Clinical utility of PCEHR an urgent priority: UGPA
General practice representatives have called on the new federal government to address what it says are significant clinical utility issues associated with the PCEHR.
The United General Practice Australia (UGPA) group has issued a statement saying its members had unanimously agreed that the focus of the PCEHR needed to be redirected to clinical utility and standardisation.
The move follows the resignation of all but one of NEHTA's clinical leads, including high profile clinicians such as Mukesh Haikerwal and Nathan Pinskier, in August.
Many of those clinicians believe the PCEHR is a worthwhile endeavour, but that there are a number of aspects that need improvement, especially ease of use for clinicians – particularly for GPs – a streamlined registration process and meaningful use of the system.
One former clinical lead who did not wish to be named told Pulse+IT that while he believes the PCEHR will be clinically useful eventually, it had become apparent that neither NEHTA nor the Department of Health were listening to the concerns of GPs who were actually using the system.
AMA president Steve Hambleton said that by “clinical utility”, doctors were referring both to information that would be useful but is not yet in the PCEHR, as well as the actual ease of use of the system.
“[Clinical utility] really really means both,” Dr Hambleton said. “Something that doctors will find useful in their day to day lives and something that is easy to use, that more than 'does not interfere with workflow', more 'enhances efficiency'.
While the AMA wants greater GP involvement in every aspect of the system's development, that does not mean taking away control from the patient, he said.
“The AMA wants to make sure that clinicians have confidence in the information that is there, that it is up to date and the most recent health summary is indeed the most recent health summary, making it clinically useful,” he said. “We have no problem with the patient being fully engaged in their own health record.
“[But] unless there is more than a critical mass of accurate, accessible, clinically relevant information, there can be no clinical use.”
The UGPA statement also called for a system that is “supported by an acceptable, and robust legal and privacy framework”. Asked if these issues had not already been resolved, Dr Hambleton said the statement was more about the confidence of clinicians that these indeed exist.
“If they were all sorted out last year and indeed most of them were, then that information needs to be shared,” he said.
He said the main problem was that an enormous amount of work was being done on extra functionality “when what was required was a focus on what the hard-working GP in the suburbs wants to help coordinate and make their patients' health care safer”.
Australian Medicare Local Alliance (AMLA) representative, NSW GP Tony Lembke, said what UGPA wanted to see was a system that is practical and usable in the clinical context by grassroots GPs.
“We realise that's a work in progress but it needs to remain a focus of development,” Dr Lembke said. “I think the shared health summary as designed being uploaded and curated by GPs is quite an appropriate first step because it's clinically relevant and useful and we should focus on making that work before we move on to more high level functioning.
“Let's do one thing, build it, make it work and move on. The next thing I think they need to work on is a central point of truth for medication management, which would have a lot of clinical impact.”
Dr Lembke said each software vendor had implemented the system differently, and some of them offer a smooth connection to the PCEHR while others are a bit clunky. He uses Genie in his practice and welcomed the introduction of an in-built Assisted Registration Tool (ART) to sign patients up, but he said registrations weren't the problem.
“We need to focus on clinical usefulness of the PCEHR, not just registrations. The functionalities behind it aren't as useful as they could be.
“And when you do access the PCEHR, the information that is presented there is in a way that isn't really clinically useful in that the way the medications and MBS data [is presented] is useless.
“It makes it difficult to … find what you're wanting in a reasonable way. Certainly, work on improvements to Australian medication management would be really useful clinical benefit.”
Dr Lembke, who acted as a clinical lead for NEHTA until last year, said NEHTA was well aware of the issues raised in the UGPA statement. “The clinical leads will continue to advocate for clinical functionality and usability and ownership as the key to having a successful rollout,” he said.
From AMLA's perspective, it is enthusiastic about the potential benefits of eHealth and wanted to ensure that the work that has been done to date is leveraged rather than wasted.
“We are enthusiastic about eHealth having the potential to benefit community health outcomes, and we feel that usability, clinical ownership, clinical benefit, safety and funding, are the key issues.”
Andrew Howard, former head of the PCEHR with NEHTA, said one of the problems with the PCEHR at the general practice end was the poorly designed interfaces in GP software.
He said the provider portal that acute care clinicians are using is a much better designed product. This portal was designed by Orion Health; Mr Howard is now head of eHealth for Orion.
He said some of the criticism about clinical utility was probably due to usability in the general practice environment, which he says is very poor.
“Frankly, the software vendors did the minimum amount to connect and get the practice compliant with the connectivity requirements of the PIP payment, but they didn't actually look at the clinical process flows in most cases,” Mr Howard said.
“So you've got poorly designed screens and poor interfaces in that environment. As part of the certification process for practice software, software doesn't actually need to go through a clinical usability test as part of the certification. So that's the sort of issues in the GP environment.”
He said NEHTA and Orion had spent a lot of time on clinical usability when building the provider portal, both in the design of the clinical documents and the mechanisms to access the PCEHR.
When GPs see the provider portal, they “love the interface”, he said. “The portal is a much better user experience than their GP software, which is a crying shame because the GP software [vendors] should be spending the time to build something better.
“The theory of the program was that the portal should be a stop gap and that the innovation should take place in the GP end, or any other system that was connecting to the PCEHR.”
The provider portal is live in hospitals in the ACT and some in NSW, where Mr Howard said there was “a seamless integration to the PCEHR”.
“A clinician in the ACT is accessing pathology results that might be stored in a local hospital system, that's pulled out of those systems and stored in a clinical repository that's displayed through the portal.
“In exactly the same interface they can click on another document, which might be the shared health summary on the PCEHR. So for them, the clinical workflow is seamless, whereas if you're in a GP software system you have to go to a different screen, do a bunch of things and when you pull down the document it's not rendered properly.
“The experience in that environment is ugly, the experience in ACT Health is seamless and straightforward. If you survey clinicians in that environment they probably don't even know they are looking at PCEHR data, it's coded differently on the document tree, it's got a different highlight on it, but to them it's just another clinical document in their flow.”
Mr Howard said that with GP software, there were some good examples but more were bad. While the submission process was easy, it was in viewing the documents on the PCEHR that was the problem.
“The viewing side of things is where the cumbersome side starts to kick in in practice software,” he said. “I can view a document but the way to do that is through four or five screens. They haven't focused on how to display the information.”
Federal government review
The federal government has promised to review the PCEHR, telling Pulse+IT when in opposition that it would do a ”stocktake” of the system if it gained government. Health Minister Peter Dutton also committed to reviewing the system as part of his pre-election eHealth policy.
In its statement, the UGPA said “significant issues” with the system had been identified and there was no alignment between consumer registration and meaningful use through engagement with the clinical community.
“In August 2013 a number of key clinical leads resigned from National E-Health Transition Authority (NEHTA),” the statement reads. “This was amidst ongoing concerns and requests for NEHTA and the Department of Health and Ageing (DoHA) to review the PCEHR development cycle and re-establish meaningful clinical input.”
The UGPA states that DoH has become the system operator since August (it has in fact been system operator since 2011) and that since then “opportunities for clinical engagement have been less clear”.
Following the mass resignations, a DoH spokeswoman said the department was now taking the lead from NEHTA in consultations with medical groups.
In its statement, UGPA said it was "calling on government to implement strategies to ensure the PCEHR is best structured to improve the health outcomes of all Australians. The process should be profession led and include:
- GP input at every level of the PCEHR development life cycle; including planning through to implementation
- ensuring the system is clinically safe, usable and fit for purpose
- supported by an acceptable, and robust legal and privacy framework
- secure messaging interoperability is a critical dependency priority.
“E-health and the PCEHR have the potential to transform Australia’s health system and provide superior, safer and more efficient healthcare to all Australian patients. UGPA members believe that this potential will only be fully realised if there is meaningful clinical engagement at a grassroots level.”
UGPA comprises the Royal Australian College of General Practitioners (RACGP), the Australian Medical Association (AMA), the Australian Medicare Local Alliance (AMLA), the Australian General Practice Network (AGPN), General Practice Registrars Australia (GPRA), the Australian College of Rural and Remote Medicine (ACRRM), and the Rural Doctors Association of Australia (RDAA).
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