Doctors' views on patient access to EHRs "need to evolve"

A recent survey by technology services company Accenture found that while most Australian doctors want patients to actively participate in their own healthcare, there is still a great deal of reluctance about allowing patients full access and input into their electronic health records, a view that will need to evolve as patient expectations change.

Leigh Donoghue, managing director of Accenture’s health business in Australia and New Zealand, said more needs to be done to enable consumers to play an active role in their own care, including overcoming the cultural issues that suggest Australian doctors may be more resistant to change in this area than doctors in comparable countries.

Accenture's survey of 3700 doctors worldwide included 500 in Australia. Of those Australian doctors surveyed, 83 per cent said they want patients to actively participate in their own healthcare by updating their electronic health records.

The survey found broad agreement among Australian doctors that patients should be able to update standard information in their health records, including demographics (87 per cent) and family medical history (78 per cent).

However, a significant proportion of doctors were opposed to patients providing updates in areas such as medications (29 per cent), medication side effects (28 per cent), allergic episodes (26 per cent) and lab test results (59 per cent).

The level of opposition to such patient input was notably higher than most other countries, the survey found.

“That is the thing that stood out for me when I look at Australia and the other countries surveyed,” Mr Donoghue said. “There was commonality across countries, and a growing interest reported, in the benefits of increased use [of EHRs and EMRs], but it was around patient access and the patient's ability to contribute to the record that we saw some notable differences.”

Mr Donoghue said some of this is likely to reflect cultural differences but there were economic reasons as well. In the US system, for instance, patients have more choice in healthcare provision, which Mr Donoghue said adds a competitive element not apparent here.

“You see countries at one end of the continuum like the US where it seems that clinicians' attitudes are that not only should patients have access to much of the record, but they should be able to play an active role as a co-contributor,” he said.

“Australia is towards the other end of the continuum with countries like Germany, where doctors are more reluctant. I think there are some pretty legitimate reasons why they may feel uncomfortable with some of this; for instance, the ability of patients to contribute to the interpretation of their pathology results.

“Most doctors would feel uncomfortable with that, but again it's the comparison across countries that points to a more deep-seated cultural issue around perceptions of the patient and the role that the patients play and should play in the management of their own care.

“I think some of it is a lack of familiarity with models of care where the patient is actively involved and plays a useful role. In the US, because the patient has more choice arguably, there's a competitive dimension to put more emphasis on the patient experience. I think coming from a public health system we don't have that natural driver.”

The survey found that less than a quarter of Australian doctors (18 per cent) believe that a patient should have full access to his or her own record, 65 per cent believe patients should have limited access and 16 per cent say they should have no access.

Australia ranked second highest of the eight countries surveyed in the proportion of doctors that say patients should have no access to their record.

Mr Donoghue believes this will have to change as patients become more accustomed to having easy electronic access to their own information.

“It is going to have to change,” he said. “That is what we are seeing in other industries. One of the big differences is the uptake of mobile devices and the consumer having information and the ability to transact at their fingertips. If I can do that in banking and with telecommunications and I can do it with many of the services that I receive, why can't I do that with healthcare?

“It is the road to the digital citizen and the digital citizen doesn't take a different approach to healthcare. That's why I think these cultural issues and their implications for how we provide health services are going to have to be tackled.”

Doctors themselves are more routinely accessing clinical data electronically, with 83 per cent saying they were actively using electronic medical records and roughly 70 per cent reporting improved quality of diagnostic and treatment decisions as a result of their use of shared electronic health records.

The survey also reported a 62 per cent increase over a similar survey in 2011 in the number of Australian doctors who said they routinely access electronic clinical data about patients previously seen by a different health organisation, from 26 per cent in 2011 to 42 per cent in 2012.

The 2012 survey was conducted in October and November last year so the effect of the PCEHR cannot be factored in as a part of this rise, but Mr Donoghue, who was involved in building the PCEHR as part of the Accenture-led National Infrastructure Partner consortium, said this will change in time.

“The combination of smartphones, faster broadband, mobile access to the PCEHR system, and a growing array of mobile health applications will trigger fresh demands from consumers for more active participation in managing their own care,” he said.

“There are obviously some things that have to be done and which are happening now. There are infrastructure issues that have to be addressed – one of the biggest gaps in our health system is connecting hospitals and supporting the sharing of information from hospitals.

“Clearly some key constituents in the healthcare ecosystem don't have electronic medical records at all – allied health specialists, even in aged care there are some big gaps – so we need to fill those gaps to start with, and then look at some of the incentives that are required to encourage the sharing of information, but that has implications for our care models.”

He said there are some deep-seated education, training and cultural issues that will need to be overcome to improve information sharing, which will have a flow-on effect on models of care.

“When you are moving from independent physicians to more multi-disciplinary care as is required around chronic conditions, there are new models to be looked at and the sharing of information is critical to being able to provide the quality of care that patients need and physicians want to deliver,” he said.

Incentives are also required, both from the public and the private sector, he said, and sectors that are not well connected, such as aged care, will need to overcome problems with a basic lack of infrastructure.

“Some of it has started. The ePIP program that the government has introduced – that seems to have had a real impact in terms of GPs upgrading their systems to be conformant with the PCEHR and to support a higher level of sharing.

“Aged care is a great candidate because there is such a focus in terms of health reform and eHealth has a huge role to play as part of that.

“One of our shared challenges is to take eHealth from being a niche focus and mainstream it and connect it to some of the other reform initiatives that are happening so that it just becomes part of how care is delivered.”

Posted in Australian eHealth

Comments   

# Edwin Kruys 2013-07-23 10:16
"If I can do that in banking and with telecommunicati ons and I can do it with many of the services that I receive, why can't I do that with healthcare"

Do banks allow you to change figures in your online statements?The flaw in thinking here is that there is a difference between a patient eRecord and a professional eRecord. Patient access to a professional eRecord is fine, but allowing patients to change e.g. their medication record will lead to more confusion and potentially errors.

Patient-centred care needs a clinician-centr ed eRecord. Make it easier for professionals to do their jobs, not more confusing.
# Mike C 2013-07-23 12:54
Great point Edwin - thoroughly agree with you. The analysis in the article is quite limited in that it does not actually address the issues that are of concern to practitioners.
# Kath N 2013-07-23 14:07
Having experienced patients with their self diagnosis and also one lady who bought in her version of her medical history, which turned out to be acutely inaccurate, I would be extremely reluctant for patients to enter their "version" of their medical history.
# Paul Jenkinson 2013-07-23 15:28
This article demonstrates the lack of experience that people working in e- health have in dealing with people in the community across all the spectrum who have a infinite number of different health scenarios relating to their physical,psycho logical,spiritu al and social well being.Some people could be relied upon to input accurately into their health record but,unfortunate ly,after 40 years in the game,I know they would be in a small minority.
# Heather Leslie 2013-07-24 10:46
Lets tease out some of the issues here:
Of course all the right security, access rules etc needs to be in place to underpin a collaborative EHR environment - this is a given. Let's assume this is technically achievable.
And lets also assume that patient input is 'appropriate' – ie that their contributions are clearly marked as patient-entered (vs clinician-enter ed); they cannot edit/modify existing clinician documentation directly as this is a medicolegal issue, but they could potentially annotate it or make comments on existing clinical notes, especially if there are errors in the notes. I cannot fathom why patient contributions that are included in the health record in a sensible, safe and transparent manner cannot be a useful contribution to the EHR. You either talk take a history from a patient or read what they've written. A user interface that focuses on the user will also help – ensure a sensible clinical focus for each type of clinician, and likely a slightly different view and even terminology for patients/consumers.
It is the human issues that are somewhat more complex, especially clinician attitudes/comfo rt with sharing health records. If you talk to Jamie Ferguson from Kaiser Permanente (keynoted at HIC last week), their real-life experience with doctors and patients collaborating openly is exactly the opposite. His point is that they have learned IN ORDER TO PROVIDE EFFECTIVE TEAM-BASED CARE, EVERYONE NEEDS TO BE ABLE PARTICIPATE. The docs who work at KP and their patients embrace that philosophy and apparently are finding it hugely successful - this is not the usual way of practice elsewhere in US, nor currently in AU. I think we are seeing a shift in attitude as collaborative care comes to the fore here.
# Edwin Kruys 2013-07-24 11:36
"lets also assume that patient input is 'appropriate' – ie that their contributions are clearly marked as patient-entered (vs clinician-enter ed); they cannot edit/modify existing clinician documentation directly as this is a medicolegal issue, but they could potentially annotate it or make comments"

Great, go for it! This sounds a lot better than the PCEHR where patients can 'hide' certain information - which is one of many reasons why clinicians find it hard to use & rely on the PCEHR.
# Sue Rostron 2013-07-24 12:34
Yes, I agree Edwin. This gives patients a chance to record their understanding of events and (gasp) potentially challenge professionals; recoding of health events and interventions.
Dear to my heart after many mis-diagnoses with our younger son's care that still haunt us now when we try and get care for him.
Why is health still one business where the consumer is always wrong until a professional proves them right?
# Edwin Kruys 2013-07-26 10:17
Good question Sue, not easy to answer of course. It has inspired me to write a blog post. Hope you like it.
"Why is the health consumer always wrong?" http://doctorsbag.wordpress.com/2013/07/26/health-consumer-always-wrong/

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