Trust me, I'm a ... data manager
“Grete long cures note in folio/ shorter common cures that come or send in half side or quarto/ note visiting cuers in a manuell." Thus wrote Dr Barker in early 17th century England, advising his colleagues on the way to record medical treatments. It was early days in Western medical data management and the routine recording of a patient's clinical details was a long way off.
Things changed little for centuries. The doctor's diary was, like Samuel Pepys', a personal record of his life. While it contained some clinical details, it was for private thoughts and memoirs and was not written with the patient in mind. The physician's day book was more financial than clinical record and Dr Finlay's Case Book was produced primarily for the edification of the audience.
Dr Joseph Bell, Conan Doyle's inspiration for Sherlock Holmes, would have had little need for documentation. A brilliant mind and shrewd observation seemed to make both history taking and medical records superfluous.
By the early 20th century, science and medicine had changed. Early diagnostic testing added to the volume and complexity of the data that needed to be managed. More people were involved in an individual's care. In 1906, Dr Henry Plummer of the Mayo Clinic sparked a revolution in medical data management. The "unit record" contained all the patient's data in one folder that accompanied the patient around the clinic.
Despite computerisation changing both the world and medicine in the last 40 years, medical records have been surprisingly resistant to its advances. The vast majority of Australian hospitals still use paper records for patient management, but the business case for computerisation in general practice has been much stronger.
Over the course of 10 years from the early nineties, electronic health records progressed from printing scripts, producing health summaries and generating letters to note taking, pathology and radiology processing and finally document handling. By the early 2000s, many practices were completely "digital".
Form follows function, but function does not follow form. Cheap, near instantaneous communication has been a reality since the late nineties. Education, banking and the business supply chains have readily embraced it. It continues to make significant inroads into retail. Ten years ago it seemed inevitable that the medical IT marketplace would develop solutions for rapid, seamless, secure communication.
It didn't happen. Clusters of proprietary medical data transport systems developed in pockets around the country, but the coverage was patchy at best. There was no incentive for competing companies to interoperate and many medical practitioners, after dabbling in electronic communication, returned to the lingua franca that paper provides.
In 2005, the government established the National E-Health Transition Authority (NEHTA) to break the impasse. To the outsider, the pace of change has been glacial. This is probably inevitable given the foundation work needed for developing the legal framework, medical IT standards and specifications, and for developing the authentication infrastructure for the Australian populace. These were major undertakings but made no change to a GP's day to day medical practice.
This is about to change. Since May 1 2013 all commonly used general practice software suites can interact with the personally controlled electronic health record (PCEHR). In the initial phase, the PCEHR is focusing on producing a shared health summary (SHS), a communication tool between the GP and the patient, summarising their significant health issues, medications, allergies and vaccinations.
While patient education and involvement in their clinical management is a crucial component of modern medical management, the cost of this new activity is borne by the general practitioner. Significant government incentives have been required to encourage GPs to engage with the process.
With the eHealth infrastructure in place we are now over the crest of the hill. The business case for GP involvement will be compelling. When GP software is able to auto-populate a health record from a shared health summary, hundreds of thousands of hours of GPs' and secretaries' time will be saved. eReferrals should come on stream from 1 August to provide similar functionality for specialists and hospitals with electronic record systems.
Medication management may improve using the PCEHR system, although early implementation has been problematic due to the failure to incorporate patient Individual Health Identifiers (IHI) in the script submissions. This will change as the use of the national patient identifiers becomes more widespread. Once electronic records develop the tools to merge the differing medication lists that currently plague a GP's working day, medication errors should decrease.
The handling of investigations and reports may also change. Posting comments and instructions on significant pathology and radiology reports to the PCEHR may both speed and smooth the patient's journey. How GPs will use these and the other new capabilities of the PCEHR is yet to unfold.
There has been much debate about the privacy of online records. Almost daily breaches of medical record repositories are reported in the USA. While the PCEHR privacy controls are reasonable, there is no guarantee, or even likelihood, that any online record is 100 per cent secure.
In Western societies, healthcare is increasingly complex, invasive and costly. Sophisticated, technically advanced, diagnostic and therapeutic interventions require a similarly sophisticated system to handle the data that they produce. Dr Plummer's paper chart is no longer fit for purpose. Information and communication technologies have the potential to make healthcare better and cheaper by reducing both the loss and duplication of medical data.
Patients can no longer rely on a Dr Finlay, or even a Dr Bell, to be all knowing about the best way to manage their case. To get the benefits of the system, patients will have to trust the system, accepting some loss of privacy in the process. For certain groups, particularly the elderly and the chronically ill, it will be a trade off that many will take.
Dr David Guest is a general practitioner at the Goonellabah Medical Centre in Lismore, NSW. He has a long-standing interest in IT for general practice and is a member of the Improvement Foundation's eCollaborative project.
Posted in Australian eHealth