Lessons from the coalface: the PCEHR in practice
Western Sydney has been at the heart of the rollout of the PCEHR, with many local GPs taking part in the early implementation plan as part of the Greater Western Sydney Wave 2 project.
That project involved not only early trials of the PCEHR itself, but also several initiatives launched by NSW Health as part of its HealtheNet project.
These include electronic discharge and event summaries, a clinical repository for CDA documents and one for diagnostic imaging, an electronic Blue Book for newborns, and a clinical portal to allow hospital and community clinicians to view the PCEHR from within clinical software.
Local GPs have also been heavily involved, including Kean-Seng Lim from Mt Druitt Medical Centre, Shanthini Seelan of Bridgeview Medical Practice in Toongabbie, and Toby Nasr of Metella Road Family Practice, also in Toongabbie.
Dr Lim, formerly a member of NEHTA's clinical leads team, was one of the first in the country to upload a shared health summary to the PCEHR last year. Dr Seelan has always been a strong advocate of the PCEHR, predominantly due to the benefits she could see for many of her patients. Dr Nasr, on the other hand, was a reluctant participant at first and voiced many of the concerns that other GPs have raised.
For all three, using the PCEHR with patients has not been overly burdensome and they all intend to stick with it. That is not to say it has been an easy ride, or that there are not problems with the system that need to be looked at.
Dr Lim was one of a raft of clinical leads who did not renew their contract with NEHTA, following the lead of the head of the program, Mukesh Haikerwal.
Dr Lim prefers not to get into the politics of that saga, but is happy to discuss the benefits as well as the limitations of his experience with the PCEHR. One of those limitations is the overall cumbersomeness of the system, which he believes needs to be improved.
“There were quite a lot of lessons to be learned about how you do and how not to implement a program,” Dr Lim said. “There were lessons learned at a number of different ends. Certainly the sign-up process was extremely cumbersome. It is still cumbersome now but it is less cumbersome than what it was, and that is sign-up from a provider perspective as well as from a consumer perspective.
“From a consumer perspective it has become less so through the use of the assisted registration tool, but even so all that really does is transfer the workload from one person to another. It's an improvement but certainly I think it is still something that can be improved on.”
Added administrative workload is still one of the main barriers to the seamless use of the system, but Dr Lim has found – like others – that it is mainly in the data quality within GPs' clinical systems that is the main problem rather than PCEHR itself.
“The workload actually arises from three different aspects,” he said. “The first one is the data quality before the very first upload of information. Even though we were and had been preparing for this for a few years, we still found there was work to be done on preparing our data, in such a way that it could be easily shared with others.
“That is because general practice databases are generally structured from the point of view of the person who is using it and not for external consumption.
“Having a shareable summary of information actually requires looking at the information from a slightly different viewpoint, so there is a bit of a paradigm shift in creating documents for external consumption rather than internal consumption. That is one level.”
Once that level is overcome, the next hurdle is the software interaction with the system itself, he said.
“Different software vendors have implemented the system in different ways and some have made it easier to create a document than others. In some the document creation process is cumbersome or isn't immediately intuitive and as a result that is probably where some of the criticism has been coming from.
“Providers have been finding it frustrating at some levels because of those software implementation issues, and again this is something that hasn't been uniformly implemented. There has been quite a lot of variation in the way vendors have implemented it. That is the second part of the learning curve.
“And then of course the third part is maintenance of the data and uploading information whenever there is a change or a significant change. There is no question it does take a bit more time, but how much more time it takes depends on how good the quality of data is and how good you are with your software.”
Dr Lim said his practice had passed the first two hurdles but was now confronted with putting up a new summary whenever there is a significant change. In advance of receiving electronic discharge summaries, for example, any change has to be input manually.
“It would be nicer if that process could be made quicker,” he said. “The current workflow pattern is that we receive notifications by the original paper format, which we then have to transcribe into our computer and then upload it. This is another criticism that GPs will have, and that is we are putting up a lot of stuff but we are not getting a lot of stuff back.”
As Pulse+IT has reported, actually getting started with the system can also prove a difficult process, both for providers and consumers. For Dr Seelan, however, that process has been made much easier with the help of WentWest, in particular its eHealth program manager, Maria Pipicella.
“I'm supposed to the be the [responsible officer] but Maria, step by step, she kept us on track and helped us set it all up,” Dr Seelan said.
Dr Seelan's practice, which includes eight GPs, four nurses and a number of allied health practitioners, serves a very multicultural clientele, many of whom speak English as a second or third language. While some believe that Medicare Locals have been signing up patients without fully informing them of how the system actually works, Dr Seelan has not had this experience.
Bridgeview Medical Practice was armed with a consumer recruiting agent earlier this year who was stationed in the waiting room to introduce patients to the PCEHR, she said.
“We had been talking to them before about what it was, but the drawback was they had to register themselves and some of them were not very IT savvy, so this person was a godsend. She has done all of our registration for us.
“I also do a few talks to our local community. I'm from a Sri Lankan background and we have a lot of Sri Lankan senior citizens, and that is a group that is so ideal for the PCEHR. I did a talk to them about preventative healthcare and took her along, and she talked about the PCEHR, and we had 99 per cent uptake – everybody signed up.”
Bridegeview Medical Practice was recently awarded the NSW and ACT RACGP Practice of the Year, and Dr Seelan said one of the points in the practice's favour was how it had embraced the eHealth record and was using it to its maximum potential.
“I do honestly feel that good communication results in excellent health service and an impressive, highly favourable health outcome,” she said. “In a practice like ours, right in the heart of multicultural western Sydney, CALD central, having access to accurate concise information about health matters is practising good, safe medicine.
“We are now looking forward to registering another wave of patients using the ART software, concentrating this time on our growing chronic disease population.”
While Drs Lim and Seelan were keen to be involved from the start, Dr Nasr was not so sure. His predominant concerns were patient privacy and security, particularly people accessing records fraudulently or for non-medical purposes.
Dr Nasr said most of his concerns were overcome when he actually started using the system, and he now believes that not taking part is a disservice to patients.
“They should have the opportunity to be part of it,” he said. “And GPs should get more information – most of the concerns, if they spoke to people who know about how it works, are alleviated.”
Each doctor has uploaded a fair amount of shared health summaries – Drs Nasr and Seelan having uploaded summaries in the double figures, while Dr Lim estimates his practice is now in the triple figures – and all three agree that while it does take time, it is becoming easier as data collection is improved.
However, with the PCEHR system and its implementation now being reviewed, Dr Lim has some advice from someone at the coalface.
“Without a doubt there has to be some review of the implementation processes at the vendor level,” he said. “Ideally we should see some uniformity because a large part of how well it is taken up and how efficient the system is, is going to depend on how easy it is for providers to access and to upload information to the system.
“Receiving information in the system is just as important and therefore there have to be easier ways of doing it. Currently, the only way to get the full amount of information from the system is going directly into the provider portal, but the provider portal entry is a cumbersome process because of the need to re-transcribe a patient's details and enter your personal password in conjunction with your NASH certificate.
“Having a usable B2B entry through our software system would make a very big difference. Again, it is one of those situations where the more information that providers can see on there, and the more useful they see it, then the more likely are they to use it, and that includes both reading and writing data.”
While he no longer takes part in the clinical leads program, Dr Lim is intent on sticking with the system.
“I actually think it is a very good system and there is a lot of potential, but at the moment I see it as a base that we can build on,” he said. “Apart from the obvious, tangible and measurable outcomes that people are focusing on such as numbers of shared health summaries, numbers of reads and numbers of writes, there are a lot of other factors, and that includes improvements in overall communications and interestingly enough, this has benefits for data quality for everyone.
“The visibility of this information will improve the communication between the different health providers, so I think it has a lot of benefits beyond the obvious.”
Dr Seelan believes the positives outweigh the negatives. “If you come and see our practice, it is a no-brainer,” she said. “We would be silly not to embrace this as we really need it.”
Posted in Australian eHealth