AMA calls for opt-out PCEHR, reduced patient control

The Australian Medical Association (AMA) has recommended that the PCEHR become an opt-out system rather than the current opt-in process, and has also recommended that exemptions be placed on what clinical documents and information are controlled by the patient.

In its submission to the three-man PCEHR review panel – one member of which is the AMA president, Steve Hambleton – the association said the emphasis on personal control had “stalled its implementation”.

AMA vice president Geoffrey Dobb issued a statement today saying there should have been equal emphasis on clinical utility in the development of the PCEHR.

“Despite the clear input by clinicians of the clinical needs of the PCEHR, the ‘personal control’ concept prevailed over the core objective of improving the efficiency and effectiveness of the delivery of health care,” Professor Dobb said.

“The current PCEHR arrangements allow patients to restrict access to information that has been agreed to by patients to be uploaded by doctors to the PCEHR, and patients can remove those documents without trace.

“To encourage use of the PCEHR, and to gain the most health benefits from the PCEHR, GPs, community specialists, and emergency department specialists must be confident that the PCEHR contains accurate, up-to-date information.”

The submission states that advocates for personal control justified it on the basis that patients can withhold information from healthcare practitioners today.

“This is true. Patient control of health information presents practical clinical limitations for the treatment of the patient – even for the most skilled medical practitioner.

“But we wonder at the value of building an expensive electronic system that, by its very design, does not seek to improve access to key clinical information across healthcare settings for the good of the health system.”

In its submission, the AMA recommends that patient control over medications, adverse events, discharge summaries, recent results of diagnostic tests and shared health summaries be exempted.

“All other information on the PCEHR would remain subject to patient control,” it states.

“Patients can remain confident that there are strong safeguards in the PCEHR legislation to prevent access to their records without appropriate reason, and deal with any breaches accordingly.”

Professor Dobb said that the AMA also recommended the PCEHR be an opt-out system, rather than the current opt-in arrangement.

“A patient opt-out system would ensure high consumer participation, particularly from patients with high needs, which would provide doctors with a better incentive to commit to using the system,” he said.

“Doctors would be much more likely to fully embrace the new system if a majority of their patients had a PCEHR.”

Professor Dobb said the AMA supported people taking greater responsibility for their own health, “but patient control should not mean that the PCEHR cannot be relied upon as a trusted source of key clinical information”.

“Without a fundamental change to increased clinical confidence, the PCEHR does not serve the best interests of patients. As a result, it would be rejected by many doctors and would fail.”

In terms of design, the submission states that GP desktop software interfaces “were built quickly and in current versions are not fit for regular use”.

“Early experiences are that clinical workflow is neither seamless nor intuitive, adding to the time spent by doctors in accessing and uploading documents to the system. The AMA welcomes the work of the Clinical Usability Program to address usability issues. This work should continue.”

It also recommends that a test or 'practice' environment be established that doctors can use to become familiar with the PCEHR before they use it in a clinical context.

Pulse+IT understands that this is already underway in association with NEHTA.

The AMA states that “despite long-held concerns with the way in which the PCEHR has been designed and implemented, the AMA continues to support a properly built and governed PCEHR system as a tool for the healthcare system”.

“The AMA welcomes this review. It comes at a time when, without a clear purpose and direction, and without some critical adjustments, the PCEHR could instead languish as an expensive experiment for the Australian health care system.

“It is possible to change the direction and the dynamics of the PCEHR system and begin to realise its benefits for patients, clinicians and the health care system in general.”

Other submissions

To review a table of submissions to the PCEHR review compiled by Pulse+IT, click here. This resource will be updated as more submissions become public.

Posted in Australian eHealth

Comments   

# cybersecurity 2013-11-26 20:21
If the PCHER incorporation into clinician software has been done so poorly that it is almost unusable - what makes anyone think the security in those systems - the part that no-one really asks about - was done well... or even adequately...

How do i officially 'opt-out'...
# Prof. Branko Celler 2013-11-27 11:39
This is a very constructive and positive response from the AMA. Their endorsement of the PCEHR with a small number of very important amendments, should greatly encourage use of the PCEHR by clinicians and patients alike. The PCEHR is an important initiative of real national significance but needs to satisfy the needs of both the community and clinicians for it to realise its full potential. I would also strongly endorse the opt-out option in preference to the opt-in option for patients registration.
# Terry Hannan 2013-11-27 12:11
This discussion has raised several important issues.
While working in the initial phases of implementing an e-health system in Kenya (now www.openmrs.org) we found that opt out greatly enhanced patient care registration and compliance with the system. In all health economies not being a part of the appropriate e-health system (opt in or opt out) means the individual accepts care under current systems failures and poor quality of care, etc.
I have deep respect for Branco's points of view but have to state that based on my experiences with complex e-health systems nationally and internationally that the PCEHR "as a model" is inherently defective. the "concepts" underlying a national standardised e-health system are legitimate however the structure, implementation processes and the measures of performance of the PCEHR defy the existing historical knowledge for such systems. Small amendments will not fix the PCEHR for effective health care delivery. In addition to the deficiencies in the PCEHR model the administration of the project out of the Federal Government has been deplorable and has not effectively involved end users. It is an IMPOSED system. Regarding patient involvement we know that they need to be the primary managers of their health care information and if they are not nothing works in the long term anyway. The current PCEHR does NOT permit the effective clinician-to-pa tient information management and sharing. Also clinicians need to understand that they are not the sole "owners" nor "supreme decision makers" in the delivery of health care [The Wisdom of Crowds-J. Surowiecki].
What the PCEHR does not address are the issues defined by Coiera in 2003. He stated As Coiera stated in 2003 the “The biggest information repository in most organisations sits within the heads of those who work there, and the largest communication network is the web of conversations that binds them. Together, people, tools, and conversations – that is the “system”.
# Colin Jones 2013-11-28 15:32
Branko

Well said. Finally a sensible and thought out response to making what we have work over the longer term.

Unfortunately, all to often the commentary is about it is broken and won't work with very little or no discussion of how to resolve it. Constructive contributions to the debate are rare but the AMA is showing leadership here. And the interfaces are improving, but I am sure there will still be a howl of despair despite any changes. Doctors are very difficult to get to agree, and each want their own particular interface. Talk to the desktop software vendors. It ins't a PCEHR issue.
# Anton Cush 2013-11-29 21:03
Very exciting proposition for the PCEHR to be opt-out. There are many cases to cite worldwide where this approach has been successful.
# Diane 2013-12-13 21:40
They really don't care at all about patient rights, do they?

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