ACRRM advocates secure messaging over PCEHR

The Australian College of Rural and Remote Medicine (ACRRM) has recommended that the federal government widen the focus on electronic sharing of health information from the PCEHR to more foundational elements, such as interoperable secure messaging, incentivising medical specialists and allied health to implement clinical information systems, and increasing the value of clinical documents.

In its submission (PDF) to the three-man panel reviewing the PCEHR, ACRRM also takes aim at the supposed lack of clinical input into the design of the system, the lack of consultation with rural and remote practitioners, and highlights how a lack of basic infrastructure such as high-speed broadband will inevitably limit the value of the PCEHR in rural and remote Australia.

While ACRRM doesn't recommend it, the college does raise in its submission the option of clinicians taking control of the record rather than the patient, and a reversion to an opt-out system.

ACRRM states that basic point-to-point sharing of information should have been the emphasis before widening the scope to the PCEHR.

“If information is not flowing electronically today between the patients’ healthcare providers then it’s a stretch to implement this for the PCEHR,” the college states.

“ACRRM recommends measures to increase the implementation of e-clinical systems used by other healthcare professionals (especially specialists, aged care and allied health) to enable the management of patient care to occur electronically point to point before introducing the capability to share this information electronically with any other providers.

“The college recommends measures to continue to support an open national secure message delivery solution – interoperable across all vendors.

“eHealth needs to support the sharing of relevant clinical information to relevant healthcare providers responsible for the care of the patient. If this cannot be done in a patient controlled repository then another repository or redesign of the existing solution should be considered.”

Controversially, the college dismisses claims that there has not been significant clinical input into the design of the system. It does criticise the “near total failure” of NEHTA to engage with the college as a key stakeholder and reports that it took a direct approach to Department of Health CIO Paul Madden before it was “belatedly” offered a place on NEHTA's clinical usability program (CUP).

However, in terms of clinical input, ACRRM says that while it agrees there was insufficient breadth and quality of strategic clinical input, it was not true that GPs and their organisations were not heavily involved.

“For example, the Royal Australian College of General Practitioners (RACGP) has been heavily represented at all levels of governance related to the PCEHR from the outset and has been in receipt of substantial grant funding from DoHA to provide input into and to promote the PCEHR,” it says.

“It is also the case that high profile clinical leaders from both the RACGP and AMA were recruited to manage change and ensure clinical input into the PCEHR.”

These include Chris Mitchell and Mukesh Haikerwal, past presidents of the RACGP and the AMA respectively, who have both had high-profile, salaried, leadership roles in NEHTA.

“Whilst employed as the Head of Adoption, Benefits and Change at NEHTA, Dr Mitchell also chaired the board of RACGP Oxygen Pty Ltd – a controlled entity and technology enterprise established by the RACGP in 2011.

“Another RACGP representative, Dr Nathan Pinskier, served on two NEHTA advisory committees, was engaged with the NEHTA Clinical Unit and is also an RACGP Oxygen Pty Ltd board member. The NEHTA Model of Ehealth Care display is located in the RACGP head office.”

However, Dr Pinskier told Pulse+IT that he had never been a member of the RACGP Oxygen board, and he was not sure which two NEHTA advisory committees ACRRM was referring to.

“I was the deputy head of the clinical unit under [Dr Haikerwal] and that involved attending a lot of meetings but there were no specific two advisory committees that I was a member of, to the best of my knowledge.”

He said ACRRM's criticism of individuals was “inappropriate and really disappointing”.

ACRRM states that the members of the NEHTA clinical leads program participated in the DOHA-funded, $2.5 million RACGP PCEHR Advocacy Workshop Project, which was still operating in October 2013.

“These workshops saw the RACGP and its GP representatives advocating for the uptake of the PCEHR in its current form whilst at the same time the RACGP began [publicly] criticising NEHTA and DoHA for not consulting with the profession and for producing a critically flawed product.

“It is the view of ACRRM that any blame for deficits in clinical functionality and design of the PCEHR must be shared by others, and cannot be wholly placed with NEHTA and the Department.

“Future development of the PCEHR and eHealth should seek to strengthen systems of probity and management of conflict of interest in dealings with peak medical bodies and their leadership in provision of strategic advice, consultancies, employment and in related-party dealings.”

The submission states that a survey of ACRRM members found that very few were actively participating in the PCEHR, and that the commonly raised concerns over accuracy, privacy and medico-legal issues were also real barriers to use of the system in rural and remote Australia.

One particular issue for rural Australia is the lack of bandwidth and network speed to support the use of eHealth tools. “Without a patient identifier communication with the PCEHR cannot occur. Accessing the Medicare Identifier service is not always possible at that point in time – the service could be down or the response time slow.”

It recommends that eHealth tools are architected to run efficiently in low bandwidth areas.

Among its other recommendations are:

• A re-think of the model of patient control
• Redesign of the PCEHR to improve usability by clinicians
• Incentivise specialists to use a CIS to improve uptake of electronic patient records across the system
• Build on shared care arrangements with specialists and develop that relationship as the basis for sharing data (as exemplified by telehealth)
• Resolve legal, governance and privacy concerns (whether perceived or real)
• Focus on clinical benefit – currently no benefit is perceived. Quality shared health summaries/discharge summaries will increase perceived benefit
• Focus on an open secure messaging system as a priority
• Support implementation more appropriately and compensate clinicians.

“ACRRM recommends an increased emphasis on information flow electronically between (to and from) the patient’s GP and other healthcare providers and their organisations point to point using national standards for clinical documents such as a referral, prescription, pathology and diagnostic imaging order and result and a discharge summary.

“Cut red tape and reduce the number of authentication certificates required by clinicians and healthcare organisations to perform clinical and government transactions.

“Work with clinicians and industry to create specifications for critical clinical communications and embed terminology into clinical documents as required to support smarter working.”

It also suggests that separate ePIP funding be made available even when practices do not participate in the PCEHR “to avoid a complete stand-still of eHealth innovations”.

“Currently all ePIP stops flowing if practices do not sign a PCEHR participation contract,” it says.

Considerations for inclusion in ePIP are quality telehealth involving secure transmission of data and encrypted messaging, security measures and dedicated internet connection for eHealth and telehealth in rural areas with low bandwidth.

It also wants government to provide a centralised training environment containing the practice management systems and clinical information systems used by hospitals, allied health and aged care and the PCEHR.

Other submissions

To review a table of submissions to the PCEHR review compiled by Pulse+IT, click here. This resource will be updated as more submissions become public.

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