11 October 2018

The digital health land that time (and govt) forgot

MyHealthRecord TheHill

At last month’s senate hearings into the My Health Record (MHR) one of the star witnesses for the defence (the defence of the MHR that is), was the Australian Digital Health Agency’s (ADHA) chief operating officer, Bettina McMahon. 

Ms McMahon is a very strong second act to the ADHA’s charismatic and articulate CEO Tim Kelsey. Mr Kelsey was previously an accomplished war correspondent, highly successful entrepreneur in healthcare, and a senior figure in the British government’s rollout of transformational digital health strategies through the NHS a few years back.

Neither Mr Kelsey nor Ms McMahon get rattled much. And they’ve had a lot of reasons to be rattled lately. 

Even though the MHR opt-out rollout had faltered enough on privacy and a few other key issues to be referred by the Greens for a senate inquiry, and many in the public were aiming their submissions aggressively and squarely at what they felt was some fairly major screw-ups in rolling out this major piece of future health system infrastructure, both Mr Kelsey and Ms McMahon maintained an air of calm. And, importantly, they usually had a reasonable and logical-sounding explanation for nearly everything that was thrown at them.  

It was rare that one of their senatorial inquisitors, even the Labor ones, who seemed a lot more interested and clued up on the issues surrounding the project than the Liberals ( perhaps because they now think they are going to have to deal with the whole thing in government very soon)  could trip up either Mr Kelsey or Ms McMahon.

But deep into the hearings on September 17, someone asked Ms McMahon a question that seemed to catch her off guard.

After ADHA representatives had confidently despatched some impressive statistics around growing engagement in the MHR, including that nearly 7000 GP practices and 4000 pharmacies had already registered to use the system, a pesky senator followed up with the question: “How many specialists can access the system?”

Ms McMahon was initially perplexed. It was as if she had never been asked that question before. She thought for a bit and then had to dive into a pile of files and whisper to a minder to get some answers. Eventually, in her inimitable style, she delivered.

The answer was 287. 

287? 

It seemed like it couldn’t be right, given all those impressive other figures for major  professional health provider groups. Although Ms McMahon didn’t know the figure by rote, as she did with so many others, she must have known that this number was extraordinarily low compared with all the other important groupings.

Of the nearly 14,000 healthcare organisations that qualify for a HIP-O number, and are hence cleared to access the MHR, of which GPs make up just about half, only 287 private specialist practices have registered for the MHR.  Remember, registering does not mean a practice or their doctors actually use the MHR. 

A few months back it was estimated that outside of GPs who were uploading patient summaries as a part of the PIP, only about 6% of the GP workforce was regularly engaging in the MHR.

Apply that ratio to the 287 number and you get a very clear sense  that our approximately 30,000 private practising specialist workforce is largely disengaged with the MHR project. 

This article started life as a suggestion by a  board member of a sister publication to The Medical Republic, who is a specialist. Having fleetingly seen something on a bus stop poster  on the way to work recently that worried them a little, they thought that specialists might be in need of a bit of a dummies guide to the MHR. They pointed out that they didn’t know much about the MHR  but they thought that maybe they now should, given all the recent bad media, and the implied importance of the project. 

When starting to research the “dummies guide” angle, I had assumed that most specialists would at least know the most basic things about the MHR (like what does MHR stand for), some of the history and objectives of the ADHA,  and its potentially pivotal role in reinventing key aspects of efficiency and safety in Australian healthcare delivery. Most GPs have some view on all this stuff, no matter how vague.  

But not long into research this assumption rapidly broke down.

Most specialists don’t even remember getting theirletter from the ADHA  in mid May this year outlining the impending opt-out launch. They got that notice via email (maybe that’s ironic given the digital angle). 

The letter was mostly high-level, futuristic, good-news material. All good stuff and interesting. But not in the orbit of most specialists focussing on their clinical schedules and their businesses. And there was nothing at all about how specialists would actually fit into the MHR scheme of things. 

I asked some of other board members of this publication what they thought of the MHR. 

This was a typical answer:

“I think I heard about it on the news, but I’m not really sure. I don’t use it.

My patients don’t mention it. I have [a patient management system but] I have never noticed it [the MHR] and don’t know if it’s in there.

“I don’t have a MHR, and I have opted my whole family out. Personally I would like to pick up the phone and talk to the right person to get the right information to care for my patients, rather than relying on potentially outdated online information of questionable provenance.”

It looks like we might be actively isolating specialists on an island of non-digital integration with the rest of the healthcare system

This sort of “sample of one” anecdote,understandably, tends to drive the ADHA apparatchiks a bit crazy. 

But if you add these anecdotes to the registered numbers on record, and you look at where in the ADHA’s national digital healthcare strategy specialists seem to be countenanced (not really anywhere in 63 pages), you suspect that the situation probably is as bad as that anecdote suggests. 

Specialists are ill-informed about, indifferent to, and not engaged with, the MHR. That’s not good. The MHR is an important integrated system-wide project. GPs engage a lot with specialists now and not that well. 

Even if GPs aren’t spending their spare time worrying about how digital their upstream, better-paid cousins are, having specialists left off the digital-integration menu is going to significantly retard general practice and, by implication, the whole system.  

As things stand, as a group, specialists look set to continue on this path for some time without understanding just how important digital system integration with something like the MHR might be in their clinical and working lives and related healthcare professionals around them.

It looks like we might be actively isolating them on an island of non-digital integration with the rest of the healthcare system. An island that time, and the government, hasn’t exactly forgotten, but certainly has pencilled in the diary as a problem to be solved at a later time.

There are quite a few more specialists and specialists in training in the country than GPs, and despite stories of hoards of croaky 72 year olds dictating their notes to be transcribed by their equally aged PAs, many are modern and digitally savvy. And frustrated at how they are viewed and treated.

According to  James Scollay, the CEO of major specialist patient management vendor Genie Solutions, specialists are unclear on how or when they should be engaging with the MHR. 

He says that their major concern with the initiative is that they won’t be caught out by their patients with something on the MHR they need to have done, or that their patients expect they’ll be able to easily access. Their concern probably should be a little more strategic and long term than that. But they aren’t being engaged in the process, so it’s hard to blame them.

Genie, which services more than 50% of the 85-90% of privately practising specialists in the country, has MHR access capability within it. It is the only specialist PMS that does. Which means that a not insignificant number of specialists could access the MHR if they were engaged enough to go through the registration process. On our numbers, maybe 16,000 or so of the 30,000 or so privately practising specialists. 

Mr Scollay, who says he is working closely with the ADHA “to help advocate specialist requirements” and is “committed to making sure our products give specialists the best possible interaction with MHR” believes that the MHR will be very important to the future of specialist practice. 

“MHR needs to provide a complete view of a patient’s healthcare and specialists are a vital part in the mix as they are usually involved in the most complex and important elements of healthcare but don’t necessarily have an ongoing relationship with patients”, he told TMR. 

“Therefore, having good access to the data related to their treatment is vital to their ongoing wellbeing.”

But with only 287 practices registered, or about 3.5% of the total, it is apparent the specialist community has been, at the very least, parked to one side by the ADHA.

The question is, why?

Well it wasn’t a flip of coin as to who got first dibs, GPs or specialists. GPs are in front because of a perceived low level of computerisation by specialists, and, to some degree digital literacy, at least as it pertains to digital health systems.

GPs have literally been showered with attention and money by the ADHA in the recent relaunch of the MHR into it’s opt-out format. PHNs have been funded into the millions to educate and train their GP flocks, and the RACGP has been engaged deeply at various levels in recruiting GPs into the plans.

In essence, the ADHA and the government feel that the best “bang for buck” is going to come from GPs, pharmacies and hospitals, all of which have very high levels of computer use and literacy.

Someone described this decision to me as “sequencing, not prioritising”, which might even make sense. Do GPs first, as they have higher patient management system usage and connectivity, and they are at the intersection between most primary and tertiary care. Then deal with the specialists.

So there is a degree of logic in what the ADHA has decided. It’s just that it feels an awfully big hole to backfill at a later date.

How less computerised than GPs are specialists, and perhaps more importantly, why and how does the government close that gap?

The figures are not well understood. 

It is estimated that somewhere around 85-90% of private specialist practices use a PMS, but some don’t use them for clinical workflow, and therefore they aren’t really used by the specialists themselves, but by back-office staff. 

It’s very hard to determine how many of that 90% of private specialists actually engage on   day-to-day basis with the digital world via their work computer. 

But even discounting heavily for the effect of back-office use only, it feels like specialists in private practice are  still reasonably well computerised. 

We think about 30,000 specialists are in private practice and the rest are public. Public practising specialists all have access to sophisticated hospital-based systems, but it is difficult to gauge just how much they engage with them and how much they engage with the MHR as a result. Hospital systems vary by hospital, by state and are eclectic at best.

We know that private and public hospital MHR registration is high and growing fast. We don’t know clearly how much doctors actually access and use the MHR within those registered institutions. But there is a big push from the ADHA into hospitals, mainly because they want to break the traditional disconnect between primary and tertiary health, the poster child of which has been the extremely poor record of GPs being able to access sensible and timely hospital discharge summaries.

The thing is, if you add up all this potential specialist access, it doesn’t feel like specialists are the dinosaurs in the digital health land that time forgot, but it feels a little bit like how the ADHA is treating them.

Mr Scollay says that most specialists he talks to are very computer savvy and quite frustrated by the limitations they face with their technology. 

Around 1994, the federal government put a stake in the ground on GPs and computers, determining that for various reasons of efficiency in the system, they’d prefer GPs to be using computers to prescribe and record all their patient data. 

The government introduced a scheme through the PIP, and essentially offered every GP in the country enough in a one-off grant to set themselves up with a computer and an electronic scriptwriter.

At the time, MedicalDirector, which is one of our major patient management system vendors today, had just been acquired by Health Communication Network (HCN). Until that time, HCN was struggling big time with its business models. But with the new PIP and MedicalDirector, it struck gold. 

Within three years, nearly 90% of GPs had a computer and were using electronic scriptwriting and record keeping. That was a seminal few years for Australian healthcare because, to this day, Australia has one of the most computerised GP sectors in the world. 

We wonder whether the ADHA should rethink the “land that time forgot” paradigm with specialists, and use some of that $350 million it gets each year to run its centralised database and educate everyone, to encourage the specialist community to gear up in a manner that will allow them to integrate digitally with the other vital parts of the system.

That should bring specialists unheard-of efficiencies, standards of safety and connectivity to the healthcare community.