26 April 2019

Softly, softly – what we can learn from the US experience

Technology

Australia is a land of sweeping plains: a land of sweeping health reform it is not.

A long article in a recent edition of Fortune magazine (18 March, 2019) is a surprising and ill-conceived attack on the electronic medical record. More interestingly, it highlights the risks of rush when it comes to health system transformation.

The title, Death by a Thousand Clicks: Where Electronic Health Records Went Wrong, sums up the argument against the electronic medical records in the US. The physicians in the sample complained, “about clumsy unintuitive systems and the number of hours spent clicking, typing and trying to navigate them – which is more hours than they spend with their patients”.

Australian GPs grumble about aspects of our software, however few are as dissatisfied as their American colleagues interviewed for this article. Most GPs in this country are now very comfortable with the keyboard in their consulting room.

The sample chosen by these US investigators is unlikely to be representative. Despite interviewing a hundred or so players with an interest in healthcare delivery, from physicians through to administrators, it is a surprise that the authors did not find any support for the electronic medical records.

But, as The Medical Republic recently noted, the American healthcare system is terrible but “the best parts of it are also the best in the world”. (3 April 2019).

In the best American health systems, such as Cambridge Alliance in Boston, South East Texas Medical Associates (SETMA) and Kaiser Permanente in Southern California, clinicians value the electronic medical records.

Most importantly, in these organisations, electronic records are not only seen as a necessity, but also as the basis of a better system of healthcare delivery overall.

The reorganisation of the workflow, the building of teams, and the continuous quality improvements that are enabled by (but not created by) electronic medical records result in the increased professional satisfaction that is a feature of these excellent American healthcare systems.

It is not enough simply to replace a paper record with an electronic medical record. Australian discussions about improving electronic medical records (including the My Health Record) must include parallel discussions about this system transformation to realise its potential.

The Fortune article has another take-home message for Australians; there are risks in rushing transformation.

Ten years ago, then President Barack Obama committed $US36 billion to the nationwide introduction of the electronic medical record.  It seems he had two motives, first the need to spend quickly in order to stimulate an economy depressed by the global financial crisis, and, second, to improve the effectiveness and efficiency of healthcare provision. With the rush came rapid growth, use of short-cuts, poor design and poor implementation.

In “America’s Bitter Pill: Money, Politics, Backroom Deals and the Fight to Fix Our Broken Health Care System”, Steven Brill tells an enthralling tale of the stories behind the implementation of the Affordable Care Act, or “Obamacare” as it is commonly known.

One of these was the botched debut of the website, HealthCare.gov. Only six people were able to enrol on its first day of operation! The story is complex, but in simple terms, things needed to happen quickly and, at the last minute, a private IT giant stepped in to clear up the mess created previously by government officials.

The external expert warned the president that the fix would be satisfactory but not perfect. A project of this size and complexity had to be built from scratch with each new module being thoroughly tested before moving on to develop the next.

In Texas, where such an electronic transformation did occur, it took seven years from the time the decision was made, to move to an electronic system of record keeping and data sharing. Proceeding in a logical, stepwise manner, they finally arrived at a fully functioning “patient-centered medical home” located within an electronically connected health system.

The perils of rushing reform are evident outside the health system. Australia remembers the pink batts insulation scheme.

Both Obamacare and pink batts were bedeviled by time pressure and poor government regulation.

Death by a Thousand Clicks may seem like a black cloud on first reading, but there is a silver lining. The good news is that many potential pitfalls in the transformation of a health system are avoidable, provided they are recognised early. Australia needs to proceed incrementally, learning as we go and tolerating error.

This includes learning how to better regulate the system.

We need conversations focused on the broader health system, not simply on improving the electronic medical record and the My Health Record.

There must be balanced debate on system reconfiguration if the move to a totally electronic health system is to have a chance of achieving its full potential.

Dr Michael Fasher is Adjunct Associate Professor at University of Sydney and Conjoint Associate Professor at Western Sydney University