Barriers to PCEHR uptake in the real world
One of the main criticisms of the PCEHR rollout that has featured in Health Minister Peter Dutton's public statements on the system is that it seems to be significantly underused, with many doctors reluctant to take part and those that are equipped to use it seemingly slow to begin uploading shared health summaries.
It is notable that two items on the PCEHR review panel's terms of reference are to investigate the level of use of the PCEHR by healthcare professionals in clinical settings, and barriers to increasing usage in those settings.
One person who has a great deal of knowledge about the relative level of uptake and the barriers in the general practice community is Katrina Otto, the well-known medical software trainer and principal and owner of Train IT Medical.
Ms Otto has trained hundreds of doctors in not only using clinical software like Medical Director and Best Practice but all aspects of eHealth, including secure messaging, ePrescribing, clinical coding and database cleansing, as well as the PCEHR itself.
For Ms Otto, there are a number of factors as to why the PCEHR might be considered “underused”, and most of them are reasonably easily overcome. Those that are the major sticking points are data quality and medico-legal concerns, she said.
“One question I get asked regularly is ‘What is the best medical software’,” Ms Otto said. “My answer is, ‘We can actually use any software badly, it’s about learning how to use them well.'
“The doctors I know who are real advocates of the PCEHR are already using their software well. They say, ‘What’s the big deal, we have that shared health summary information in our patient records, we print them now’. But when I am training onsite I sometimes see patient records with 120 items in the past history list and 20 will be serious and the other 100 shouldn't be there.
“Many are just ‘reasons for visit’ like care plans, cough, dressing – items that nobody looking at the PCEHR needs to know. This is now an enormous job for those practices, even focusing on their regular patients. Cleaning up one patient’s record could literally take an hour.”
Ms Otto said that when the PCEHR was first mooted several years ago, there was an enormous amount of negativity towards it, something that she still sees commonly enough today. However, she believes that much of the negativity arises from misunderstandings about the length of time it will take to curate or upload a shared health summary, about what actually goes on a shared health summary – some doctors still think it is their progress notes – and what can and can't be omitted from the record.
“It is 99 per cent misunderstanding,” she said. “If I get the chance to discuss each concern and educate about how it works – that we print out and share health summaries now and that's all this is at the moment – once I show them that and I can explain that, I don't have many issues at all.
“What I am hearing now, a typical comment when uploading a shared heath summary is, ‘It was underwhelming. After all that hype it was actually incredibly easy’.”
Ms Otto said there are two problems that she believes are serious barriers and they are issues she cannot answer. One is the issue of patients choosing not to include certain conditions, hiding parts of the record from view or not allowing a document to be uploaded, which is a common criticism from doctors.
“Something that does bother just about every doctor, I find, is the fact that patients can omit information and there is no way of knowing that is the case,” she said.
“While I could argue this is not dissimilar to patient referrals and health summaries we print now – they often are incomplete, and/or inaccurate – and perhaps not dissimilar to the current situation we have now where patients may not disclose all information in a consultation, the idea of viewing a PCEHR perhaps does imply an accurate reflection of the current patient health summary.
“Even so, many doctors feel just knowing the names of medications, rather than the patient having to remember them, will be incredibly beneficial.”
Medico-legal risk is a much bigger barrier, she said. Two recent events – the turning off of dispense notifications by the prescription exchange services at the request of the RACGP for duty of care reasons, and the negligence suit against a GP by an obese patient who developed liver cancer – have seriously disturbed many in the GP community.
“The fact that they turned off the the dispense notification functionality in our software with ePrescribing, that gastric banding case – the doctors talk about it,” she said. “They say they now have to follow up every referral, every test – there is this constant feeling like they are at increasing medico-legal risk and the PCEHR is another whole area that is untested. I think those worries are very valid and I can't answer those particular questions.”
Another common complaint is the lack of remuneration. As others have argued, even if curating a summary takes little time, over the course of a day and having seen many patients, it all adds up. Ms Otto is firmly of the view that a separate MBS item number should have been introduced from the start.
“Every doctor I have met agrees the PCEHR ideally would be helpful for accessing patient’s up-to-date medical information. The problem lies in who will keep that information up to date. It falls on the GPs to be the curators of this information and keeping it up to date in their software so it is ready to upload can be a huge job, especially for a patient with chronic conditions, for whom the PCEHR could be especially helpful.
“Every time that patient sees a specialist or allied health professional or is discharged from hospital the GP ideally updates that patient’s health summary – even though they may not see the patient again for a year or even possibly ever see them again. And they don’t get paid to do that.
“The other option is to wait until the patient makes an appointment to get their shared health summary uploaded, which they can only charge if it is part of a consultation, and then spend the time updating it. Doctors worry this will totally blow out their waiting times.
“There should be an MBS item number to create it, and that would have gone a long way to getting them on board. If the patients have complex, chronic conditions and complex team care, and the GP hasn't seen them for a couple of months because they have been off seeing their specialists and allied health professionals, that is going to take longer if they haven't been doing it on a regular basis.”
Some of the other barriers are simple: a lack of a clear understanding of what the PCEHR is from practices, and a very low level of knowledge of the existence of the PCEHR from patients, she said.
However, she does not believe that there should be pressure on clinicians to add documents, or those who have built the system to add extra functions.
“One of my concerns is that if we do rush it too much, we are going to end up uploading a mess. I've been working in the medical world for 25 years and we are focused on patients, not technology; we just don’t do change fast, we need to know it will be safe and beneficial. I actually think the PIP incentive was a really good idea. It did incentivise practices to take that next step with their technology use.
“All of this talk about why aren't we using it, it must be a failure – the more we rush it the more likely it is that it's going to end up being useless, whereas it could be fantastic. I was working in an outback WA Aboriginal Medical Service recently and especially in those rural and remote areas of Australia you can really see how helpful this could be, but it's just going to take time.
“I believe many Medicare Locals have done a great job providing IT support to help practices with this huge change and facilitating education but ongoing support is definitely a key requirement for increased use of the PCEHR, as is continuing discussion to address doctors’ concerns.”
If there is one major criticism she has of the PCEHR rollout, it is that moves towards interoperable secure messaging should have come first.
“I think secure messaging would have been the smartest way to start because when that works, it has so many benefits for the whole practice – it’s significant, time-saving progress,” she said.
“At the moment everyone is still drowning in scanning; privacy is compromised and we are still chasing vital patient information. Across Australia I hear practices complaining about the scanning workload because we don’t yet have an easy interoperable secure messaging system in place.
“Once all that medical information is received electronically, hopefully it will become a seamless process.”
Posted in Australian eHealth