Ready, set… slow

What’s the hold-up on a national, linked electronic health system? Kathryn Eccles finds out.

BEING called to hospital at 2 am to assess a patient with chest pain is part of an average week for Dr Peter Rischbieth.

At his most recent early morning call-out, the RDAA president would have been forced to rely on a 73-year-old patient and her relatives for a medical history were it not for his computerised practice. But a few clicks of the mouse were all that was needed to compare the patient’s current ECG with one from a month earlier.

The comparison showed Dr Rischbieth the ECG was normal for that patient, saving her an 80 km journey to Adelaide, an $800 ambulance bill, the cost of a back-up ambulance crew to provide cover, and time waiting in casualty.

E-health, even at its most basic level – allowing doctors to access patient notes from the local hospital – is not only proving cost effective, it is also saving time and lives.

Research shows that computerised prescribing systems can significantly lower medication mistakes and adverse drug events. And, given that about one in 10 general practice patients experiences an adverse drug reaction over a six-month period (MJA 2006;184:321-24), the potential to make a difference is huge.

This is why progressing the e-health agenda across the country is crucial, says Dr Rischbieth.

“[My] system’s great... I don’t have the worry of leaving notes in the car or nipping back to the surgery.

“But if a patient comes in from out of town, I have no idea of their medical history, such as allergies or current medication.”

And, for many doctors, this lack of symmetry is where the frustration lies. Patience is wearing thin among GPs who have been waiting what seems like an eternity for a functional national system to develop.

They want to see a system that can provide crucial medical details at the touch of a button, that allows professionals to ‘talk’ to each other via secure messaging; to write and process prescriptions electronically; and to scrap the clutter of paperwork.

While all of this does happen to an extent in some areas at a local level, national progress could be described as glacial.

Original plans to introduce a national shared electronic health record were based on a 2010 timeframe.

But that now looks unlikely, with 2012 looking like a more realistic, but still challenging, goal.

Groups in charge of driving the process include the National E-Health Transition Authority (NEHTA), which has been entrusted by the Council of Australian Governments (COAG) to develop standards for the seamless delivery of e-health across every state and territory.

Consultancy firm Deloitte Touche Tohmatsu has been handed $1.3 million by COAG to prepare a national e-health strategy, due later this year.

Former chair of the now-defunct General Practice Computing Group Dr Ron Tomlins believes the extended timescale is simply because NEHTA has “picked the pineapple up by the wrong end”.

“They should be focusing on resources that people already have and encouraging them to use them better and more appropriately rather than search for some... magic solution.”

The Commonwealth had the opportunity to introduce widespread electronic health records a few years ago but chose not to do it because it was “thick”, he argues.

The opportunity involved linking an electronic health record to the immunisation register for all children and would have cost just $1 million.

Despite this missed opportunity, he says the government now needs to explore and expand systems that are up and running, primarily in divisions.

But NEHTA’s acting CEO, Andrew Howard, insists that’s exactly what is happening.

“It’s a series of building blocks. Each one of things we are building becomes infrastructure that everyone else will feed off. It’s about allowing innovation at a local level versus trying to go too far in building this almighty health system.”

A ‘one size fits all’ approach is not feasible, he says.

“Clinicians need to drive the change and, once we’ve got that, we can start to construct systems that are interoperable on a national scale. There are a series of models around... that have been demonstrated to work. It’s about sharing that work on a broader scale.”

Federal health minister Nicola Roxon agrees any national approach being developed needs to take into account, and link with, existing systems and facilities.

“While this is a complex task, it is realistic to envisage some aspects of e-health being organised and delivered on a national basis, with others being managed on a regional or local basis,” she says.

So what’s working out there now?

The Northern Territory is seen as the leader in the electronic sharing of information.

The state has electronic health records for 24,000 mainly Indigenous patients, with 1300 healthcare workers accessing them. Health workers interact using a secure messaging service and the territory is also ploughing forward with electronic prescribing.

NSW has also had success incorporating 60,000 patients into its Health e-link system. Two pilot schemes in the Hunter and Greater Western Sydney regions have meant doctors, hospitals and health clinics have access to summaries of health information for registered patients.

It is hoped, once reviewed, the scheme will roll out statewide.

Queensland and, on a smaller scale, Victoria also have similar systems up and running.

But none of these systems can communicate electronically with each other at present, meaning even patients with electronic health records cannot use them in other states or even outside their local area.

This was supposed to be the job of HealthConnect, a joint federal-state e-health strategic plan to allow the electronic exchange of health information between providers and across jurisdictions.

The scheme fizzled out in 2006, when the momentum needed to drive it forward at a national level was lost.

Dr Mukesh Haikerwal, NEHTA’s clinical lead, says the systems have got to come together. “For people to commit to keep doing what they are doing, we need to morph into one system.”

NSW rural GP and IT consultant Dr Horst Herb agrees, and argues a simple mandate from government is all that is stopping forward progress.

“There are vast numbers of incompatible systems out there and these will keep on sprouting up because a simple mandate is lacking,” he says, describing e-health as “a headless chook”.

“Very few people seem to know how important this is. We have just to wait now for some direction... and hopefully some clarity will emerge, because there’s a lot that needs to be done sooner rather than later.”

To ensure GPs’ continued enthusiasm for e-health, three things need to happen, according to Dr Tomlins.

It needs to be clear “the new systems improve quality of care and safety”, that “they improve efficiency for GPs and practices”, and they won’t “cost practices large amounts of money”.

AMA Council of General Practice chair Dr Rod Pearce agrees about the cost.

“If the government does this cheaply and doesn’t recognise the true cost of change, people won’t change.”

The Howard government’s mass underspend of $41.5 million in the 2006-07 Budget was typical of the cost of e-health not being recognised, he says, adding that although the Rudd government has not hinted at mass computerisation incentives, it must come to the party in order to achieve widespread change.

However, the government’s key role for the present, through NEHTA, is to set standards.

“We need to have the capacity to talk between systems, and that’s where NEHTA’s work is important – to develop those standards,” Dr Tomlins says.

Dr Rischbieth says a good way forward would be to start with basic patient details such as address, date of birth, allergies, medication and significant illnesses.

“Get that up and running and then start to link in discharge summaries and pathology results later down the track.”

NEHTA plans to take such a proposal to COAG in October.

It wants COAG to kick off a national e-health system by funding a summary health profile incorporating basic personal details, chronic disease and allergies, along with a section for the patient to access.

It is hoped COAG provides the boot that is needed for the kick, and many remain optimistic.

“Movement is slow... but it is moving,” Dr Rischbieth says.

But whether e-health can make a meaningful difference to the national problem of medication misadventure remains in doubt until those entrusted with its progress can move it on from being just a great idea.

WHAT HAS TO BE DONE?

• Set up a national service to uniquely identify patients and healthcare providers
• Establish authentification to ensure identity of individuals
• Develop a terminology service to exchange clinical information in a common language
• Build accurate directories that identify medicines, medical products, devices and consumables.

WHY BOTHER DOING IT?

• Inappropriate use of medicines costs public hospitals $380 million a year
• About 25% of a clinician’s time can be spent collecting clinical information
• Up to 35% of hospital referrals are considered inappropriate.

Source: NEHTA