, those listings may be in error. I consider they cannot be trusted. Knowing what I know about actual medical practice, I cannot assume that work has been done. I cannot be held responsible for errors and omissions in what the patient tells me at the time I see them. Certainly we will contact the previous clinic for a faxed summary statement from that clinic’s medical database. And one makes a clear distinction between the patient who is formally moving from the care of one clinic to another clinic - and the patient who is ‘travelling through’, has an intercurrent problem, or has run out of medication.
5. What really disturbs me is that you, as a ‘non-doctor’, are actually telling us how we should do our work. And, implicitly, what payment we should be prepared to accept for doing it. I know you do not see it that way, and I am making no allegation of impropriety - just an inability to get into the ‘clinical mind’. The medical record process is an integral part of clinical care. What is a competent medical record - medical record process - medical treatment process - is a question for fully trained and registered doctors to consider. As an IT person, with substantial skills in medical, clinical IT, you are very valuable. This process will proceed, and you will be part of it. There must be found competent and efficient ways of improving clinical care. Those ways will continue to acknowledge that the clinician’s brain and mind - and hands - are the primary tools of clinical care. Clinical knowledge, experience, judgment, wisdom - and precision - are the fundamental attributes of a competent doctor. The attempt to substitute silicon intelligence for any of these is retrogressive.
There are real problems with the ‘Medicare cloud in the sky’. Like there are real problems with the NBN. Both may be overtaken. With the Medicare cloud in the sky having already cost two billion dollars. Money that should have gone into primary clinical care.
# Kate McDonald 2018-02-07 12:44
Just to clarify, GPs are not expected to upload discharge summaries. They are uploaded to the patient's My Health Record by the hospital itself, where the patient, their GP and other healthcare providers can also see it.

This has been in place in Queensland public hospitals since late 2013: https://www.pulseitmagazine.com.au/news/australian-ehealth/1671-queensland-hospitals-sending-discharge-summaries-to-pcehr

Some private hospitals can also upload discharge summaries: https://www.pulseitmagazine.com.au/news/australian-ehealth/2889-private-hospitals-using-hips-to-upload-discharge-summaries-to-myhr
# Glenn Rosendahl 2018-02-07 12:57
Thank you Kate, I did not know that. Do you know what recourse a patient has, if they are not happy with, or disagree with, information disclosed in the discharge summary?
# Kate McDonald 2018-02-07 13:01
The patient is able to "hide" documents if they so choose. That has been a big topic of debate, as some argue that would mean their record is incomplete.

Patients can also withdraw consent for having their discharge summary uploaded automatically when they are admitted to hospital.

Queensland GPs will still receive discharge summaries by Medical Objects or other secure messaging services (or by fax or post).
# Kate McDonald 2018-02-07 13:05
You also asked earlier about the process for uploading pathology reports and how the consent/authori sation model would work. This article might help clear a few things up:

https://www.pulseitmagazine.com.au/news/australian-ehealth/3803-copy-to-doctor-how-test-reports-will-be-added-to-my-health-record
# Ian Mcknight 2018-02-08 22:35
Hi Glenn,
1) Forgive me if I don't send you my CV. You are not offering me employment, and if you were, I suspect it would end in tears,... probably mine :-)
Suffice to say I worked from mid 2002 to mid 2016 in an organisation that morphed from a Division of General Practice to a Primary Health Network. After the first 12 months I was given the brief of helping general practice use their clinical systems more efficiently. I was lucky enough to be given a reasonably free hand in how I did things as long as I undertook to listen to the needs of my customers, principally but not just GPs. This freedom started to erode with the more convoluted bureaucracies that prevailed in the phn world. So my core business was (and is) tutoring clinicians in the effective use of Medical Director and Best Practice, with a view to saving clinicians valuable time, and enabling them to create and maintain a quality electronic medical record. Since August 2016, I have been doing the same work in a private capacity for a large number of Tasmanian Practices, (none of whom have ever asked for my CV)

Your inference or rather claim is that I have a vested interest. I can promise you that my promotion and endorsement of the MyHR has never resulted in any financial benefit to me. I would concede, I suppose that some knowledge of the subject matter may influence some of my customers to retain me. However I have always only promoted things that I personally see value in, so I do spend a lot of time encouraging MyHR takeup by clinicians as well as the use of electronic correspondence, both of which are components of the clinical software that I support.

When I first started back in 2003 I was almost embarrassed that precious public health dollars were spent on people like me, rather than clinicians or medical equipment. I felt that, and I imagined the GPs I was dealing with were thinking that too. Every day we would hear about long hospital waiting lists and clinician shortages, and yet the feds were funding us. So this made me feverishly keen to a) "win over" GPs by being as useful to them as I could, and b) to have a "red hot go" at helping improve things in the health space, as opposed to confirming to some of the lazy behaviors that can prevail in public service type organisations.

I must confess, despite being no longer funded publicly, I have retained those motivations in my private role. Don't worry, there is absolutely no business or lifestyle benefit to me in staying up till 2 in the morning, typing reams of text, trying to move an immovable object!

2) You said too much here for me to have any hope of covering, but 2 things. In Tassie at least, the public hospitals are uploading discharge summaries for patients who have a MyHR at the same time as they send it to General Practice. I don't know whether it depends on human behaviour or is fully systemised, but they are uploading a quantity.

Regarding me being cowed about expressing my true opinion, you really don't know me. If I had just been a "message of the week" guy, there is no way I would have built the trust I have with my customers. If you ask me what I think, I will tell the truth, regardless of who is or used to pay my salary. So when I say "I don't have an opinion", I really don't, and I try quite hard not to have opinions on stuff I know nothing about,...you may disagree!
3) For sure there will be simple summaries and complex ones, no doubt. I may be guilty of over-simplifyin g here, but I still feel that if the local electronic record is in good order, then creating a shared health summary will just flow from that. I may be over-simplifyin g the effort in maintaining a good local record for a complex patient I guess, although I'd feel happier about accepting your claims if you'd actually done a shared health summary.

4) Re onerous responsibilitie s, I hear you, but everything that you point out that is potentially missing from the MyHR could easily missing from the faxed health summary you just requested from the previous practice. What if their GPs were not fastidious with their maintenance of their local emr for that patient? It seems you would rather request a fax be sent rather than click a button, despite being time- poor and underfunded. It seems you are accepting of the possibilities of errors or omissions using old technology, but horrified about the exact same errors occurring in new technology.

5) Gee I really don't think I was telling you how to do your job. Yes the conversation has broadened, but essentially all I have tried to do is correct some of the incorrect or exaggerated claims I feel you made around the MyHR. You have issued other questions and I have tried to answer them. You are absolutely right when you say progress has to happen with clinical and technological minds working together, but awkwardly, not all clinical minds share your point of view around the MyHr issue. I know skeptical or "anti" GPs for sure. I also know several who have "come around", and some of varying ages who could see the possibilities and were keen from the get-go. Certainly amongst fresh out of hospital registrar types, many of them want to know what the hold-up is!

And yes, connecting every single household and business in the 6th biggest country in the world to high speed internet is going to cost a lot of money....go figure. There's a lot to do and we tend to pay high wages in this country. And Yes a nationwide electronic health repository accessible real-time from all parts of the health sector will cost a lot of money. Of course it would cost a bit less if we didn't have to pay incentives to practices to use it....
# Glenn Rosendahl 2018-02-10 23:01
Kate, thank you for those comments. I will respond:
1. Just because Queensland Health does now upload summaries, they are not necessarily timely (I have to chase discharge summaries that should be sent to me on discharge by Medical Objects. They must be written, first.)
2. I found the article you cited confusing. That is not your fault. Your summary made more sense.
3. Acknowledged, that patients can choose on hospital admission NOT to have discharge information uploaded - but that process makes a mockery of ‘informed consent’. The patient has no idea on admission what diagnoses will be made, whether embarrassing data will present itself. ‘Consent’ has no meaning unless it is ‘informed’ - which can only happen at discharge. What medical IT is stating - as it has now stated for over a decade: ‘We cannot do this any better. You must be content with this’. Try and set up the same medical records process for ‘in hospital care’ as a junior version of the Commonwealth My HR - well you have just written the article on it! Its called EPAS! The pollies are condemning it. It is now an issue in an election!

Ian, again I thank you for your comments…
1. What you have sent me is what I wanted to know. Many thanks. (Perhaps I could find more on your LinkedIn posting?)
2. You make an income - in part - by and from your knowledge of IT. That is fine. What you are saying that you teach people to use MyHR, but you are not selling it, nor making any profit by the process of enrolling patients in it. Which is an implicit acknowledgement of the ‘vested interest’ of my colleagues who DO make income from enrolling patients in it, but presumably do not disclose that conflict of interest.
3. You make a naive assumption: ‘if the local electronic record is in good order…’ But you are not a GP, so how can you know? As a locum over the past 3+ years, I have viewed the records kept in numbers of practices, contributed to by a much larger list of GPs. In the land of bulk billed medical practice, there is commonly no formal attempt to keep patient medical files ‘up to date’. Nor can I afford to be the bunny who curates and updates all the files I get to see as well as giving that patient the appropriate time for the problems they bring. (And they will try me out with their ‘shopping list’, and I am give kudos if I am prepared to consider it.) I have no doubt this will continue, and other doctors reading MyHR will be confronted with notes written in acronyms, One line statements, bad spelling, or a substantial page of negative (normal) findings, documented as the standard diagnostic templates dropped from BP or MD (makes the record look good, but I wonder if all the historical matters recorded are actually covered, all the exam results are real…) particularly if the diagnosis is a common respiratory infection, treated with an antibiotic, all the patient probably needed (wanted) was a sick certificate…
But just look at the Blog piece from Kate McDonald about EPAS: ‘Pity the poor software vendors’. There are problems all over the place.

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