The inconvenient truth about EMRs

It's a common tactic of incoming governments facing big budget shortfalls to call for an independent inquiry to investigate the horrors bequeathed by their vanquished foes, and it happens no matter what stripe your political colours.

Tony Abbott federally and Campbell Newman in Queensland were big fans of “commissions of audit”, arranging them as soon as they took government in the high hopes that the blame for all nasty manner of remedial action could be sheeted back to their predecessors.

The WA government under Labor's Mark McGowan has done the same, ordering a commission of inquiry into government programs and projects in May last year that was charged with looking at some big ticket infrastructure items, including a billion dollar hospital or two, that may have had a hand in gutting WA's once healthy balance sheet.

An accompanying Sustainable Health Review was also called with the express mandate to look at how to rein in expenditure growth in the health budget. The review panel, headed by former NSW Health director-general Robyn Kruk, handed down its preliminary findings this week, warning in its preface that the state need to confront some inconvenient truths.

So we were surprised when the panel, hearing from consumers and clinicians that access to medical information was increasingly important but still quite haphazard, decided in its wisdom to recommend that the government consider implementing a statewide electronic medical record, pending available finance. Considering the review was aimed at reining in spending, we were mildly perturbed by this.

The inconvenient truth for our industry is that no matter what is promised, EMRs can cost a hell of a lot of money and cause all manner of heartache. Did the panel take a peek at how certain other states had fared with their EMR roll-outs? As a former NSW D-G, Ms Kruk would be well aware of the dramas that befell eMR version one in that state.

Victoria had its HealthSmart, Queensland has been accused of blowing its budget and South Australia continues to feel pain from EPAS. The smaller jurisdictions in their wisdom haven't tried as yet, although the NT is about to begin, at a cost of $259 million.

With all of the billions spent, we are yet to see any compelling evidence that this is something WA needs to get going on at the moment.

We also believe that with the dramas WA experienced with Fiona Stanley Hospital's IT systems – now, we understand, much improved – and with Perth Children's Hospital's drinking water problems still fresh in the memory, it would make anyone think twice about plunging into a big new spend. And WA Health's handling of clinical and administrative IT has not been the Mae West in the past, pardon the pun.

Just last week, WA Health was given a warning by a former under-treasurer looking at its infamous Fujitsu contract that it really needs to be a bit more careful next time, so while we think there are some very good suggestions in Ms Kruk's report – increasing the use of telehealth, which makes so much sense to anyone with a map of WA, and closer information sharing with GPs – we'd be a bit wary of rushing into a digital strategy and a state EMR when the finances are so tight and the resources to support it simply aren't there.

Elsewhere in what was a busy week in digital health, we heard from MedicalDirector's CEO Matt Bardsley, who despite the misgivings of his industry association thinks the idea of introducing some minimum standards for clinical IT systems has some merit, not the least for assuring twitchy doctors that their software is safe and secure. We also heard from MD's former owner Primary Health Care, which has launched itself down its own digital route.

Australian Digital Health Agency CEO Tim Kelsey popped down to Canberra for Senate Estimates, where he poured cold water and not a little scorn on a report from last year by News Corp that there were no plans to put an ad on the telly to publicise the advent of the opt-out period for the My Health Record. Sadly though, interrogations of the government's eHealth policies keep being consigned to the last session of what is a very long day and at a time when only political tragics and Michaelia Cash's whiteboard are prowling the corridors of power.

And finally we had news this week about some rather ambitious plans to begin the task of digitising baby and child health records, with the National Children’s Digital Health Collaborative announcing a five-pronged strategy to investigate how technology can help bring up a new generation of healthy nippers.

We reckon this is rather interesting stuff and we'll watch with interest. There's no doubt it will be tough converting the Red Book, the Yellow Book, the Purple Book, the Green Book and the Blue Book into various eBooks, but we think this is a worthwhile endeavour. The iPhone generation lives in a digital world so it won't be much use capturing it on paper for much longer.

We'll have more on that next week but in the meantime, have a think about our poll question. Do you think WA would be throwing good money after bad if it introduced a statewide EMR?

To vote in our weekly polls, sign up for our weekend edition or leave your comments below.

Last week we asked if you though the Global Digital Health Partnership would bear fruit for Australia. The global gabfest didn't seem to capture our readers' attentions: 38.5 per cent said yes while 61.5 per cent said no.


0 # Terry Hannan 2018-03-03 15:51
Kate, this summary is excellent but not unexpected. It brings to mind a quotation by April Warner Slack of Harvard University. “Medicine is not a business. Our business is clinical medicine”. The frustration from clinicians you document would seem to indicate- and there is evidence for- that they were not involved in the EMR design. Also if they have been involved the EMR adaptation is not well founded upon good knowledge and research into “clinical information systems’. If it was and there was collaboration across the clinical and administration. If there was then system choice and design would much more likely to be successful.
0 # Glenn Rosendahl 2018-03-03 17:21
I am intrigued. State and Territory 'wide' public hospital based EMRs create an intervening level between individual practitioner (typically GP based) EMRs - such as MD and BP - and the Federal government's My Health Record EMR system, that is in beta development mode. Admittedly, public hospitals need a medical record system - and they all have one. Creating a standard model is a 'good idea'. The (physically) two public hospitals on the Gold Coast have an integrated EMR - I have no idea whether the other Queensland public hospitals use this same model, nor how integrated they are for database and function. But what will - in practical clinical terms, be the interaction of the individual GP clinic EMR, State or Territory (hospital and remote public clinic) EMR, and the Federal government EMR? There is a very practical problem as a corollary. Where the users of these systems are on salary (are not expected to perform unpaid overtime) and none of the money paid to them is diverted to cover the running costs of the institution, the problem does not exist. Where the users are paid 'fee for service', and that money has to pay for the running of the institution - and the duration of each service is extended in the 'curating', coordination and integration of several EMR's, clinical practice will rapidly become inadequate and non-commercial. This problem is not even admitted, let alone addressed.
It is a very convenient assumption by the Federal government that the final integration and validation of a patient's My Health Record is an ethical responsibility of the GP, and as such it is incumbent on the GP to create and maintain a ‘fully competent’ My Health Record at no additional cost to the government - nor to the patient. I fear we will be expected to contribute to the relevant state and territory EMRs on the same basis.
Unless, of course, the State and Territory EMRs will have automatic access to the Commonwealth My Health Record of every patient - living in, having lived in, or travelling through their domain.
0 # Kate McDonald 2018-03-03 18:19
Yes, hospital clinicians have automatic access to the My Health Record through their hospital EMRs. All hospitals in Queensland and NSW have had access for quite a few years, as have most of those in the rest of the states and territories. Victoria is still lagging behind a bit.

Queensland hospitals use the statewide integrated electronic medical record (ieMR), which is the Cerner system. Some such as PAH and Cairns, and I think Gold Coast, use the "digital hospital" version, which is more functionally rich than the basic version that has been used for the last decade or two. Most of the major hospitals will get that version in the next few years.

There is no interaction as yet between GP practice management systems (PMSs) and the Queensland ieMR, or any other EMR used in Australia, but work is happening right now to make that possible by using the FHIR standard. However, all Queensland GPs can request access to their patients' hospital records through a portal. This story has a bit more information on it:

The My Health Record is what we call an electronic health record (EHR), not an electronic medical record (EMR). Pulse+IT uses the standard meaning for an EMR, which is an electronic medical record used in hospitals.

The My Health Record is intended to be a repository of data from records held in different systems that are as yet not interoperable. I'm not sure what you mean by "beta mode". The My Health Record has been live since 2012.

GPs are subsidised for the time it takes to contribute a shared health summary to the My Health Record through the MBS and through the eHealth Practice Incentive Program (ePIP). They don't have to use it if they don't wish to, and probably about half of all GPs don't. They are not required to curate different records or create and maintain their patients' MyHR, but they are asked to be the nominated healthcare provider as they see their patients the most.
0 # Glenn Rosendahl 2018-03-03 19:34
Kate, thank you for your comments. I have worked in Aboriginal Health in the Remote Health Service flying to settlements out of Alice Springs, in Mareeba Qld. In general practice on the Gold Coast I get discharge summaries from the Robina and Southport sites of the Gold Coast University Hospital. At present I use Best Practice. The private hospital where I have had a pacemaker inserted and two ablation procedures still uses a paper based hand written record system. I taught myself to touch type in my 1969, my Final Year at Sydney Uni. I dictated the 'history and physical' for every hospital admission I made in 7 years as community physician in practice in Canada in the 70's. I know what good records are. I have been concerned about confidentiality issues in relation to the MHR medical records that can have an unpredictably wide circulation after their creation. However, from my reading, the content up to now has been severely synoptical. Much less detailed that the discharge summaries I receive (sometimes belatedly) from the public hospitals.
I suggest that most of my (locum) colleagues of the last 5 years would be annoyed if they had to provide daily clinical notes - with the detail that would make them relevant - to the My Health Record database. In practical terms, with a 6-10 minute patient turnaround, the clinical notes exist to simply to identify the problem, and demonstrate the service warranted an item 23 billing. There is only a modest clinical point uploading that brief information into the My Health Record.
Just what is the formal - and the practical - difference between the EMR and the EHR?
(In one Aboriginal Health Service I briefly observed, all records were - I believe deliberately - expected to be handwritten. They would not allow me to type them. Consequently there could be no accounting of time spent. Considering the distances an auditor would need to travel to visit clinics, it would have been very expensive to audit these records. Every service was billed as an item 36!
Apparently they got away with it.)
0 # Kate McDonald 2018-03-03 20:07
Happy to help, Glenn. I'm not sure where the idea that GPs have to upload daily clinical notes comes from. The My Health Record holds a shared health summary, which is supposed to include a problem list and medical history, but it doesn't need to be updated every time you see the patient unless there's a significant event. Best Practice has some online tutorials on how it works from a GP's perspective and your local PHN would have someone on staff to run you through the process if you are interested. Our friend Katrina Otto from Train IT Medical also has lots of info:

There's no separate MBS item number for preparing a shared health summary but you can claim level C if you are writing one and it takes longer than a normal level B consultation.

If you don't see any point in uploading a shared health summary then as a locum, you probably shouldn't worry too much. It might change when opt out comes in and everyone has a MyHR, but the idea was always that it was people with chronic illnesses and the elderly who'd benefit most. For Aboriginal people, the system might actually work if the AMS is using clinical software. It certainly did with the Northern Territory's version of the system.

Private hospitals are starting to hook up to the system but as you say, many are still on paper. Ramsay uses a system called Meditech, which is one of the big US companies in competition with Cerner, Allscripts and Epic, but they only use it for patient administration and billing. There are clinical modules that may be introduced if the Ramsay sees the worth (doubtful at the moment), but for the purposes of the My Health Record, the most important thing from hospitals is the discharge summary. Lots of private hospitals just post this out or if you're lucky send it by M-O. If it appears pretty quickly on the My Health Record then it might turn out to be useful for GPs.
0 # Kate McDonald 2018-03-03 20:26
After all of that, I didn't actually answer your question about the difference between an EMR and an EHR.

In the US they are used interchangeably but in the general Australian context, an EMR is the hospital record, accessible only by clinicians, while an EHR is a system that gathers information from disparate sources in and out of hospital, and includes info added by the patient. We generally call GP/specialist software PMSs or clinical information systems.

In terms of the national EHR, what was formerly called the Personally Controlled Electronic Health Record is just that: it is owned by the patient and includes records from disparate sources, such as a shared health summary written by the person's GP, event summaries written by GPs or nurses perhaps, a prescription and dispense record, hospital discharge summaries, but also patient-entered information, immunisation records and advance care directives.

Pulse+IT distinguishes between EMR and EHR mainly in that in the latter, data comes from different sources but also includes general health information that the patient can upload. And the patient generally owns the record, not the doctor. The thinking behind this is part of a global movement to make patients more responsible for their own healthcare by being better informed about it.
0 # Glenn Rosendahl 2018-03-04 11:01
Kate, who 'owns' the 'My Health Record'? The patient, the patient's GP, or the government? I would welcome the government's decision that a patient's MHR was 'owned' by the patient. I would ask the patient for a USB stick, copy the consultation onto it, and request the patient to update their own MHR - with whatever data they considered appropriate. But most patient's immediate response would be: 'that is too complex, please do it for me'. Implicitly... 'on your time, as part of this consultation'. Perhaps even: 'after I have left'. (Can you bill for that?)
Please be practical.
0 # Kate McDonald 2018-03-04 11:39
Hi Glenn. The patient owns their record. The government manages it, and GPs can look at it if they wish. They are being incentivised to update it, but they don't have to.

USB sticks are not practical, or safe.

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