Unfixable: Time to ditch e-health record scheme



This article is by David Glance, director of the University of Western Australia Centre for Software Practice. It originally appeared on The Conversation.

analysis Federal health minister Peter Dutton has commissioned a review of Labor’s troubled Personally Controlled Electronic Health Record (PCEHR) project. It’s unclear whether the review committee is to decide whether to scrap the project altogether or to try and fix it. Hopefully it is not the latter because if the past year has taught us anything, it is that this is not a fixable problem. It needs to go.

The PCEHR project, which has cost A$1 billion so far, had earlier this year failed to meet a self-imposed target of 500,000 patients signed up by July 1. Of more concern was the lack of participation by GPs and the lack of any significant progress to meaningful use of the system.

The review committee will be chaired by Richard Royle, executive director of the UnitingCare Health group in Queensland. Royle will be assisted by Dr Steve Hambleton, president of the Australian Medical Association and Andrew Walduck, chief information officer of Australia Post.

The choice of CIO of Australia Post is curious given that Australia Post itself has implemented a project called Digital MailBox which has been as unsuccessful as the PCEHR. Or perhaps that is the point – Walduck may have a unique insight into recognising unsuccessful IT projects.

In principle, the idea of a shareable, internet-based electronic health record is a good one. For people in a situation where they can’t remember all the details of their medications or exact dates of operations, previous diagnoses and complications, an up-to-date summary of this information can provide critical information in the provision of hospital care.

But these scenarios are the exception and not the rule. In fact, there are unlikely to be any clear benefits from PCEHR – even if we were able to measure them. There is no research or other evidence that the PCEHR would have brought about any direct benefit to the population’s health, even if the impossible happened and it managed to sign up a significant portion of the population and achieved meaningful use.

The core of the PCEHR’s problems lie not with electronic systems, implementations, usability or the patient, but with the person charged with driving the system, the GP. It is the GP’s data that is being uploaded and it is ultimately the GP’s responsibility to ensure that the data is complete, accurate, timely and relevant. It is the GP who will be held responsible if anyone else acts on this data and something untoward happens.

But. The GP does not have control over what happens to the record, who it is shown to, what the patient can show or hide and ultimately how another person decides to act on the basis of their information. The GP does not determine how that data is subsequently used by the government or what it is used for.

This is ultimately a very big ask of time-poor GPs who may never see any tangible benefits from these efforts but face very real risks. Under the current Australian fee-for-service remuneration scheme for GPs there is no way to convince them otherwise. Specifically paying GPs to add this information would not work either, as GPs would still have to be convinced that the time spent curating the information was more valuable than seeing another patient.

The expectation that patients will drive the demand is also fanciful given the low level of understanding of the benefits and risks of the PCEHR within the public.

The review committee is due to run for six weeks and it is clear that – as has been pointed out by e-health blogger David Moore – this is insufficient time to achieve any meaningful understanding of what didn’t happen, let alone what is needed to fix it.

One can only imagine that a decision has already been made as to the outcome. But to move towards a workable e-health system in Australia, my recommendations are to:

1) Scrap the PCEHR to avoid any further effort and money being wasted. Some commentators have suggested that private industry should take it up, but this would only add commercial self-interest and a whole raft of other issues to an unachievable goal.

2) Redirect effort to implementing the standards and infrastructure that underpinned the PCEHR. This would be the health identifiers, secure message standards, authentication and underlying exchange of information. These features solve real problems being faced by health services today.

The adoption of patient health identifiers by pathology and radiology laboratories in particular would help ensure that results are correctly identified and sent to the right place.

Secure messaging standards are helping to drive more efficient exchange of information between health professionals and further support of these standards would increase the range of content exchanged in this way.

3) Bolster policy and legislation to enable the sharing of clinical information between providers at a local level. There are a number of products already on in use that provide the ability to share clinical information securely to health professionals that need access. The PCEHR provides little extra advantage over these systems.

David Glance has received funding from NEHTA and the Department of Health and Ageing. He is affiliated with a clinical product that implements standards discussed in the article. He consults to an organisation that is involved in the commercialisation of the clinical product. This article was originally published at The Conversation. Read the original article.

The Conversation


  1. Possibly its biggest hurdle, is that no one trusts that our information would be kept safe and private.

    A few years down the track, and no doubt it would be mined by the tax dept, Centrelink and dozens of other government departments.

    • The Govt. already knows everything about you they could possibly want to know.

      Centrelink, MBS, PBS, Pathology, Hospital, ATO etc etc.

      All the data is there – someone just needs to pull it together.

  2. Daniel,
    Your last paragraph applies already when one signs up to the scheme. Law Enforcement and associated agencies do have access to the data. It’s clearly stated in the small print.
    And what about Insurance companies? It needs only one rogue agent to sell your information.
    Enough said.

    • Wouldn’t be long before Insurance companies were being granted access and hiking premiums or refusing clients as well.

  3. I met the head of one of the government run heath bodies and she was abuzz at the time as she had to quickly hire 100 new employees on $140K each as her current focus. Why 100? Why not 72? Perhaps 124? Why $140? It just didn’t seem to matter – she was just out blowing money and obviously would invent enough roles when the employees came on-board.

    Similarly to the NEHTA and the PCEHR thought bubble. I’d turn up to the provided sessions to find I’d be only one of a few privately employed people in the audience. The rest of the attendees, and there would be a lot, would be from state and federal government bodies – most working for NEHTA and flown in especially from Canberra and Sydney. As to why it took so long to make any decisions and why such decisions were made was evident from the presentations and questions asked.

  4. It seems to me this article is “opinion” rather than analysis. So here are some of mine:
    I think having the record controlled by the patient is a good idea. I can see why some doctors might think otherwise. When alls said and done, the patients are paying for medical services and they should be able to require that their health providers use the system, however many people would not be able to interact with a professional in that way.
    If you talk to someone with a complex ongoing health condition or something major in their medical history, they understand the point of the system. For those of us lucky enough to have a minor and boring medical history it doesn’t seem important. Consequently number of patients enrolled seems like a poor way of measuring sucess of such a system.
    I can’t help thinking that the initial implementation should have been in a specific city or region first rather than an full national rollout.

    • This is actually the nub of the issue Plover … the PCEHR was not necessarily a bad idea … it was just badly executed. The centralised approach was a triumph of hope over experience in this country.

      the key lesson from the way cloud services have evolved in the globally diverse marketplace is simply to start with something that is proven to work and to scale it over time as folks find it useful. Generally David’s comments are right in my view – the focus should have been on lubricating the interactions via standards and interoperability frameworks and the creation of proven solutions. The centralised operational approach became self defeating in such a large a diverse sector. We would be far further ahead now with a more diverse portfolio of interoperable EHR systems gaining critical mass day-by-day as they prove their value. The tragedy is that this was all well known at the project’s outset, so the squandering of this opportunity rests entirely on the shoulders of the decision makers who elected to believe their own centralisation hubris. In theory it could have worked, but in practice the approach ignored the complexity of the Australian political and healthsector landscape. It was a high risk, unnecessary, gamble given the more devolved alternative approaches that could have been chosen.

    • A few questions Plover,

      To be completely in control of the patient, who input all the information, doctor (specialist or GP) or the patient? If it is the patient how will they ensure that what they are inputting is accurate? If it is not accurate they its relevance drops rapidly.

      How will access be granted / shared between health proffessionals? This could prove to be especially problematic for older / less technologically astute patients which defeats the purpose of the system of having a database if no one can access it.

      Personally I do not see any easy answers. It has to protect patient information, but at the same time, it has to be accessible and accurate enough that medical practioners will want use it. Not an easy balance to achieve.

  5. The article completely misses the point.

    People want this. Health Professionals want this.

    The idea is sound.

    The clinician facing implementation is wrong.

    Privacy is almost a non-issue. Most people think this kind of information transfer happens anyway.

    Fix up the clinician facing implementation and there would be no issue.

  6. Seriously?

    David Glance has received funding from NEHTA and the Department of Health and Ageing. He is affiliated with a clinical product that implements standards discussed in the article. He consults to an organisation that is involved in the commercialisation of the clinical product. This article was originally published at The Conversation.

    He’s essentially a climate denier with a different hat on; why is this junk on here?

    Renai, The Conversation is junk,; thats why nobody reads it! Please stop recycling it so we can reduce it.

  7. Hmmm … this is a very complex issue all round, but one insight is to examine the conclusions of a recent review of the Victorian HealthSMART program published by the Victorian Auditor General’s office: http://www.audit.vic.gov.au/reports_and_publications/latest_reports/2013-14/20131030-clinical-ict-systems.aspx

    The report concludes:

    “This audit examined the clinical ICT systems of eight public health services to see whether they were appropriately planned and implemented and whether expected outcomes and benefits are being realised. It examined the HealthSMART clinical ICT systems implemented at four health services and clinical ICT systems implemented at four other health services.”

    “The Department of Health (DH) failed to complete the expected implementation of clinical ICT systems across 19 Victorian health services due to poor planning and an inadequate understanding of system requirements. It significantly underestimated project scope, costs and time lines, as well as the required clinical workflow redesign and change management efforts.”

    “In contrast, non-HealthSMART sites have used their own internally generated funds and implemented clinical ICT systems at a fraction of the cost of implementing HealthSMART.”

    “The installed clinical ICT systems do not currently deliver interoperability across the Victorian public health sector. Both HealthSMART and non-HealthSMART clinical ICT systems do not enable patient data to be shared across Victoria’s public hospitals.”

    So, even at the level of one state government jurisdiction, the Victorian State Government, the centralised roll out of a standard suite of clinical applications has (a) not been successful, and (b) even where it was implemented not delivered an interoperable EHR. The problem is the ‘brute force’ power games required to prosecute a centralised strategy overwhelm practical commonsense and naturally collaborative behaviours.

    This is why the answer has to be more focused on an acknowledgement that a devolved approach is the only practical way forward … and hence we need an approach to creating interoperable records in a diverse healthsector. One PCEHR to rule them all is a Tolkien fantasy replete with Balrogs, Orks, and other scary creatures. The magical promise of the ‘one ring’ PCEHR corrupts the logic of a diverse healthcare sector in the same way that the precious ring corrupted poor Sméagol.

  8. It’s only $1 billion…i forgot how many zeros are there in a billion dollar.
    Tax payers, comeon start to work even harder so that the money can be down the drain like this as it is explained in the article.

    And what surprise me was on what benefit the business case was presented and approved. We could have used that money for a better purpose. Was that a top priority for Australia…lets think..

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