RACGP calls for suspension of further PCEHR development

The Royal Australian College of General Practitioners (RACGP) has called for the development program for the PCEHR to be suspended immediately in order to consolidate the existing system and test for clinical benefit, usability and safety.

In its submission to the panel reviewing the PCEHR, the RACGP has criticised the lack of clinical input into the interfaces between the national system and general practice software, as well as major problems it sees with the next phases of development of the PCEHR – including plans for uploading advance care directives and pathology and diagnostic imaging results – as well as existing functions such as the Child eHealth Record (CeHR).

The RACGP also wants the system's developers to work on consolidating existing PCEHR functionality, especially the shared health summary, to allow GPs to directly access the provider portal – which many say is a far better product than the local interfaces – through their desktop software, and to better tailor the system to GP workflow.

The college has joined other organisations such as the Australian College of Rural and Remote Medicine (ACRRM) and the Consumers eHealth Alliance (CeHA) as well as independent industry players in calling for a return of focus to the foundational elements of the national eHealth system, specifically point-to-point secure messaging between GPs themselves, and between GPs and hospital-based and allied health professionals.

“Interoperable secure message delivery (SMD) will deliver better electronic communications between all healthcare providers and promote the creation of useful and shareable clinical documents,” the college says. “It is a small step to progress from the point-to-point communication (directly between two clinicians) to the point-to-share.”

RACGP president Liz Marles said she “sincerely hoped” the PCEHR was fixable and salvageable, but that it needed a refocus.

“First of all we need to identify what the purpose of the PCEHR is and have a clear vision, and then I think we really need to consolidate the key documents and focus on making it work within general practice, particularly around secure messaging. It follows a logical process: you get the point to point working and then the point to share.

“We need everyone to know that role of the PCEHR as a shared health summary doesn't replace a GP's complete record and that we don't see the role of the PCEHR as different to the one that it has.”

Concerning the calls by the Australian Medical Association and the Consumers Health Forum for the system to be made opt-out, Dr Marles said that discussion had already been had.

“And as far as I'm aware there were significant issues raised by the Privacy Commissioner around that and also around the Consumer Health Forum's belief that consumers retain some control of the record. That [discussion] has the potential to derail it."

Asked how the system could overcome many GPs' valid concerns about patients 'deleting' or hiding from view certain information the record, Dr Marles said that if there was a way to flag that information had been removed, then clinicians were then at least in the position to ask the patient about it.

“I think the key thing here is to understand that the PCEHR doesn't replace the medical records at the general practice; you still have the detailed information in your general practice record.

“We know that whenever a patient comes to see if they can choose what they tell us and what they don't want to tell us, so in a sense there is no system that is going to make all of that information available.”

The RACGP has also echoed other groups in calling for an independent governance body that is at arms’ length from the political and funding process.

“The current PCEHR development program has resulted in the delivery of a product that is overly complex with a poor interface between local GP clinical information systems and the PCEHR system," the submission states.

“The development program has been driven politically and by a desire for volume rather than high-quality, useful clinical information. The clinical community has not been effectively engaged in product development, especially with the current release program.

“This has resulted in a system that fails to meet clinical requirements, is not acceptable nor sustainable.”

As examples of what it sees as problematic developments in new functionality, it criticises the mooted plans to allow existing advance care directives to be scanned and uploaded to the PCEHR. The college wants this to be clinically curated.

It also criticises early proposals that GPs would upload pathology and diagnostic imaging reports into the PCEHR, which it says “showed a lack of understanding of sector issues”.

The ability for parents to add clinical information into the CeHR is also criticised. Parents can currently add clinical measurements such as growth rates and head circumference into their child's record – which normally should be uploaded by a GP or child health nurse – although parents are warned that this information should be dealt with by clinicians.

The RACGP also wants its representatives to have a much stronger say in deciding on further functionality and how it is designed, as well as it to take control of the delivery of education and training in the system to general practices.

The college, which has received significant funding from the Department of Health to assist in the rollout of the PCEHR, says the peer-to-peer seminars it has been staging this year have been successful.

However, it says this has not translated into meaningful use for a number of reasons, including a lack of targeted registration and education, the lack of a demonstration platform or test environment before going live – most GPs use their own record or a nominated person within the practice to test out the system – and a lack of maturity of the system.

Dr Marles said the college was disappointed by criticisms of its involvement in the PCEHR by ACRRM, which argued that there has been a lot of clinical input into the development of the system and others besides NEHTA and the Department of Health should share some of the blame for its perceived faults.

”ACRRM is a member of United General Practice and we are disappointed that they have chosen to try to create division within the profession rather than look at the bigger picture of improving the PCEHR, which we are all working on,” she said.

ACRRM has pointed out that the members of the NEHTA clinical leads program participated in the $2.5 million RACGP PCEHR Advocacy Workshop Project, which was still operating last month.

“These workshops saw the RACGP and its GP representatives advocating for the uptake of the PCEHR in its current form whilst at the same time the RACGP began [publicly] criticising NEHTA and DoHA for not consulting with the profession and for producing a critically flawed product,” ACRRM said in its submission to the review.

Asked if there was a perception out there that some clinicians were seen to accept salaries from NEHTA to work on the PCEHR and evangelise for it, before suddenly complaining and then resigning en masse, Dr Marles said she didn't share that perception.

”My perception is that they felt that they were engaged to provide clinical leadership and they felt that the PCEHR was drifting away from that, and that was the reason for their resignation.”

She said the RACGP had similar concerns to the clinical leads. “The college wrote to the department a while ago expressing our concerns about the fact that the focus seemed to have moved to signing up lots of registrations and increasing a whole lot of functions such as putting advance care directives on, having their child eHealth portal, and losing what we see as the key focus of actually consolidating a shared health summary and making sure that the clinical usability is right and that it sits within a GP's workflow,” she said.

“There has been a huge amount of investment already in this and I don't think we'll ever see that level of investment again. We do believe that improved accuracy, availability and the timeliness of communication will lead to better health outcomes. [The PCEHR] is part of that and I think we definitely want to try and make it work.”

The college's 10 key recommendations to the panel are:

  • Suspension of the current PCEHR development program
  • Consolidation of existing PCEHR functionality, especially the shared health summary
  • Direct access to the web-based provider portal views via GP clinical desktop software
  • An ongoing work program focusing on core foundation services
  • Universally available, interoperable secure message delivery
  • A transparent product development life cycle, with the RACGP as a priority stakeholder
  • Clinically useful and safe eHealth products that align with clinical systems and workflow
  • Strong, streamlined and transparent governance overseen by a single entity responsible that is accountable for all eHealth product design and release
  • Clinician-developed and led education and training that is supported and delivered to general practice by the RACGP
  • Development of a value and benefits business case to support continued general practice participation in the PCEHR.

“The RACGP supports the original foundations of the eHealth work program defined by the National eHealth Strategy in 2008, which includes the Healthcare Identifiers (HI) Service, National Authentication Service for Health (NASH), standardised clinical terminologies and universally available interoperable secure message delivery,” the submission states.

“The work program needs to re-focus on the continuity of core clinical documents (Shared Health Summary and Event Summary) and the point-to-point communication (Secure Message Delivery). These are the core functions of clinical value for GPs and other clinicians and provide the platform for engagement of the clinical community in the PCEHR.

“Once these core foundation services are effectively embedded in practice, the PCEHR can then be extended.”

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   

# Brett McPherson 2013-11-29 11:18
P lease
C an't
E veryone
H ear
R eason.

Without robust, interoperable, easy to use SMD, uptake and meaningful use of the PCEHR will not be achieved.
# Roger Hewitt 2013-12-03 22:00
Hear Hear ! Brett
If we can get INTEROPERABLE messaging used widely (akin to the ePIP expectations) we will provide a platform for consistent message content (eg the pathology report messages) and reduce the complexity of excessive sets of desktop portals.
In turn, we lay the foundation for sharing clinical documents both point to point and to the PCEHR (if a patient has one and their Clinician is on side with posting).

Roger

BTW - Bit of a pity that we called the Message Delivery : "SMD" rather than "IMD" - as I suspect many focus just on the S for Security and overlook the significance and benefits of the Interoperabilit y bewteen the messaging providers..

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