In this budget brief from the parliamentary library Dr Rhonda Jolly explores whether the current tinkering around the edges of the health record could be a prelude to a new strategy.
Dr Rhonda Jolly writes:
E health makes use of developments in computer technology and telecommunications to deliver health information and services more effectively and efficiently. The e health funding provided in this Budget represents the Government’s response to recommendations made in a 2013 review into its predecessor’s Personally Controlled Electronic Health Record (PCEHR) system.[1]
Prior to Budget night, Health Minister Sussan Ley announced that the Government would provide $485 million over four years to restructure the current system.[2] The Minister suggested that this funding would deliver ‘a fully functioning national e-health system’ that could save taxpayers $2.5 billion per year within a decade, and an additional $1.6 billion in annual savings for the states and territories.[3]
There are to be a number of major changes to current arrangements under the restructured system. These include a name change—the PCEHR will become the myHealth Record. Unlike the PCEHR, responsibility for myHealth is to be situated within a new body, the Australian Commission for eHealth. This body, which is to be established by July 2016, will take over from the National E-Health Transition Authority (NEHTA).
In response to criticisms of the model adopted under the PCEHR that required patients to request that an e health record be set up, the revamped system will trial a system that will automatically create an e health record for participants. It will be necessary for patients to request that they are not included in the system—that is, they will have to ‘opt out’. Commenting on the proposed model, a Government spokesperson maintained that rather than changing directly to the new system, the trial will be necessary ‘to ensure public confidence in the system is maintained’ and to ‘assist in evaluating the effectiveness of associated public awareness and information dissemination and education and training for healthcare providers’.[4]
Many stakeholders appear to be pleased with the decision to trial the opt out model. Leanne Wells, from the Consumer Health Forum (CHF), for example, has stated that the approach ‘will require active leadership from the Minister, an open and transparent process and a public education campaign to ensure community and clinician confidence in the security and reliability of the scheme’.[5] The Australian Medical Association (AMA) appears supportive of the proposed revision and the Royal Australian College of General Practitioners (RACGP) considers it would help to ensure future policy could be based on evidence. RACGP president Frank Jones has added, however, that the organisation considered it crucial that the trial was directed by medical practitioners, not bureaucrats.[6]
The RACGP has observed also that it would closely examine details of the revised system as they emerge, since it is eager to see where funding is to be allocated and whether training in its use will be provided to general practitioners. Moreover, the RACGP is keen to see if, and how medico-legal issues associated with the new model will be resolved, whether arrangements for governance for the new e health commission will be appropriate and whether those arrangements will include stakeholder representation.[7]
Not everyone is satisfied that the Government’s approach will deliver a well-functioning solution. E health analyst, Steve Wilson, believes it is simply not possible to switch from opt in to opt out records unless the fundamental architecture of the system is redesigned to include a ‘privacy by design’ function which is attuned to the new model. Wilson contends:
… you simply cannot invert the consent model as if it’s a switch in the software.
The privacy approach is deep in the DNA of the system. Not only must PCEHR security be demonstrably better than experience suggests, but it must be properly built in, not retrofitted.[8]
Academic Dr David Glance has commented also that while changes may increase the general usage of the e health record system, the system itself ‘remains fundamentally flawed’ because there is no guarantee that all health professionals involved in patient care will participate and supply information, nor is there a guarantee that information supplied will be complete.[9] In addition, the system will continue to allow patients to withhold information so that records may not be complete—and acting on such a record ‘becomes a significant clinical risk’ for health professionals.[10] Dr Glance considers that there are other models that may work better than that proposed by this, and the previous government, and that some alternative models have the benefit of not needing centralised infrastructure, and as a result, not needing government involvement.[11]
In a variation of Glance’s proposition, former Senator Amanda Vanstone has declared that perhaps it is time to say with regards to e health projects in general that ‘enough is enough’ and to ‘outsource the job to the private sector’.[12] Bernard Keane, from the online journal Crikey, is similarly unimpressed with the proposed changes to e health records. Keane declares the Budget simply ‘warms over’ a ‘dud’ Labor idea, which he labels ‘one of the most spectacular wastes of money of recent decades after War on Terror funding’.[13]
Regardless of the legitimacy of these types of criticisms, it is most likely too much to expect any government to abandon the PCEHR in its entirety, given the substantial investment in the e health project made by various federal governments since the 1990s. And as Steve Hambleton, the former AMA President and current chair of NEHTA has remarked, while the PCEHR could have been more efficient, the foundations of the e health record system are in place.[14] So it may be impractical to abandon work already accomplished. Nevertheless, at the very least, technical issues such as those raised by Wilson would seem worthy of further investigation. So too is the idea that the opt out trials should not only include advice from health practitioners, but also the expertise of medical health information technicians.
It may be that the suggestion from long-time critic of the current e health record system, Dr David More is pertinent—the funding in this Budget represents ‘a holding action’; that is, a prelude to the development of what Dr More thinks will be a ‘new’ strategy for e health.[15] It is more likely that the new strategy will actually be a variant of the old strategy, simply because it is too costly and difficult to replace existing e health architecture. At the same time, it will be interesting to see how the opt out model contributes to a new or improved or revised strategy, and to what extent the suggestion of more inclusive system development, which has accompanied the myHealth announcement, is realised to the satisfaction of government, health practitioners, medical software and other industry stakeholders and patients.
[1]. Department of Health, Review of the Personally Controlled Electronic Health Record (Royale report), December 2013.
[2]. S Ley (Minister for Health), Patients to get new myHealth Record: $485m ‘rescue’ package to reboot Labor’s e-health failures, media release 10 May 2015.
[4]. K McDonald, ‘Budget 2015: money for PCEHR reboot is to last four years’, Pulse+IT, 11 May 2015.
[5]. Consumers Health Forum, Online health records trial a big step forward, media release, 19 May 2015.
[6]. Australian Medical Association (AMA), Spectre of 2014 Budget overshadows modest measures in 2015 health budget, media release, 12 May 2015 and McDonald, op. cit.
[8]. S Wilson, Why the Govt can’t simply go opt-out for e-health, itNews, 11 May 2015.
[9]. D Glance, New name and opt-out policy won’t save the personal health record, The Conversation, 11 May 2015.
[12]. A Vanstone, ‘Increased taxes a sure loser’, Canberra Times, 11 May 2015, p. 4.
[13]. B Keane, Deficit, schmeficit: Hockey focuses on the short term, Crikey, 13 May 2015.
[14]. A Gartrell, Budget to revive health scheme on life support, Sun Herald, 3 May 2015, p. 10.
[15]. D More, ‘Here are the main details of the e-health area of the Budget for 2015-16. Very, very interesting!’, Australian Health Information Technology blog, 13 May 2015.
[15]. A Gartrell, Budget to revive health scheme on life support, Sun Herald, 3 May 2015, p. 10.
[15]. D More, ‘op. cit.
No system pleases everyone, but it’s an excellent idea so let’s hope there’ll be more cooperation than is often the case among various interested entities. Those who suggest there’s something wrong in principle with beginning to move to the scheme asap, knowing that there will need to be changes, and these can be dealt with along the way.