Pathology on the PCEHR: seven-day delay v authority to post

Debate over the best method to upload pathology and diagnostic imaging reports to the PCEHR is continuing just a month away from the Department of Health's preferred deadline for the functionality to go live.

Pulse+IT understands that the next release of the PCEHR is set for November 30 or December 1 and will feature a number of fixes to existing problems with the system as well as the availability of the long-awaited pathology and imaging reports.

However, it is highly unlikely that diagnostic reports will actually be uploaded any time soon, as few private pathology or radiology practices are registered with the Healthcare Identifiers (HI) Service, a necessary prerequisite to use the system.

Pulse+IT understands the December release will contain a repository that can receive the reports, but that there will be no capability to send them. The department confirmed late on Friday that the functionality will be available in the next release, but that changes will be required to pathology and diagnostic imaging software to be able to post reports.

The uploads will contain the diagnostic provider's complete report as an immutable PDF, rather than simple results as atomic data. This has been agreed to since last year to overcome the pathology sector's concerns over safety and to allow cumulative results to be uploaded.

In the meantime, debate has been reignited by concerns raised by the new president of the Royal Australian College of General Practitioners (RACGP), Frank R Jones, in a communication to GPs last week.

Dr Jones wrote in the RACGP's In Practice newsletter that the college had significant concerns about plans to enable the automatic upload of pathology reports after seven days, which it says may result in patients learning about clinical results before visiting their GP.

As reported in August, a series of consultation workshops had concluded that an automatic upload after seven days – allowing time for a GP to contact the patient if there were abnormal results – was a faster method than the alternatives and would prove less of a burden on GP workload.

However, Dr Jones told Pulse+IT this week that the issue was not necessarily that patients potentially had access to their information before the GP saw it, but about who ultimately had responsibility for interpreting the results.

“I believe that the original referring doctor has the clinical responsibility for interpreting the results,” Dr Jones said. “If something is missed then it is ultimately the GP who will be blamed. What we need to do is develop a tried and tested process.”

Dr Jones said the college's national standing committee for health information systems had worked on the understanding that pathology reports would be sent to the GP in the normal manner and they would decide to upload it or not in consultation with the patient.

This refers to the authority to post (ATP) method, which had been developed by the National E-Health Transition Authority's (NEHTA) diagnostic services reference group over several years. This group, which involved representatives from the RACGP, the Royal College of Pathologists of Australasia (RCPA) and the Royal Australian and New Zealand College of Radiologists (RANZCR), amongst others, had planned to use ATP as the safest method to upload results.

It would involve the pathology or DI report being sent by secure messaging direct to the requesting GP's clinical information system, as is the current practice. The GP would then review the results and send a message back to the pathology practice to give them authority to post the reports directly.

This would then allow the pathology or DI practice to capture the necessary healthcare identifiers – the Individual Healthcare Identifier (IHI) for the patient, the Healthcare Provider Identifier Individual (HPI-I) and the Healthcare Provider Identifier Organisation (HPI-O) – which are not yet sent with many referrals, either electronic or paper.

The chair of the RCPA's informatics committee, Michael Legg, said it appeared that the department had accepted the college's argument that whatever method is used to post the results, there had to be a way not to post a report.

“There has to be the opportunity for the patient and requester to decide whether it is appropriate to post it or not at the time of request, even accounting for the current policy of having a time delay before the report could be viewed by the patient,” Dr Legg said.

“In my view it would depend on the nature and policy of the requester’s practice what the default would be but in any event there has to be a way of signalling that this report should not be posted to the PCEHR. That means that you have to have a way of being able to post a report at a later time, which may be after review of the results and/or discussion with the patient depending on the agreement they have.

“My understanding is that those views have now been broadly accepted, and there's work going on to try and work out the detail of how to do this. The point is that the clinical colleges wouldn't accept as being safe to do otherwise.

“This policy position reflects what is being done in other countries such as Denmark where they have had experience with making reports available to patients and clinicians through electronic health records for some time.”

Patient benefits

One drawback of the authority to post method besides the time burden on GPs is the delay in providing the information to the patient. The majority of pathology results are normal and do not require the doctor to recall the patient.

The Australasian College of Health Informatics (ACHI) has endorsed the direct upload method, arguing that patients should not have to wait indefinitely for their pathology results to be viewed and uploaded by a clinician before accessing them on the PCEHR.

ACHI has prepared an article for the November issue of Pulse+IT as part of its program evaluation committee's biannual evidence review (BER). The article outlines ACHI's targeted literature review of research and articles published locally and internationally about the ability for patients to access their pathology results through technologies such as a patient portal.

ACHI president Chris Pearce said the review found that there was no evidence demonstrating harm from access to pathology and diagnostic imaging results.

“The college acknowledges however the clinical cultural issues, and endorses the suggested seven-day delay,” Associate Professor Pearce said. “The current proposal has results being posted after a seven-day delay, allowing clinicians time to review and contact patients before they get direct access.”

A/Prof Pearce said the review acknowledged the concerns about the effects direct access might have on GPs' traditional role as gatekeepers and the anxiety that could be experienced by patients reading results before their GPs have been able to curate them. However, for clinicians with modern health informatics systems, this should not represent a barrier to access.

“The alternative, that all results should be clinically curated, represents an unacceptable workload on busy GPs,” he said.

“Our review shows patients value access, but are lacking on information as to why and what patient outcomes might be. Accordingly, ACHI support the proposed model, with appropriate safeguards. Allowing consumers direct access to pathology results is new technology and must be framed in the context of improving the quality and safety of care.

“This means working with consumers to understand access and health literacy issues as well as targeting those with chronic diseases, where regular pathology is part of the care plan.”

Informed consent

In his communication to members, the RACGP's Dr Jones said the college was also concerned that there was a lack of informed consent and transparency for health consumers registering for the PCEHR, the majority of which are established via assisted registration.

DoH figures show that the vast majority of patients leave the access controls in their PCEHR at the default setting, meaning any authorised healthcare provider can view all of the clinical documents it holds.

The RACGP is concerned that documents containing sensitive information such as a diagnosis of a genetic disorder or sexually transmitted disease could be viewed by any healthcare provider, not just those intimately involved in their care, if the patient does not restrict access.

Dr Jones said the college was concerned that many patients registered with the system lacked an understanding of the controls they can enact over who is able to access certain documents.

(Many doctors have cited the opposite as the reason they won't use the system, arguing that if the patient is able to hide a particular document, then the PCEHR does not contain a full clinical record and it cannot be relied upon.)

Dr Jones said he personally had no problem with consumers being able to restrict access. “I accept that this is the patient's record, it is personally controlled, but I am a practical person and I think we should be working to find a way that this system can work, that it is right for each user.”

He called on the developers of the system to find a practical way that it can work for both patients and clinicians.

“In my own practice, I check all of my incoming pathology results at lunch time and at the end of the day, so I check twice a day. Today I rang two patients personally because I felt that was necessary, but otherwise the results are sent to the patient's record in my system with the press of a button.

“There is no reason why this could not also be done with the PCEHR. In fact, you should be able to use the same button.”

The RACGP would also like to see one method agreed to for both pathology and diagnostic imaging rather than separate methods.

Posted in Australian eHealth

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