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Your thoughts on the good and bad of eHealth in primary health care?

(Nov 23: see update at bottom of post)

What are the strengths and limitations of eHealth technologies in primary health care?

Olga Anikeeva at the Primary Health Care Research and Information Service is drafting a “research round-up”  about the use of eHealth technologies such as electronic health records, decision support systems and e-prescribing software by primary health care providers in Australia.

If you’ve an interest or expertise in the area, and can spare a few minutes – please have a look at her draft below and send your feedback by November 3 (contact details are at the bottom of the post).

 

(DRAFT)

 

Abstract

eHealth aims to improve the quality and safety of Australia’s health system byintroducing a more efficient way to collect and share information such as prescriptions and test results.1 The primary health care sector could benefit substantially from thewidespread use of eHealth technologies.2 The National E-Health Transition Authority is currently working with numerous stakeholders, including GPs and allied health professionals to develop an eHealth uptake plan.2 This RESEARCH ROUNDup focuses on the use of eHealth technologies in primary health care, by exploring the benefits and current limitations of a number of eHealth tools.

What are eHealth technologies?

eHealth involves the use of information and communication technology in the field of health care, with the aim to streamline communication between various providers by enabling records, referrals, and clinical information to be stored and communicated electronically in a secure manner.3,4,5

Examples of eHealth tools include electronic health records, health information websites, decision support programs and electronic prescribing software.3,6,7

Electronic health records

The central aim of electronic health records is to make health information available to all providers involved in the care of a patient, at any time and in any health care setting.8 Electronic records have the capacity not only to contain medical histories and treatment notes, but also to include digital images and scanned documents,8 enabling the creation of a complete medical history. Personally controlled electronic health records (PCEHR) are controlled by individual patients, who make decisions about what information is made available to which providers.3,8,9,10

Electronic records are easier to access, modify, store and share compared to their paper-based counterparts.8 For primary health care providers, the main advantage of using electronic health records is improved access to important health information,9 which may result in better care and reduce duplication of services.8,11,12,13 These benefits are particularly important for current health challenges such as chronic disease management. Access to shared clinical information by a multidisciplinary team of providers is likely to support team-based care across geographical boundaries; and lead to improved continuity of care.13

Electronic clinical decision support systems

Electronic clinical decision support systems typically involve the storage and use of electronic patient and prescription data in order to:

Þ  generate patient-specific advice

Þ  issue warnings about potential drug interaction effects

Þ  prompt reminders regarding screening and lifestyle modification.7,14

Demographic and clinical patient data are used in conjunction with current guidelines to generate appropriate and current limitations of a number of eHealth tools.The alerts, prompts and reminders are issued to providers during a standard patient consultation and can be active, in that they require aresponse, or passive, where no action from the provider is required.8

The main benefit for primary health care providers is instant and automated decision support.11,16 These systems have the potential to enhance practitioner performance, by improving decision making in areas that are frequently overlooked, such as diet and exercise advice.8

Computerised provider order entry and electronic prescribing

Computerised provider order entry systems are designed to simplify the process of entering and reviewing orders and results for laboratory tests, radiological images and referrals.8,14 Electronic prescribing, which is an extension of these systems, is frequently integrated into the software packages. Electronic prescribing enables direct communication between health care providers and pharmacists and is used to input, modify and fill medication prescriptions.8 The systems can perform automatic dosing adjustment calculations based on stored patient information.14,15

The benefits of using these systems include:

Þ  greater efficiency, as various orders and test results are no longer required to be physically transported between providers, reducing turnaround time8

Þ  direct and efficient communication between providers and pharmacies, rather than relying on patients or courier services, which may result in delays or loss of information8

Þ  improvements in legibility, which are likely to result in fewer errors and associated delays8

Þ  improved patient safety through the use of automatic dosage adjustments, which would reduce the likelihood of dangerous or ineffective medication doses being prescribed.14,15

Current limitations and challenges

While many primary health care professionals understand the benefits of using eHealth technologies, uptake of clinical decision support systems and other tools is generally low, with availability not guaranteeing uptake.7,15,17,18 Common barriers identified by primary health care professionals include a lack of training, costs associated with buying or upgrading equipment and concerns about a potential increase in workload.14,15,17,18,19,20 Some providers feel that overreliance on computers in the practice room may have a negative impact on the doctor-patient relationship if patients perceive the computer as an intrusion.8,14

The main barriers to the adoption of the PCEHR include concerns about privacy, unintentional leakage of information and potential withholding of information by consumers.9,11 While consumer control is an important feature of the PCEHR, it may compromise care ifconsumers are too focused on protecting their privacy and fail to share important clinical information.

Alert fatigue is the major limitation of clinical decision support tools. If these systems provide too many general warnings and recommendations, some health professional may disable the alerts or become desensitised to them.7,8,21,22 On the other hand, overreliance on decision-support systems and overestimation of their effectiveness and accuracy could lead to a deterioration of health care providers’ skills, and ultimately contribute to poorer performance.8

Future directions

While many of the identified barriers have been the focus of programs and projects undertaken by Divisions of General Practice across Australia, ongoing coordinated support and planning are required to achieve successful implementation of eHealth technologies.

Þ  Financial incentives are likely to encourage adoption of new technologies,11,12,18,19,20 and minimise the relatively higher costs faced by smaller practices and practitioners located in rural and remote areas.23,24

Þ  The poorer infrastructure in rural and remote areas would also need to be addressed.18,23

Þ  Systems need to be in place to provide ongoing and comprehensive training and technical support.18,23

Þ  It is important that the systems used by primary health care providers are easy to use and incorporate all of the necessary tools in one place, which would ensure that providers are able to use these tools to enhance their interaction with patients, rather than detract from it.7,15,16,18,25,26

Þ  Providers using different computer systems or software programs need to be able to effectively transmit information between systems.27

Þ  In order to address alert fatigue, alerts can be graded by severity, making it difficult to ignore or override alerts of high clinical importance.15

Finally, it is important to put in place a system of accreditation and minimum standards for eHealth software.21,22,28 This would ensure that the programs are suitable for use in the Australian context and are up to date with the latest clinical guidelines.

• Please send your feedback to olga.anikeevaATflinders.edu.au by next Thursday, Nov 3.

(And of course please feel free to add comments to the post as well…)

***

References

1 NEHTA. (2011). What is eHealth? Retrieved from http:// www.ehealthinfo.gov.au/what-is-ehealth

2 NEHTA. (2011). Primary Care Sector Plan. Retrieved from http:// www.nehta.gov.au/ehealth-implementation/sector-plans/primary-care

3 Stokes D. (2010). Electronic health records are coming! InPsych: The Bulletin of the Australian Psychological Society, 30-31.

4 Oh H, Rizo C, Enkin M, Jadad A. (2005). What is ehealth (3): a systematic review of published definitions. Journal of Medical Internet Research, 7(1), e1.

5 Pagliari C, Sloan D, Gregor P, Sullivan F, Detmer D, Kahan JP, et al. (2005). What is ehealth (4): a scoping exercise to map the field. J Med Internet Res, 7(1), e9.

6 Kreps GL, Neuhauser L. (2010). New directions in eHealth communication: opportunities and challenges. Patient Education and Counseling, 78, 329-336.

7 Robertson J, Moxey AJ, Newby DA, Gillies MB, Williamson M, Pearson SA. (2011). Electronic information and clinical decision support for prescribing: state of play in Australian general practice. Family Practice, 28, 93-101.

8 Black AD, Car J, Pagliari C, Anandan C, Cresswell K, Bokun T, et al. (2011). The impact of eHealth on the quality and safety of health care: a systematic overview. PLoS Medicine, 8(1), e1000387.

9 Liaw S-T, Hannan T. (2011). Can we trust the PCEHR not to leak? MJA, 195(4), 222.

10 Lehnbom E, McLachlan A, Brien J. (2010). E-Health: what are we talking about? Internal Medicine Journal, 21(1a), 72.

11 Jha AK, Doolan D, Grandt D, Scott T, Bates DW. (2008). The use of health information technology in seven nations. International Journal of Medical Informatics, 77, 848-854.

12 Georgeff M. (2007). E-health and the transformation of healthcare: Australian Centre for Health Research. Retreived from http:// www.achr.com.au/pdfs/ehealth%20and%20the%20transofrmation% 20of%20healthcare.pdf

13 Haikerwal MC. (2010). Health reform in Australia and the place of ehealth. Japan Medical Association Journal, 53(3), 193-198.

14 Hannan TJ. (2010). Now is the time for e-prescribing. Internal Medicine Journal, 40(3), 242-243.

15 Moxey A, Robertson J, Newby D, Hains I, Williamson M, Pearson S-A. (2010). Computerized clinical decision support for prescribing: provision does not guarantee uptake. J Am Med Inform Assoc, 17, 25-33.

16 Wright DM, Print CG, Merrie AEH. (2011). Clinical decision support systems: should we rely on unvalidated tools? ANZ Journal of Surgery, 81(5), 314-317.

17 Richards H, King G, Reid M, Selvaraj S, McNicol I, Brebner E, et al. (2005). Remote working: survey of attitudes to eHealth of doctors and nurses in rural general practices in the United Kingdom. Family Practice, 22, 2-7.

18 Moffatt JJ, Eley DS. (2011). Barriers to the up-take of telemedicine in Australia – a view from providers. Rural and Remote Health, 11, 1581.

19 Ludwick DA, Doucette J. (2009). Adopting electronic medical records in primary care: lessons learned from health information systems implementation experience in seven countries. International Journal of Medical Informatics, 78, 22-31.

20 Masters K. (2008). For what purpose and reasons do doctors use the Internet: a systematic review. International Journal of Medical Informatics, 77, 4-16.

21 Magrabi F, Coiera EW. (2009). Quality of prescribing decision support in primary care: still a work in progress. MJA, 190(5), 227-228.

22 Sweidan M, Reeve JF, Brien JE, Jayasuriya P, Martin JH, Vernon GM. (2009). Quality of drug interaction alerts in prescribing and dispensing software. MJA, 190(5), 251-254.

23 Liaw S-T, Humphreys JS. (2006). Rural eHealth paradox: it’s not just geography. Aust J Rural Health, 14, 95-98.

24 Gunter TD, Terry NP. (2005). The emergence of national electronic health record architectures in the United States and Australia: models, costs and questions. J Med Internet Res, 7(1), e3.

25 Shachak A, Jadad AR. (2010). Electronic health records in the age of social networks and global telecommunications. JAMA, 303(5), 452-453.

26 Bacigalupe G. (2011). Is there a role for social technologies in collaborative healthcare? Families, Systems & Health, 29(1), 1-14.

27 Bates DW. (2010). Getting in step: electronic health records and their role in care coordination. Journal of General Internal Medicine, 25(3), 174-176.

28 Liaw S-T. (2011). Decision support systems: a general practice research journey. Australian Family Physician, 40(9), 711.

***

Update, Nov 23: From Olga Anikeeva

PHC RIS would like to thank David More, Tim Senior and Ron Batagol for their insightful comments on the draft of the Research RoundUp eHealth technologies in primary health care: current strengths and limitations.

The document has now been updated and includes a greater focus on the concerns of primary health care providers with regard to using eHealth technologies, specifically privacy and security. The potential to use electronic health data for the purposes of quality improvement within individual practices and for benchmarking and comparison with other similar practices in Australia is also discussed.

While there were other very useful comments with regard to the architecture of the PCEHR and the potential negative impact of consumer control of the PCEHR, unfortunately, due to space constraints, these issues could not be explored in greater detail. It is hoped that the Research RoundUp will serve to provide an introduction to the variety of eHealth technologies available to primary health care providers and stimulate debate and discussion that could lead to further improvements in these tools.

Once again, thank you to the reviewers for their interest in the document and for taking the time to provide comments.

The final version of the document can be found at:
http://www.phcris.org.au/phplib/filedownload.php?file=/elib/lib/downloaded_files/publications/pdfs/news_8368.pdf

Comments 1

  1. ron batagol says:

    The concept of electronic health records is great and if properly set up and managed will revolutionise medical care especially in emergency situations or treatment in away-from-home locations etc. One only has to work in institutions which have scanned medical records to get the “flavour” of the vast potential of this such a programme.

    Unfortunately, the achilles heel of what has been proposed goes to the very heart of the PHECR concept, as indentified in the draft when it says:” While consumer control is an important feature of the PCEHR, it may compromise care if consumers are too focused on protecting their privacy and fail to share important clinical information”.

    I would go even further and, firstly dispute the phrase “important feature” and also say that in fact it beggars belief that it has been decided that we can produce a reliable National e-Health PCEHR programme by allowing the consumer to “cherry-pick” which medication records can be excluded from the PCEHR record- never mind that some people with sensitive conditions — such as mental illness, sexually-transmitted diseases, HIV or epilepsy — may choose to omit clinical information considered medically necessary to ensure safe patient care.

    (Think significant, potenially life-threatening interactions between warfarin and some antiretrovirals or warfarin and metronidazole which may be missed because vital medical information is withheld by the consumer!)

    Furthermore, it has yet to be decided if it will be clear to other health professionals that clinical information has not been included!

    Am I being overly cynical? – moi never! –

    Just pointing out the bleeding obvious to anyone who has a modicum of understanding about drug management issues and how they relate to important proposed or existing public health initiatives, which include nonsensical and dangerous caveats dreamed up by pollies and their various “expert health consultants” who don’t seem to comprehend the health dangers that may arise from consumers selectively withholding important clinical information!!! (BTW yes I know we don’t get all that now, but I thought this system was aimed at providing vital information electonically when it is needed!)

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